Greentree Manor Nursing And Rehabilitation Center

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 two residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings include: A. Resident #1's diagnoses included depression and anxiety. The Resident Care Plan (RCP) dated 4/24/2025 identified Resident #1 was incontinent of bladder. Interventions directed to provide incontinent care every two hours and as needed, and update the nurse for any areas of skin breakdown. The quarterly Minimum Data (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and required substantial assistance to dependent with ADLs (activities of daily living). B. Resident #2's diagnoses included congestive heart failure and mental disorder due to known physiological condition. The admission MDS assessment dated [DATE] identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents (Resident #22) reviewed for choices, the facility failed to make a reasonable accommodation for an individual with mobility needs. The findings include: Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent for transfers, required maximal assistance with personal hygiene and bed mobility, and utilized a motorized wheelchair. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #22 required assistance with Activities of Daily Living (ADLs). Interventions included assisting with ADLs, mechanical lift for transfers, and reposition Resident #22 in his/her power wheelchair every 2 hours. An interview with Resident #22 on 4/29/2025 at 9:54 AM identified he/she was unable to leave his/her room…

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 1 of 4 sampled residents (Resident #22) reviewed for abuse, for the only sampled resident (Resident # 27) reviewed for hospitalization, and for 1 of 3 residents, (Resident #36) reviewed for smoking, the facility failed to develop and implement comprehensive Resident Care Plans. The findings include: 1. Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent for transfers, required maximal assistance with bed mobility, and utilized a motorized wheelchair. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #22 had communication difficulties as a result of a stroke. Interventions included speaking directly to the resident while facing him/her, ask simple yes/no questions, and provide speech therapy as needed. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and interviews for 1 of 3 sampled residents, (Resident #7), reviewed for choices, the only sampled resident (Resident #13) reviewed for rehabilitation, the only sampled resident, (Resident #22), reviewed for abuse, the only sampled resident (Resident # 27) reviewed for hospitalization, the only sampled resident (Resident #52) reviewed for care planning, and the only sampled resident (Resident #56) reviewed for hemolytic treatments, the facility failed to review and revise care plans per the requirement and failed to hold quarterly Resident Care Plan (RCP) meetings as required. The findings include: 1.Resident #7's was admitted [DATE] with diagnoses that included seizure disorder, chronic obstructive pulmonary disease, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition and was independent with transfers and walking 150 feet.…

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 clinical records, facility documentation, facility policy, and interviews on 1 of 4 units reviewed for medication to residents, (Resident #1, Resident #4, Resident #8, Resident #16, Resident #17, Resident #36, Resident #37, Resident #38, Resident #39, Resident #45, Resident #46, Resident #49, Resident #50, Resident #55, Resident #56, Resident #66, Resident #68, Resident #75, Resident #77, Resident #233 and Resident #282), the facility failed to ensure meds given greater than once daily were administered at the correct time per the physicians orders. The findings include: Based on observations, review of clinical records, facility documentation, facility policy, and interviews for Residents #1, #4, #8, #16, #17, #37, #38, #39, #46, #49, #50, #55, #56, #68, #75, #77, #233, #282, the facility failed to ensure medications were administered at the correct time per the physician's orders. The findings include: 1. Resident 1's diagnosis included chronic obstructive pulmonary disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and interviews for 1 of 2 residents, (Resident #22), reviewed for food, the facility failed to accommodate a resident's preferences for meal items. The findings include: Resident #22's diagnoses included hemiplegia of the right side, aphasia, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 had a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition, was dependent on transfers, required maximal assistance with bed mobility, and utilized a motorized wheelchair. A Nutrition assessment dated [DATE] identified Resident #22 was on a LCS diet, had food preferences that should be honored, was to receive large portions, and was to receive a bedtime snack daily. The Resident Care Plan (RCP) dated 3/5/2025 through 4/29/2025 identified Resident #22 was on a regular LCS diet. Interventions included ethnic foods, encourage to eat healthier options, and provide bedtime snacks every evening shift.…

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

Based on observations, facility documentation, facility policy, and interviews the facility failed to ensure the steam table was washed and sanitized after every use, failed to ensure open food items were appropriately dated, and failed to ensure expired foods were removed from storage. The findings include: During a tour of the kitchen with the Director of Food Services on 4/28/2025 at 9:50 AM the following was identified: a. 2 half gallons of milk, each with an expiration date of 4/23/2025, were on a drink cart and were not set in ice. 1 half gallon was 1/2 full and 1 half gallon was full. An interview with the Director of Food Services identified that he was not aware the milk was expired and indicated the milk was intended to be used to serve the residents. b. The walk-in fridge had a soup bowl containing tuna salad dated 4/10/2025. c. 1 tray of cranberry jelly/sauce was dated 2/9/2025. d. 1 tray of cranberry jelly/sauce was dated 4/9/2025. e. 1 open plastic container of cranberry jelly was dated 4/6/2025. f. 2-12 ounce open bags of non-dairy topping, both 1/8 full, was noted 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 F814 [NAME] final Scope and Severity: E Based on observation and interview, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner and refuse was appropriately contained. The findings include: Observation of the facility's dumpster area with the Director of Food Service on 4/28/2025 at 10:24 AM identified the following items littered on the ground in front of 2 dumpsters: a. One, 3 cushion sized couch, flipped upside down, with visible water stains and dirt. b. One wood table with padding, upside down with wood in various stages of decomposition/rot. c. One tabletop with cover and foam. Foam was disintegrating and pieces of foam had been chewed away. d. Five cardboard boxes. e. One pedestal table with a metal base. f. One snow shovel. g. One used incontinence disposable under pad (Chux pad). h. Multiple used face masks, used bandages, paper scraps, plastic bags, and Styrofoam cups. An interview with the Director of Food Service on 4/28/2025 at 10:24 AM identified that he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy for 3 of 4 sampled residents, (Resident #13, Resident #285, and Resident #287), reviewed for advance directives, the facility failed to ensure that residents had the opportunity to make care decisions and obtain signed consents regarding care to be provided upon admission. The findings include: 1. Resident #13 was admitted on [DATE] with diagnoses that included epilepsy, dysphagia, and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, required set up assistance with personal hygiene, and supervision with transfers and walking 150 feet. A review of physician's orders dated 10/22/24 through 4/30/25 identified that Resident #13 was receiving Seroquel (an antipsychotic medication), and had an order to administer Potassium Iodide in the event of a nuclear disaster. Although the Resident Care Plan (RCP) dated 1/22/2025 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 sampled residents (Resident # 23) reviewed for accidents, the facility failed to notify the physician following a fall with a major injury. The findings include: Resident #23's diagnoses included dementia, malignant neoplasm of the anal canal, morbid obesity, and was actively receiving chemotherapy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #23 was dependent on staff for bed mobility, toileting, bathing, and transfers. The Resident Care Plan dated 1/28/2025 identified Resident #23 was a fall risk related to a history of falling. Interventions included, keep the bed in lowest position, remind Resident #23 of self-limitations, and encourage the resident to ask for assistance with personal care. Review of the Physical Therapy Evaluation and Plan of Treatment…

