New London Sub-Acute And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of seven (7) sampled residents (Residents #1, #2 and #6) who were reviewed for medication administration, the facility failed to notify the provider of medication omissions when the medications were not available. The findings include: 1. Resident #1's diagnoses included malignant neoplasm of the ovaries, schizoaffective disorder, anxiety, delusional disorders, restlessness and agitation and depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of zero (0) out of fifteen (15) indicating memory recall deficits. The Resident Care Plan dated 4/28/25 identified Resident #1 received hospice services for a diagnosis of ovarian cancer. Interventions directed to administer medications per the physician's orders. a. A physician's order dated 1/11/25 directed to administer morphine sulfate oral solution 100 milligrams (mg) in 5…

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, facility policy and interviews for two (2) of five (5) nurse aides reviewed for performance evaluations, the facility failed to ensure annual performance evaluations were completed. The findings include:1. NA #2 had a hire date of 7/13/23 and was due to have his/her annual performance review in 2024 and 2025, however documentation of the performance reviews was not available for review and could not be located. 2. NA #1 had a hire date of 4/30/24, had a probationary employee evaluation on 6/30/24 and was due to have his/her annual performance review on 6/30/25, however documentation of his/her performance review was not available for review in his/her personnel file and could not be located. Interview with the Administrator on 8/21/25 at 1:26 PM identified annual performance evaluations are to be done yearly but that he was unable to locate the performance evaluations for NA #1 and #2. Interview with Human Resources on 8/21/25 at 1:31 PM identified NA #1's annual performance evaluation for 2025 was due on 6/30/25 but that it had been…

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, facility policies, and interviews for facility QAPI review, the facility failed to maintain compliance with deficiencies previously cited. The findings include:A complaint survey was completed on 6/30/25 with findings related to significant medication errors and failures in notifying the provider. The facility Plan of Correction (PoC) identified audits would be conducted for three (3) months or until substantial compliance with QAPI oversight. Resident record review identified three (3) residents (Residents #1, 2 and 6) who were not administered scheduled medications, and the provider was not notified of the missed administrations. Resident record review identified three (3) residents (Residents #4, #6 and #15) who were administered scheduled medications late and the provider was not notified of the late administrations. Review of the 7/16/25 QAPI meeting identified the meeting included a review of the 6/30/25 survey results, including medication pass timeliness and noted that audits were ongoing and showed ongoing compliance improvement. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) who were reviewed for an allegation of physical abuse, the facility failed to ensure the resident was supervised when ambulating within the facility per the plan of care to prevent a resident-to-resident altercation. The findings include:Resident #3's diagnoses included Alzheimer's disease, history of falls, muscle weakness, delusional disorder, anxiety disorder and major depressive disorder. The significant change Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview for Mental Status (BIMS) of four (4) out of fifteen (15) indicating poor memory recall, required moderate assistance for bed mobility and supervision assistance with transfers and ambulating. The Resident Care Plan (RCP) dated 5/30/25 identified that Resident #3 has limited physical mobility related to Alzheimer's disease and gait abnormalities. Interventions…