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 #18) reviewed for Activities of Daily Living (ADL), the facility failed to provide showers as scheduled for a dependent resident. The findings include: Resident #18 's diagnoses included Parkingson's disease, anxiety disorder, and spinal stenosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was moderately cognitively impaired and required substantial maximum assistance with bed mobility, transfers, and dressing, and required total assistance of staff with personal hygiene. The Resident Care Plan dated 4/14/2025 identified Activities of Daily Living (ADLs) Interventions included assisting with bathing, dressing, and hygiene as ordered. Interview with a family member on 5/1/2025 at 1:20 PM identified that Resident #18 was scheduled to get a shower on Tuesdays and Thursdays and Resident #18 had not received showers on Tuesday 4/29/2025 or Thursday 5/1/2025. In an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility policy, and interviews for 1 of 3 sampled residents (Resident #20) reviewed for pressure ulcers, the facility failed to follow physician orders for wound care, failed to obtain physician orders for wound care treatment, failed to report a change in skin integrity, and failed to ensure the wound care nurse conducted weekly head to toe skin assessments for a resident with a pressure ulcer per the facility practive, and for 1 of 4 sampled residents, (Resident #52) reviewed for nutrition, the facility failed to follow a physician order to obtain weekly weights. The findings include: 1. Resident #20's diagnoses included epilepsy, bullous pemphigoid, diabetic/pressure ulcer, and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 had a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, was dependent on transfers, required extensive assistance with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 2 of 4 sampled residents (Resident #54 and Resident #285) reviewed for nutrition, for Resident #54, the facility failed to reweigh a resident after a significant weight loss and for Resident #285 the facility failed to obtain a timely admission weight and and failed to reweigh a resident with noted weight loss and receiving nutrition via a gastrostomy tube. The findings include: 1. Resident #54 was admitted to the facility in July of 2024 with diagnoses that included dysphagia (difficulty swallowing), dementia, diabetes and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment, required partial/moderate assistance for personal hygiene, bed mobility and transfers. A Resident Care Plan in effect in January of 2025 identified Resident #54 was on mechanically altered diet secondary 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, facility policy, and interviews for the only sampled resident (Resident # 27) reviewed for hospitalization, the facility failed to assess a symptomatic resident with a history of congestive heart failure and for the only sampled resident (Resident #44) reviewed for respiratory care, the facility failed to change oxygen tubing in a timely manner. The findings include: 1. Resident #27 's diagnoses included respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #27 required a walker for ambulation, required supervision with transfers, and partial assistance with dressing and tub/shower transfers. The Resident Care Plan (RCP) dated 12/20/2024 did not address conditions related to the Resident #27's admitting diagnoses including congestive heart failure…

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 clinical records, facility policy, and interviews for the only sampled resident (Resident #56) reviewed for hemolytic treatments, the facility failed to ensure the treatment center was notified when appointments were going to be missed due to transportation and failed to reschedule the appointment per the hemolytic center's request. The findings include: Resident #56's diagnoses included end stage renal disease, dependence on hemolytic treatment, anemia and amputation. A quarterly Minimum Data Set assessment dated [DATE] identified Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, was dependent on staff for personal hygiene and transfers and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for the month of April of 2025 identified Resident #56 was on hemolytic treatment. Interventions included encouraging Resident #56 to go for the scheduled hemolytic appointments, monitor lab work, monitor 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 observations, review of the clinical record, facility policy, and interview for 1 of 5 residents (Resident #1) observed for medication pass the facility failed to ensure unused medications were properly stored/destroyed. The findings include: Resident #1's diagnosis included thyroid disease and heart failure. Observations on the South Center Unit on 5/1/2025 at 8:42 AM, with LPN #2, identified she disposed of medications that were unused into a garbage can attached to the side of the medication cart. LPN #2 prepared to repour medications that had been disposed of, and was stopped by the surveyor. LPN #2 indicated that the unsued medications should not have been placed in the trash can due to safety concerns as the medications would be accessible to residents. Subsequent to surveyor inquiry, LPN #2 donned, gloves, removed the medications from the garbage and placed all unused medications in the covered and locked sharps container affixed to the other side of the medication cart. Review of the undated Medication Destruction and Disposal policy, identified, in part, that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility policy, and interviews for 1 of 5 sampled residents (Resident #69) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were reviewed and acted upon. The findings include: Resident #69's diagnoses included Non-Alzheimer's dementia, anxiety, and depression. A physician order dated 9/26/2024 directed to administer 2 tablets of 325 milligram (mg.) acetaminophen by mouth every 4 hours as needed for general discomfort. The Resident Care Plan (RCP) dated 3/5/2025 identified Resident #69 had depression and anxiety. Interventions included medications as ordered, evaluation of the drug regimen to be reviewed by the medical doctor and allowing the resident to verbalize feelings related to the disease process. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #69 had a Brief Interview of Mental Status (BIMS) score of 0 indicating severe cognitive impairment, required moderate assistance with personal…

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, facility documentation, facility policy, and interviews for 1 of 4 medication carts reviewed for medication storage and labeling, the facility failed to ensure medication carts were locked when not attended and failed to remove expired medications. The findings include: Observations on 4/29/2025 at 11:53 AM on the South Wing identified the medication cart lock in the open position and left unattended at the end of the hallway near room [ROOM NUMBER]. The surveyor pulled on the medication cart drawers and all of the drawers were opened allowing access to the residents' medications. The surveyor immediately asked the staff to get the Director of Nursing Services (DNS) while continuing to monitor the unsecured medication cart. Interview with the DNS on 4/29/2025 at 12:00 PM identified the medication cart was unsecured and unattended. She could not explain why the nurse had left the medication cart unlocked and unattended and locked the cart herself. The DNS indicated she would address the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of clinical records, facility documentation, facility policy, and interviews for 1 of 5 residents, (Resident #1), reviewed for medication administration, the failed to ensure medications were handled in a clean manner, for 1 of 3 sampled residents, (Resident #20), reviewed for pressure ulcers, and for 1 of 4 residents reviewed, (Resident #285), for nutrition, the facility failed to ensure Personal Protective Equipment (PPE) was worn for residents on Enhanced Barrier Precautions (EBP), for Resident #20 failed to perform hand washing and changing gloves during wound care, and for 1 of 2 medication rooms reviewed, failed to ensure a clean and sanitary environment in the medication room was maintained. The findings include: 1. Resident #1's diagnosis included thyroid disease and heart failure. Observations on the South Center Unit with LPN #2 on 5/1/2025 at 8:42 AM, during the medication administration pass, identified LPN #2 pour Resident #2 Medications. During the medication pour, 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 review of the clinical record, facility documentation, facility policy and interviews for 4 of 5 residents (Resident #13, Resident #282, Resident #285, Resident #287) reviewed for immunizations, the facility failed to obtain a current status for immunizations, failed to offer immunizations, and failed to obtain consent for immunizations. The findings include: 1. Resident #13 had diagnoses that included epilepsy, dysphagia, and depression. The Resident Care Plan (RCP) dated 1/22/2025 failed to identify a contraindication or allergy to any immunizations. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, and was independent with personal hygiene, transfers, and walking 150 feet. A review of Resident #13's clinical record identified that consent forms for vaccination administration forms were blank and unsigned. 2. Resident #282's diagnoses included sepsis, (a life-threatening…

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, interviews, and facility policy for 1 of 3 residents, (Resident #13), reviewed for advance directives, the facility failed to offer a covid vaccine. The findings include: Resident #13's admission date was 10/22/2024 and had diagnoses that included epilepsy, dysphagia, and depression. The Resident Care Plan (RCP) dated 1/22/2025 failed to identify any contraindications with vaccination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, and was independent with personal hygiene, transfers, and walking 150 feet. A review of Resident #13's clinical record identified that consent forms for vaccination administration were unsigned. An interview with the Director of Nursing Services (DNS) on 4/30/2025 at 9:18 AM identified that the Licensed Practical Nurse (LPN) or Nurse Supervisor was responsible for ensuring resident consent forms were signed no later than the second day…

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 documentation, and interviews for two (2) nursing units, the facility failed to provide a clean, comfortable, and homelike environment. The findings include: Observations on 3/24/25 at 9:30 AM, 11:30 AM and 2:00 PM during a tour of the facility with the Director of Maintenance identified the following: 1.Handrails that were sticky were noted to have debris stuck on them, 2. Plastic kickboards on resident room doors on the North and South wings had noticeable streaks on the front and behind the board, 3. Shower room [ROOM NUMBER] wall tiles were missing with plastic covering the missing tiles on the walls, 4. The walls on the North and South wings had peeling wallpaper, 5. Resident door jams on Rooms #1, #3, #7, #23, #27 and #30 have a reddish-brown rust appearing substance. 6. Bed rails in Rooms #9, #27, and #31, were observed to have a reddish-brown appearing substance. Interview with the Director of Maintenance on 3/24/25 at 10:10 AM he stated he recently took over 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 abuse and/or neglect, the facility failed to ensure an allegation of abuse was reported immediately to the State Agency as required. The findings include: Resident #1's diagnoses included bipolar disorder with psychotic features, anxiety disorder and delusional disorder. 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 was dependent on staff for toileting hygiene and transfers, and required substantial assistance with bed mobility. The Resident Care Plan dated 9/13/24 identified that Resident #1 had accusatory behaviors, refused care and services at times and has a history of making racial slurs with interventions that included to monitor for behaviors, allow the resident to calm down and reapproach as needed, 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, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for abuse and/or neglect, the facility failed to provide evidence that an allegation of abuse was investigated. The findings inlcude: Resident #1's diagnoses included bipolar disorder with psychotic features, anxiety disorder and delusional disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eleven (11) indicative of moderately impaired cognition and was dependent on staff for toileting hygiene and transfers, and required substantial assistance with bed mobility. The Resident Care Plan dated 7/11/24 identified that Resident #1 had accusatory behaviors and refused care and services at times. Interventions included to monitor for behaviors, allow the resident to calm down and reapproach as needed, resident was to be a two-person assist with transfers and personal…

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 abuse and/or neglect, the facility failed to ensure the resident was provided social services support timely after allegations of abuse. The findings include: Resident #1's diagnoses included bipolar disorder with psychotic features, anxiety disorder and delusional disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eleven (11) indicative of moderately impaired cognition and was dependent on staff for toileting hygiene and transfers, and required substantial assistance with bed mobility. The Resident Care Plan dated 7/11/24 identified that Resident #1 had accusatory behaviors and refused care and services at times. Interventions included to monitor for behaviors, allow the resident to calm down and reapproach as needed, resident was to be a two-person 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who were reviewed for an allegation of physical abuse, the facility failed to ensure Resident #1 was not punched by Resident #2. The findings include: Resident #1's diagnoses included dementia, depression, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, did not exhibit any behaviors, and was independent with ambulating. The Resident Care Plan dated 9/26/24 identified Resident #1 had depression and anxiety. Interventions directed to administer medications as ordered, encourage participation in purposeful activities, psychiatric consult as needed, and schedule regular walks. Resident #2's diagnoses included depression, cardiomyopathy, and chronic kidney disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall…

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 (Residents #3) who were reviewed for an allegation of abuse, the facility failed to stop the provision of care and attempt again later when Resident #3 became agitated during incontinence care and failed to notify the charge nurse Resident #3 was resistive to care as outlined in the care plan. The findings include: Resident #3's diagnoses included bipolar disorder with psychotic features, anxiety, and delusional disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily life, experienced hallucinations and delusions, and was dependent on staff for toileting, bathing, personal hygiene, dressing, bed mobility, and transfers. The Resident Care Plan dated 3/22/24 identified Resident #3 required assistance with daily living skills, was non-compliant with care, and exhibited accusatory behavior towards…

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 elopement, the facility failed to supervise a resident who required assistance with ambulation resulting in the resident leaving facility grounds unsupervised The findings include: Resident #1's diagnoses included alcohol abuse, muscle weakness, difficulty in walking and a history of falling. The admission Nursing assessment dated [DATE] identified Resident #1 was alert with some forgetfulness, exhibited short-term memory loss and required assistance due to decreased range of motion in both the upper and lower extremities. The Resident Care Plan (RCP) dated 9/9/24 identified that Resident #1 required assistance with Activities of Daily Living (ADL's) with interventions that included to assist with bathing, dressing, hygiene, transfers and ambulation as ordered. Review of the Elopement Evaluation dated 9/7/24 at 8:37 PM identified that Resident #1 was not at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was reviewed for the end of Medicare coverage and the appeals process, the facility failed to review the appeals decision and know that Resident #1 had won the insurance appeal that was filed and not discharge Resident #1 without giving him/her the option to remain at the facility for continued care. The findings include: Resident #1's diagnoses included cellulitis of right toe, generalized muscle weakness, Parkinson, anxiety, depression, and type 2 diabetes. The admission Resident Care Plan dated 7/23/24 identified Resident #1 had a self-care deficit, altered mood patterns, was at risk for falls, had discharge planning in place, and impaired skin integrity. Interventions directed assistance with daily living skills, transfers and ambulation; encourage resident to express feelings and provide realistic feedback, psychiatric consults; physical therapy as ordered,…