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

Based on clinical record reviews, facility documentation, facility policies, and interviews, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include:The facility administration failed to: Ensure continued compliance with the plan of correction from a prior survey to ensure medications were administered per physician's orders. Ensure the residents were administered scheduled anxiety and narcotic pain medications. Ensure medications were refilled prior to exhausting the supply and ensure medications were delivered to the facility. Ensure the Advanced Practice Registered Nurse (APRN) was notified of medication omissions. Ensure annual performance evaluations were completed when due. Ensure the clinical record was complete and accurate. Please cross reference F580, F730, F755, F760, F842 and F865. Based on the deficiencies during the survey, immediate jeopardy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) reviewed for medication administration, the facility failed to ensure complete and accurate documentation of medications in the Medication Administration Record (MAR). The findings include:1. Resident #1's diagnoses included malignant neoplasm of the ovaries, schizoaffective disorder, anxiety, delusional disorders, restlessness and agitation and depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of zero (0) out of fifteen (15) indicating memory recall deficits. The Resident Care Plan dated 4/28/25 identified Resident #1 received hospice services for a diagnosis of ovarian cancer. Interventions directed to administer medications per the physician's orders. a. A physician's order dated 1/11/25 directed to administer morphine sulfate oral solution 100 milligrams (mg) in 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation and interviews for eleven (11) of eleven (11) residents (Resident #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, and #24) reviewed for physician's orders, the facility failed to ensure residents' orders were reviewed and signed by the physician monthly. The findings include:1. Resident #14 was admitted to the facility on [DATE].Review of physician orders identified medical orders were not reviewed and signed on 5/1/25 or 6/1/25 in accordance with facility practices.2. Resident #15 was admitted to the facility on [DATE].Review of physician orders identified medical orders were not reviewed and signed on 6/1/25 in accordance with facility practices.3. Resident #16 was admitted to the facility on [DATE].Review of physician orders identified medical orders were not reviewed and signed on 5/1/25 or 6/1/25 in accordance with facility practices.4. Resident #17 was admitted to the facility on [DATE].Review of physician orders identified medical orders 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, facility policy and interviews for one (1) of eleven (11) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the provider was notified of a change in condition when it was identified that the resident was having difficulty swallowing. The findings include:Resident #1 's diagnoses included dementia without behavioral disturbances, epilepsy (a brain disease where clusters of nerve cells signal abnormally causing a seizure), type 2 diabetes mellitus and adult failure to thrive.The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), was dependent on staff for eating, bed mobility and transfers and identified Resident #1 exhibited no signs and symptoms of a swallowing disorder.The Resident Care Plan (RCP) dated 6/7/25 identified Resident #1 had impaired cognitive functioning/dementia. Interventions included administering…

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 two (2) of four (4) residents (Resident #4 and #7) reviewed for neglect, the facility failed to ensure allegations of neglect were reported to the State Agency timely. The findings include:1. Resident #4's diagnoses included heart failure, chronic pain and type II diabetes mellitus.The Resident Care Plan (RCP) dated 12/23/2024 identified Resident #4 had diabetes mellitus, chronic pain, altered cardiac status and an implanted cardiac defibrillator (an implanted device under the skin that corrects life threatening heart rhythms). Interventions included administering medications as ordered by the physician and monitoring and documenting side effects and effectiveness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.Interview with Resident #4 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of four (4) residents (Resident #4 and #7) reviewed for neglect, the facility failed to ensure an investigation was completed timely and thoroughly following an allegation of neglect. The findings include: 1. Resident #4's diagnoses included heart failure, chronic pain and type II diabetes mellitus. The Resident Care Plan (RCP) dated 12/23/2024 identified Resident #4 had diabetes mellitus, chronic pain, altered cardiac status and an implanted cardiac defibrillator (an implanted device under the skin that corrects life threatening heart rhythms). Interventions included administering medications as ordered by the physician and monitoring and documenting side effects and effectiveness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.…

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 four (4) sampled residents (Resident #3) who had an order for a leave of absence with a responsible party only and had left the facility without informing the staff, the facility failed to ensure the front entrance door was secured or monitored to prevent the resident from leaving the facility unattended. The findings include: Resident #3's diagnoses included dementia, depression, and convulsions. A physician's orders dated 4/1/25 directed the resident may go on a leave of absence with a responsible party only and supervision for transfers and ambulation in the room and hallways. The Elopement Risk Assessment conducted on 5/15/25 identified Resident #3 was not at risk of elopement. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had poor short- and long-term memory recall, had not exhibited behaviors of wandering or elopement and ambulated without a device. The Resident Care Plan…

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 policy for 1 of 2 sampled residents (Resident #43) reviewed for care planning, the facility failed to allow a resident to participate in Resident Care Conferences (RCC). The findings include: Resident #43's diagnoses included dementia, hypertensive heart disease with heart failure, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment, required maximal assistance for his/her personal hygiene and chair/bed to chair transfers, and used a manual wheelchair. The Resident Care Plan (RCP) dated 2/28/25 identified Resident #43 was dependent on staff for meeting his/her emotional, physical, and social needs related to physical limitations. Interventions included inviting the resident to scheduled activities, inviting the resident to attend special events, and providing the resident with materials for individual…