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, interviews and review of facility documentation for one of three residents reviewed for abuse or neglect (Resident #2), the facility failed to report a resident-to-resident threat of bodily harm to the proper authorities. The findings include: 1. Resident # 2 was admitted with diagnoses that include dementia with agitation, schizoaffective disorder, Huntington disease and diabetes mellitus. A resident care plan (RCP) dated 4/26/2024 identified Resident #2 was a wandering/elopement risk and has a mood problem with a history of anger outbursts. The RCP directed to check the function of wander guard bracelet daily, assist to find own room, unit as needed, assist to identify sources of anxiety, provide gentle touch and redirection. An annual MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairment and was independent for bed mobility, transfer and walking with a walker. 2. Resident #12 was admitted with diagnoses that included chronic kidney disease,…

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

Based on review of facility documentation and interviews the facility failed to ensure a Registered Nurse was on duty 24 hours per day. The findings include: A review of the facility staffing identified RN #1 was scheduled until 7:00 AM July 7, 2024 and RN #5 was scheduled from 7:00 AM until 3:00 PM. All other licensed staff scheduled until 7:00 AM and scheduled to come in at 7:00 AM on 7/7/2024 were LPN's. Review of RN #1's facility timesheet for 7/6/2024 identified that she punched out of the facility at 6:04 AM on 7/7/2024. A review of the agency timesheet for RN #5 identified that she started her shift at the facility at 8:00 AM. Interview with the Administrator on 8/1/2024 at 1:00 PM identified she was contacted by the facility that the night supervisor- RN #1 had left the facility at 6:00 AM and that the day supervisor (RN #5) had not arrived at the facility until 8:00 AM. The Administrator further identified RN #1 had indicated she had coordinated with RN #5 to relieve her at 6:00 AM on 7/7/2024 as she needed to leave early for personal reasons. RN #1 indicated that she 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 of three sampled residents (Resident #2) who was at risk for skin breakdown, the facility failed to ensure Resident #1's Conservator of Person was notified when the resident developed a pressure ulcer. The findings include: Resident #2's diagnoses included depression, cerebrovascular accident (stroke) with hemiplegia and hemiparesis, muscle weakness, benign neoplasm of meninges, depression, and acute kidney failure. The Resident Information Report identified Resident #1 had a Conservator of Person (COP). The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had some memory recall deficits, required extensive assistance with turning and repositioning when in bed, getting in and out of the bed and chair, and toileting, was frequently incontinent of bowel always incontinent of bladder, had no pressure areas and had Moisture Associated Skin Damage (MASD). The Resident Care Plan dated 8/4/23…

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, facility documentation, facility policies, and interviews for one of three sampled residents (Resident #3) who were reviewed for an allegation of neglect, the facility failed to ensure the resident was fed breakfast and failed to check and provide incontinent care during the 7AM-3PM shift. The findings include: Resident #3's diagnoses included dementia, anxiety, and speech and language deficits. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily life, required maximum assistance for eating, oral hygiene, toileting, upper body dressing, and personal hygiene, was totally dependent for bathing and lower body dressing, required substantial assistance with getting in and out of the bed and chair and was incontinent of bowel and bladder all the time. The Resident Care Plan dated 10/5/23 identified Resident #3 had a self-care deficit and required contact guard assistance with all meals, used a Kennedy…

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, policies and interviews for one sampled resident (Resident #4) who was transferred to an acute care hospital, the facility failed to re-admit the resident and serve the resident a thirty (30) day involuntary discharge notice when the resident was ready for discharge from the hospital. The findings include: Resident #4's diagnoses included depressive disorder, restless leg syndrome, chronic back pain, and morbid obesity. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no memory recall deficits, was dependent on staff for most activities of daily living and received a scheduled pain medication and an as needed pain medication. The social service note dated 11/16/23 at 10:50 AM the social worker was notified this morning Resident #4's room smelled like marijuana and there was a suspicion of drugs in the room. The note identified when the social worker approached Resident #4 at first, Resident #4 was defensive saying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for pressure ulcer prevention, the facility failed to document weekly skin assessments to include measurements, staging, and characteristics of a current pressure ulcer, and failed to identify a new pressure ulcer prior to Resident #1 being transferred to the hospital, the new pressure ulcer was noted in the emergency department. The findings include: Resident #1's diagnoses included dementia with behavioral disturbance, anxiety, kyphosis depression, neurocognitive disorder with Lewy bodies, cerebral infarction, and osteoarthritis. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was dependent with turning and repositioning while in the bed, getting in and out of the bed and chair and toileting and required extensive assistance with dressing, eating and personal…

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 review, and interviews for 1 of 3 residents ( Resident # 16 ) who require assistance with transfers out of bed, the facility failed to transfer the resident out of bed per plan of care and for 3 of 3 residents (Resident #1, Resident #54 and #55) reviewed for ADLs, for Resident #1 under constant observation, the facility failed to respond to a sounding and illuminated call bell in a timely manner, for Resident #54 the facility failed to provide personal hygiene care including showering and shaving according to the plan of care, and for Resident #55, the facility failed to provide nail care according to the plan of care and for (Resident # 176), the facility failed to consistently provide ADL. The findings included: 1. Resident # 16's diagnoses included anxiety, chronic kidney disease, metabolic encephalopathy and hypertension. The quarterly MDS assessment dated [DATE] identified the resident 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #55) reviewed for abuse, the facility failed to ensure appropriate staffing to provide the resident with timely care and services. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit), and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. The care plan dated 4/12/23 identified an allegation of abuse, neglect, related to lengthy call bell response times. Interventions included to provide requests for help with elimination in a timely manner. Interview with Resident #55 on 05/18/23 11:01 AM identified that there were no nurses aide Sunday night,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the kitchen, facility policy and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure the facility emergency food and water supply were within acceptable expiration dates. The findings included: Initial observation of the Kitchen area on 5/17/2023 at 9:22 AM noted hair covering on 3 of 3 dietary workers in the kitchen area and appropriate glove usage while collecting used breakfast dishware from the unit carts. Observation of the kitchen on 5/17/23 at 10:25 AM with the Director of Dietary identified the following: 1. a. thick dust on the floor and part up the back wall behind the open food prep area to the right of the kitchen entrance. b. A dietary aide was noted prepping food on a prep table to the right of the kitchen entrance with a box to his right on top of the prep table with a tray on top that contained a spilled granular substance, several open condiment cups, paper plates, a rubber band, several pieces of cut…

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 Infection Control Program, observations, review of facility documentation and interviews for 2 of 2 ( Housekeeper #1 and Nurse Aide #1), the facility failed to follow the manufacturer's directions for disinfection of surfaces and the facility failed to ensure that COVID 19 outbreak for two employees ( NA # 12 and NA # 14) was reported to the state agency timely and for 1 of 2 residents reviewed for wound care for ( Resident # 7), the facility failed to ensure licensed staff used acceptable infection control practices when conducting wound care. The findings included: 1 .An interview with Housekeeper #1, on 5/18/23 at 9:17 AM, identified that when she uses the facility Sani-Cloth Bleach Germicidal Wipes to disinfect surfaces to prevent the spread of infection, she allows the disinfectant to remain on the surface for 2 minutes. Interview with NA #11, on 5/18/23 at 9:22 AM, identified that her understanding of the facility disinfectant Sani-Cloth Bleach Germicidal Wipes required a dwell time of 2-3 minutes. Interview with Infection Preventionist, RN #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 reviews, observations, facility policy and interviews for 2 of 5 residents (Resident# 20) reviewed for dining, the facility failed to ensure staff provided a dignified dining experience and for 1 of 2 residents (Resident# 53) observed for dignity, the facility failed to ensure privacy of a urinary collection bag at the bedside free from public eyesight. The findings included: 1. Resident # 20's diagnoses included in part dementia, contractures, and aphasia. The Nurse Aide (NA) Care Card dated 4/26/2022 indicated Resident #20 required total assistance with feeding, to be seated in an upright position for all meals and to alternate liquids and solids and to provide small bites of food and sips of liquids. The physicians' orders dated 6/26/2020 directed to provide a NAS (no added salt) diet of puree texture with nectar thickened liquids with a fluid intake goal for between 1750-2100 cc's/day. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that cognitive skills were…

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 3 residents (Resident #32) reviewed for grievances, the facility failed to honor resident choice related to getting in and out of bed timely for activities. The findings include: Resident #32's diagnoses included Depressive Episodes, Heart Failure, Chronic Kidney Disease stage 3. The care plan for ADL's related to immobility and weakness dated 5/19/22 included interventions to assist with bathing, dressing, hygiene as ordered, to assist with transfers and ambulation as ordered and to provide Physical therapy, Occupational therapy and Speech therapy consults as ordered. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #32 was cognitively intact and required extensive 2-person physical assist for bed mobility and transfers. The assessment also identified the resident required extensive one person assist for personal hygiene. Interview with Resident #32 on 05/18/23 at 11:50 AM identified she/he had not been getting out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and interviews for 2 of 6 residents (Resident # 13 and Resident # 16) reviewed for advanced directive, the facility failed to obtain a physician's order for the resident's advanced directive in accordance with facility practice. The findings include: 1. Resident # 13 was admitted on [DATE]. The resident's diagnoses included hypertension, depression, anxiety, diabetes mellitus type 2, cardiomyopathy, and hyperlipidemia. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, had memory problems and required limited supervision and oversight for most Activities of Daily Living (ADL). A review of the clinical record and the physician's order for May 2023 failed to reflect a physician's orders for the resident's Advanced Directive wishes. A review of the current physician's orders for May 2023 failed to reflect a physician's order of the resident's code status signed by the physician's orders. A review of the clinical record 5/24/23 at…

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 #32) reviewed for grievances, the facility failed to educate the staff regarding the resident's resolution to be out bed for recreational activities. The findings include: Resident #32's diagnoses included Depressive Episodes, Heart Failure, Chronic Kidney Disease stage 3. The Resident Care Plan (RCP) for ADL's related to immobility and weakness dated 5/19/22 included interventions to assist with bathing, dressing, hygiene as ordered, to assist with transfers and ambulation as ordered and to provide Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) consults as ordered. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #32 as cognitively intact and required extensive 2-person physical assist for bed mobility and transfers. The assessment also identified the resident required extensive one person assist for personal hygiene. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 residents( Resident # 39) reviewed for an allegation of mistreatment, the facility failed to ensure the resident was free from neglect. The findings included: Resident # 39 was admitted on [DATE]. The resident's diagnoses included anxiety disorders, right femur fracture, chronic kidney disease, hypertension, chronic pain, and muscle weakness. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive one-person physical assistance for bed mobility, toileting, personal hygiene and noted non-ambulatory. Additionally, the assessment identified no resistance to care and at risk for pressure ulcer but no pressure ulcer. A review of the grievance file dated 10/22 to 2/23 failed to identify any care concerns expressed by the resident and family members or conservatory. A review of the nurse's notes and social services note dated 10/22/23 to 2/2023 failed 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 clinical record reviews, review of facility documentation and staff interviews for 3 of 6 residents reviewed for abuse/ neglect (Resident # 36 and Resident # 39), the facility failed to report an allegation of neglect timely to the state agency and for (Resident #55), the facility failed to ensure the resident was free from neglect. The findings included: 1. Resident #36's diagnoses included generalized anxiety disorder, unspecified abnormalities of gait and mobility, and need for assistance with personal care. The admission Minimum Data Set assessment dated [DATE] identified Resident #36 as moderately cognitively impaired and required a one-person physical assist with bed mobility, transferring and toileting. The Resident Care Plan dated 5/5/23 identified Resident #36 required assistance with activities of daily living and alteration in elimination. Interventions directed to provide assistance to the resident with needed care and incontinence. Interview with Resident #36 on 5/18/2023 at 10:20 AM…

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 #55) reviewed for mistreatment, the facility failed to ensure a thorough investigation was conducted following an allegation of neglect. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit) and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. The care plan dated 4/13/23 identified that Resident #55 was incontinent at times, at risk for skin breakdown, and at risk for urinary tract infection. Interventions included to provide incontinence management care as needed, provide help with elimination in a timely manner, monitor for signs and symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews and staff interview for 1 sampled for ( Resident # 23) reviewed for Preadmission Screening and Resident Review , the facility failed to accurately code the resident assessment an for 1 of 3 residents reviewed for discharge (Resident #174) the facility failed to accurately code the MDS to reflect the resident's current location. The findings included: 1 Resident #23's diagnoses included schizoaffective disorder, borderline personality disorder, and anxiety disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 as cognitively intact and required extensive assistance with bed mobility, transfers, dressing, and toilet use. The Resident Care Plan dated 7/1/2022 identified the risk of altered mood pattern, use of psychotropic drugs and sleep pattern disturbance related to anxiety. Interventions directed for a psychiatric evaluation or follow-up per Medical Doctor (MD), social work follow-up, one to one visit to address concerns or needs, report…

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 1 resident (Resident # 23) reviewed for PASSR, the facility failed to ensure completion of a PASSR level 1 and level 2 in a timely manner. The findings include: Resident # 23's diagnoses included in part, Schizophrenia, post-traumatic stress disorder and anxiety. The annual MDS assessment dated [DATE] identified Resident #23 as cognitively intact. An interview and review of the Resident # 23's clinical record on the PASSR agency site, on 5/25/2023 with Social Worker (SW) #1 indicated the most recent PASSR completed on 3/29/2022 and not approved until 4/2023. Review of Resident #23's facility census with SW#1 further indicated Resident # 23 was originally admitted on [DATE] and was discharged home then readmitted on [DATE]. While reviewing the Agency PASSR site with SW #1, she indicated Resident #23 had an emergency Level of Care approved for 7 days that was completed on 7/8/2021 which noted an outcome the facility would 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 observations, clinical record review, review of facility policy, and interviews for the only sampled resident (Resident #55) reviewed for respiratory care, the facility failed to develop a comprehensive care plan for the use of a sleep apnea device. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit) and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. Observation and interview with Resident #55 on 5/18/23 at 11:13 AM identified a Continuous Positive Airway Pressure (CPAP) device with a CPAP mask attached on the resident's bed side stand. The mask was stored uncovered. Resident #55 indicated that s/he used the CPAP sleep apnea device nightly and that the mask…

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 1 of 2 sampled resident (Resident #72) reviewed for advance directives, the facility failed to maintain medical to accurately documented per policy when Cardiopulmonary Resuscitation (CPR) was implemented to meet professional standard of practice and for 1 of 2 residents (Resident #44) who was observed during Medication Administration, the facility failed to properly identify the resident prior to administering medication . The findings included: 1. Resident #72's diagnoses included dementia, atherosclerotic heart disease, atrial fibrillation, and cerebral infarction. The Resident Care Plan dated [DATE] identified Resident #72 as a new admission and required orientation and adjustment to the facility. Interventions included one to one visit to assist the resident in making a positive adjustment, advise/provide written admission information to resident and/or responsible party and explain to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews for 1 of 1 sampled resident (Resident #62) reviewed for activities, the facility failed to ensure that activities meet the needs the resident. The findings include: Resident #62's diagnoses include cerebral infarction (stroke) with residual hemiplegia and hemiparesis, depression, and diabetes type 2. The annual MDS assessment dated [DATE] identified Resident #62 as intermittently inattentive and disorganized, totally dependent for transfers with assistance of two, required extensive assistance of two for bed mobility and dressing, extensive assistance of one for personal hygiene, supervision with assist of one for toileting and supervision and set up with assistance of one for eating. A Resident Care Plan dated 3/24/23 identified the resident's quality of life should be maintained or improved by providing activities of interest. Interventions included assessing and discussing resident's needs, interests, and ability to participate in activities of choice.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview for 1 of 2 residents (Resident # 3), the facility failed to ensure that staff consistently turn and repositioned the resident according to the plan of care. The finding include: Resident # 3's diagnoses included dementia, atrial fibrillation, anemia and osteoarthritis. The quarterly assessment dated [DATE] identified the resident moderately cognitively impaired, total dependence with ambulation and extensive two persons assistance with bed mobility, transfers, toileting and personal hygiene. Additionally, the assessment identified no pressure ulcer but at risk for pressure ulcer development with intervention to provide pressure reducing devices for chair and bed. The care plan for altered skin integrity dated 2/24/21 with revision 11/1/21. Intervention directed to ensure resident is repositioned every 2-3 hours each shift and to off load the resident's heel every shift. A review of the clinical record nurses notes and ADL flow sheets for October 2021 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, facility policy, and interviews for 1 of 1 resident (Resident# 50) who was reviewed for smoking, the facility failed to ensure that emergency fire safety supplies were available at the designated smoking area and staff was educated regarding smoking emergency procedures. failed to ensure education was provided regarding the emergency procedure. The finding include: Resident # 50's diagnoses included in part Schizophrenia, anxiety, depression, and anemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #50 had no cognitive impairment required supervision with assistance of one person for dressing and independent for eating with set up. On 5/18/2023 at 11:00 AM an observation above the door leading into the courtyard had door signage indicating that this area is a designated smoking and no oxygen allowed. A seating area and table were also noted under a gazebo with a closed smoking/butt containment unit. An observation of smoking at 11:00 AM on 5/18/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, policy review and staff interviews for 1 of 1 resident (Resident #10) reviewed for indwelling urinary catheter, the facility failed to ensure the resident's urinary drainage bag was properly placed during a transfer. The findings include: Resident #10's diagnoses included quadriplegia, neuromuscular dysfunction of bladder, history of urinary tract infections, diabetes mellitus and peripheral vascular disease (blood circulation disorder). The quarterly MDS assessment dated [DATE] identified Resident #10 as alert and oriented and totally dependent with two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further identified Resident #10 required extensive assistance of one person for eating. A Resident Care Plan dated 2/24/23 identified the resident at risk and has a history of urinary tract infections secondary to urinary SP (suprapubic) tube. Interventions included assessing urine output, monitoring for temperatures, SP tube care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility policy and interviews for 1 sampled resident (Resident # 7) reviewed for nutrition, the facility failed to consistently monitor the resident's weights according to policy and plan of care. The findings included: Resident #7's diagnoses included major depressive disorder, dysphagia, and type two diabetes mellitus. The admission Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired and independent with eating and drinking. The Resident Care Plan dated 11/16/22 identified a low concentrated sweets diet of regular texture, an unstageable heel wound and needed assistance with activities of daily living related to weakness and impaired mobility. Interventions directed to assist with eating as ordered, provide dietary consult and evaluation as needed and monitor dietary intake as ordered. A physician's order dated 11/3/22 directed to weigh on admission, then continue to weigh resident for four consecutive weeks post admission, 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, clinical record review, review of facility policy, and interviews for the only sampled resident (Resident #55) reviewed for respiratory care, the facility failed to ensure a physicians order for a sleep apnea device and failed to ensure appropriate storage of a sleep apnea device mask. The findings include: Resident #55's diagnosis included anxiety, morbid obesity, osteoarthritis, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #55 was cognitively intact (no cognitive deficit) and required the extensive assistance of 2 staff with bed mobility, the assistance of 1 staff with toilet use, and was occasionally incontinent of urine and frequently incontinent of bowel. Observation and interview with Resident #55 on 5/18/23 at 11:13 AM identified a Continuous Positive Airway Pressure (CPAP) device with a CPAP mask attached. The mask was uncovered and stored on the bed side stand. Resident #55 indicated that s/he used the CPAP…

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 interviews for 2 of 4 medication carts reviewed for bimonthly narcotic audits, the facility failed to ensure a systematic, routine reconciliation of narcotics in use and conduct bimonthly narcotic cart audits. The findings include: 1.a.Observations on 5/23/23 at 2:31 PM identified narcotic bimonthly audit flow sheet for North Star wing cart was missing the following audits: 2/23 (1), 3/23 (2), and 4/23 (1). b.Observation on 5/23/23 at 2:55 PM identified narcotic bimonthly audit flow sheet for South Center wing cart was missing the following audits: 2/23 (2), 3/23 (2), 4/23 (1). Interview with RN #1 DNS on 5/23/23 at 3:12 PM identified that she was responsible for bimonthly narcotic audits, which were not performed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on environmental observations, resident screening during the initial tour, review of clinical records, review of facility policy, and interviews, the facility failed to ensure safe storage of over the counter medications on the North Star Unit closet, failed to discard an expired medication in the North Star/South Center medication room, failed to discard an expired medication on the South Center medication cart and for Resident #32 and Resident #55, the facility failed to ensure safe storage and evaluation of bedside medication use. The findings included: 1. During the initial tour of the facility on 5/17/23 at 11:21 AM on the North Star unit in the hallway where residents were present, a key pad door was noted to be closed, but was able to be opened when the handle was turned allowing entrance to the closet. Multiple over the counter medications were stored inside. Interview with LPN #1 on 5/17/23 at 11:38 AM identified that the door is usually locked and believed that the key pad had been broken…

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, record reviews, staff interviews and facility policy for 2 of 2 Residents (Resident #32 and Resident #65) reviewed for dental services, the facility failed to ensure that residents received timely dental care. The findings included: 1.Resident #32's diagnoses included Gastro-Esophageal reflux, Diabetes type 2, Depression. Interview with Resident #32 on 5/18/23 at 12:05 PM identified that s/he had a missing tooth, unable to use his/her partial plate, and that she had seen a dental hygienist some time ago but had received any dental care since. A physician's order dated 2/14/23 directed consults as ordered. A Registered Dental Hygienist consultation dated 3/9/23 identified a need for follow up with the dentist for a fractured tooth and possible decay. The annual Minimum Data Set assessment dated [DATE], identified Resident #32 was cognitively intact and required extensive assistance with bed mobility and personal hygiene. The care plan dated 3/31/23 identified Resident #32 required…

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

Based on initial screening interviews, review of policy and staff interviews for 1 of 9 residents (Resident # 32), the facility failed to ensure the residents were offered snacks. The finding include: An Interview with Dietary Services Manager on 5/24/23 at 2:26 PM identified snacks and beverages are available on the cart in each resident's wing. Pudding, apple sauce, sandwiches, and ice cream are available in the day room of each wing as well. The Dietary Service Manger s further indicated snack times are set at 10:00 AM, 2:00 PM and 8:00 PM and staff have been made aware of where snacks are in kitchen for restocking. Interview with Resident #32 on 5/24/23 at 2:50 PM identified snacks are not offered to all residents. Resident #32 indicated s/he would like to be offered a snack and beverage of choice outside of lunch and dinner time. Interview with NA# 7 on 5/24/23 at 2:55 PM identified residents requested snacks during the day, and s/he offered residents a snack after breakfast and beverages during the day. NA#7 indicated s/he offered snacks and beverages daily to residents who…

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 and interview, the facility failed to maintain annual electrical service checks on Outpatient Patient Physical Therapy (OPPT) equipment. The findings include: During the tour of the physical department on 5/23/23 at 3:20 PM, the sticker on the electric stimulation and ultrasound equipment indicated the equipment was last serviced on 3/22/22. Interview with PTA#1 on 5/23/23 at 3:25 PM indicated the facility reopened its OPPT practice in February 2023 and was awaiting a patient referral prior to servicing the electrical stimulation and ultrasound equipment. PTA #1 further identified the equipment was to be serviced for electrical safety on an annual basis. Interview with DNS on 5/25/23 at 10:22 AM indicate that the electrical stimulation and ultrasound physical therapy equipment was overdue for electrical service. The DNS further indicated she would have her maintenance staff look into this matter. Although requested, facility policy regarding the servicing of electrical equipment was not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, review of facility policy and interviews for 5 of 8 residents, (Residents # 1, 32, 50, 51 and 55), the facility failed to ensure resident equipment and supplies were maintained in a clean homelike manner. The findings included: 1. Resident #1's diagnoses included depressive episodes, diabetes mellitus type 2, and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 cognition brief interview for mental status was noted with dashes (due to staff failure to complete) and noted the resident required extensive assistance for bed mobility, transferring, toileting and personal hygiene. 2. Resident #50's diagnosis included depression Unspecified, anxiety, malignant neoplasm of unspecified breast. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 was cognitively intact and required one-person physical assist for toileting and hygiene. Observations for Resident's #1 and #50 (roommates) on 5/17/23 at 3:03 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations,interviews, review of clinical records and facility policy for 5 residents observed for respiratory equipment (Resident #1, Resident #18, Resident #20, Resident #43 and Resident #57), the facility failed to ensure nasal cannulas were changed weekly. The findings include: 1. Resident #1's diagnoses included hypertension, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). A significant change Minimum Data Set (MDS) dated [DATE] identified Resident #1 was cognitively intact and required extensive assistance of 1 for dressing. The MDS further identified Resident #1 required extensive assistance of 2 for bed mobility, personal hygiene and required oxygen therapy. A Resident Care Plan (RCP) dated 1/22/21 identified a problem with alteration in respiratory status related to COPD and respiratory failure. Interventions included to administer oxygen according to physician's order. A physician order dated 4/7/20 and updated through 2/10/21 directed to change oxygen tubing…

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 in the Dietary department, staff interviews and review of facility policy, the facility failed to ensure Dietary staff performed hand hygiene according to infection control standards and failed to ensure food contact surfaces were sanitized with the appropriate solution. The findings include: 1. Observation during a tour of the Dietary Department with [NAME] #1 (who was covering for the Food Service Supervisor) on 2/3/21 at 10:05 AM identified Dietary Aide (DA) #1 touched the front of her face mask with her ungloved right hand. Additionally, DA #1 picked up a knife with her right unwashed hand (that had just been in contact with her face mask) and proceed toward the ham to cut the ham, without the benefit of hand washing. Surveyor intervened and stopped DA #1. Interview with DA #1 at that time identified she did not was her hands after she touched her face mask because she was not aware she needed to perform hand hygiene after touching the mask. Interview with [NAME] #1 on 2/3/21 at 10:10 AM identified DA #1 should have washed her hands immediately after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #214) reviewed for accidents, the facility failed to assess Resident #214 to safely self-administer prescribed eye drops and topical medications. The findings include: Resident #214 was admitted to the facility on [DATE] with diagnoses that include COVID-19, generalized anxiety disorder and rhabdomyolysis. Physician's order dated 1/28/21 identified an order for Lotrisone Cream 1-0.05%, apply to left leg every day shift topically for venous stasis and Timolol Maleate Solution 0.25%, install one drop in both eyes one time a day. Physician's order dated 1/28/21 identified an order for Nystatin Powder 100,000 unit/gram, apply to groin, abdominal folds topically every day and evening shift for fungal rash. A 5 day Medicare Minimum Data Set, dated [DATE] identified Resident #214 was cognitively intact and required limited assistance of one-person physical support for personal hygiene. 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 review of the clinical record, review of the facility documentation, and interviews for one of one sampled residents reviewed for a specific care request (Resident #314), the facility failed to honor Resident #314's request to have only female staff provide personal and incontinent care. The findings include. Resident #314's diagnoses included COVID-19, acute respiratory failure, and congestive heart failure. An admission Minimum Data Set, dated [DATE] identified that Resident #314 was moderately cognitively impaired and required extensive assistance of two for bed mobility. Interview with Licensed Practical Nurse (LPN) #4 on 2/8/21 at 1:00 PM indicated that she admitted Resident #314 on 1/15/21 and Resident #314 requested that only female Nurse Aides (NA's) provide personal/incontinent care while Resident #314 resided in the facility. LPN #4 further indicated that she had verbally informed the next shift during report of Resident #314's request to have only female NA's provide personal/incontinent…

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 the facility documentation, interviews, and review of policy and procedures for one of three residents reviewed for mistreatment (Resident #314), the facility failed to develop an initial comprehensive baseline care plan for a resident who requested to have only female staff provide personal/incontinent care. The findings include. Resident #314's diagnoses included COVID-19, acute respiratory failure, and congestive heart failure. An admission Minimum Data Set, dated [DATE] identified that Resident #314 was moderately cognitively impaired and required extensive assistance of two for bed mobility. Interview with Licensed Practical Nurse (LPN) #4 on 2/8/21 at 1:00 PM indicated that she admitted Resident #314 on 1/15/21 and Resident #314 requested that only female Nurse Aides (NA's) provide personal/incontinent care while Resident #314 resided in the facility. LPN #4 further indicated that she had verbally informed the next shift during report of Resident #314's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and staff interviews for 1 of 3 residents (Resident #26) reviewed for pressure ulcers, the facility failed to ensure there was consistent offloading of Resident #26's heels. Resident #26 was admitted with diagnoses that included dementia with behavioral disturbance, fibromyalgia, bipolar depression, hypertension, atherosclerosis, osteoarthritis and contractures. A Resident Care Plan (RCP) dated 10/7/20 identified a problem of being dependent on staff for activities of daily living. Interventions included to transfer Resident #26 with assistance of 2 staff using a mechanical lift. The quarterly Braden Scale at Risk assessment dated [DATE] identified a significant risk for pressure ulcers. A significant change Minimum Data Set (MDS) dated [DATE] identified Resident #26 was severely cognitively impaired and did not reject care. Additionally, the MDS identified Resident #26 required extensive assistance of 1 for bed mobility, dressing, eating 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 observation, review of the clinical record, facility policy, and interviews for 1 of 5 sampled residents (Resident #28) reviewed for nutrition, the facility failed to complete weekly weights and failed to ensure the Dietician reassessed Resident #28 when he/she developed a significant weight loss. The findings include: Resident #28's diagnoses included chronic obstructive pulmonary disease, major depressive disorder, vascular dementia with behavioral disturbance and mood disorder. A quarterly Minimum Data Set, dated [DATE] identified Resident #28 was moderately cognitively impaired and required total dependence with two-person physical support for transfers and bed mobility. A Resident Care Plan (RCP) dated 12/10/20 identified a problem with requiring a therapeutic diet due to a history of diabetes and non-compliance with following dietary orders. The RCP also identified a therapeutic 10% weight loss noted in 6 months, Resident #28 recently working with Occupational (OT) and Speech Therapy (SLT)…

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

Based on observations, clinical record review, facility policies, and staff interviews for 1 of 3 residents observed during medication administration (Resident #46) the facility failed to ensure the correct dose of a medication was received from the pharmacy according to the physician's order. The findings include: Resident # 46's diagnoses included acute kidney failure, hypertension, and cerebral infarct. A physician's order dated 1/6/21 identified a reduction of Sertraline (an antidepressant medication) from 50 mg daily to 25 mg daily. A Resident Care Plan (RCP) dated 1/8/21 identified a problem with depression. Interventions included to allow Resident #46 to express feelings, allow time to express him/herself, medications as ordered, psychology consult as indicated, and report ineffectiveness of medications. Observation of medication administration on 2/8/21 at 9:10 AM with LPN #1 identified LPN #1 breaking a Sertraline 50 mg tablet in half with gloved hands. LPN #1 was unable to identify the facility policy on breaking medication in half and identified the medication was scored…

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, interview and review of facility policy, the facility failed ensure IntraVenous (IV) solutions stored in the Emergency Box (E-box) were not expired. The findings include: On [DATE] at 11:50 AM, an observation of the Emergency Medication Box (E-Box) with RN #1 identified the E-Box contained two 50 milliliters (ml) IV bags of Normal Saline with an expiration date of [DATE] (10 months past the expiration date), four 50 ml IV bags of D5W with an expiration date of [DATE] (7 months past the expiration date), and one 1000 ml IV bag of Potassium Chloride 20 Milliequivalents in Dextrose and Normal Saline with an expiration date of [DATE] (3 months past the expiration date). Interview with RN #1 on [DATE] at 12:00 PM identified that she was responsible to check the IV E-box weekly. She further stated that Nursing Supervisors were also responsible to check the IV E-box and that there was not a process in place to track if weekly checks were completed. She additionally identified the IV E-box had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review for 1 of 3 sampled residents (Resident #40) reviewed for pressure ulcers, the facility failed to ensure interventions to prevent a pressure ulcer were documented as completed. The findings include: Resident #40's diagnoses included dementia without behavioral disturbances, peripheral vascular disease, iron deficiency anemia secondary to blood loss (chronic) and COVID-19. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #40 had moderately impaired cognition with short and long term memory deficits, required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. The MDS further identified that Resident #40 was frequently incontinent of bowel and bladder, was at risk for pressure ulcer development and did not have a history of unhealed pressure ulcers. A Resident Care Plan dated 11/19/20 identified that Resident #40 tested positive for COVID-19. Interventions included antibiotic therapy, monitor temperature and…

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

Based on observations, interviews, review of facility documentation and policy for 2 of 4 residents (Resident #9 and Resident #44) reviewed for transmission based precautions, the facility failed to ensure Personal Protective Equipment was removed before exiting a resident room and failed to ensure hand hygiene was performed. Resident #9's diagnoses included COVID-19 exposure and dementia. A Resident Care Plan dated 2/4/21 identified a problem of being potentially exposed to COVID-19. Interventions included to observe Resident #9 for signs and symptoms of COVID-19 and directed a 14 day quarantine to include droplet precautions and staff were required to use full PPE. Resident #44 diagnoses included dementia and Parkinson's disease. A Resident Care Plan dated 2/4/21 identified a problem of being potentially exposed to COVID-19. Interventions included to observe Resident #44 for signs and symptoms of COVID-19 and directed a 14 day quarantine to include droplet precautions and staff were required to use full PPE. Resident #9 and Resident #44 were roommates. A sign posted on the room…

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.