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, and review of facility policy for 6 of 6 sampled residents (Resident #2, Resident #7, Resident #43, Resident #70, Resident #79, and Resident #82) reviewed for dignity, the facility failed to provide clean bed and bath linens that were in good condition and in sufficient quantity for performing resident care tasks, and for the environment, the facility failed to ensure a safe and secured area on a locked, memory care unit. The findings include: 1a. Resident #2's diagnoses included chronic obstructive pulmonary disease, heart failure, and type 2 diabetes. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was cognitively intact, dependent with showering and bathing, required set-up assistance with personal hygiene, and was independent with ambulation. An interview on 3/24/25 at 9:34 AM with Resident #2 identified the facility ran out of washcloths quite often, but he/she was not sure how many times a week there were no washcloths available. A lack 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 observations, review of the clinical records, facility policy, and interviews for 11 of 40 sampled residents (Resident #12, Resident #23, Resident #33, Resident #39, Resident #45, Resident #50, Resident #57, Resident #59, Resident #84, Resident #92 and Resident #254) reviewed for a placement on a secured memory care unit, the facility failed to identify the clinical criteria for the unit, failed to document the resident or representative was included in the decision for placement on the unit, failed to ensure a physician order for placement on the unit, failed to assess for initial placement on the unit, failed to reassess for continued appropriate placement on the unit, and failed to document that information for independent egress had been provided. The findings include: 1. Resident #12's diagnosis included Parkinson's disease, dementia and emphysema. The annual Minimum Data Set assessment dated [DATE] identified Resident #12 was severely, cognitively impaired and required substantial/maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record reviews, facility documentation, facility policy and interviews for 4 of 6 sampled residents (Resident #42, Resident #43, Resident #45, and Resident #84) reviewed for abuse for Resident #84 and #42, and Resident #84 and #45, the facility failed to ensure resident to resident physical mistreatment was reported to state protective services, for Resident #84 and Resident #43, the facility failed to report resident to resident physical mistreatment to state protective services and failed to report the allegation timely to the state agency, and for Resident #43 for a staff to resident allegation of physical mistreatment, failed to report the allegation to state protective services and failed to report the allegation to the state agency. The findings include: 1. Resident #84 had diagnoses that included dementia and delusional disorders. The quarterly MDS assessment dated [DATE] identified Resident #84 had long and short term memory problems with moderately impaired cognition,…

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 2 of 3 sampled residents (Resident #20 and Resident #47) reviewed for medication administration, the facility failed to ensure that the medication error rate was less than 5% and for 1 of 5 sampled units, Pavillion Unit, for Residents #1, #24, #37, #79, #65, #60, #45, #72, #31, #78, and # 27, the facility failed to ensure medications were administered at the correct time per the physician's orders. The findings include: 1. Resident #20's diagnoses included paranoid schizophrenia, anxiety, acute angle closure glaucoma, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 as being cognitively intact. Physician's orders dated 1/10/25 directed to administer Coreg 12.5 mg (milligrams) 1 tablet (tab) 2 times a day and hold for a heart rate less than 50, Pilocarpine Solution 1% 1 eye drops to both eyes 3 times a day, and Trazadone HCL 100 mg give one tab 2…

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 tour of the Dietary Department, staff interview and facility policy, the facility failed to ensure kitchen equipment was maintained in sanitary manner, failed to ensure open food items were dated to include dates opened/expired/use by, and failed to recheck temperatures of a resident's reheated food. The findings include: 1. Tour of the Dietary Department kitchen on 3/17/25 at 10:15 AM with the Food Service Director (FSD) identified the following: a. A heavy accumulation of white and brown debris/lint on the juice machine vent located on the upper front section of the chiller/juice machine. b. A heavy accumulation of congealed black and brown burnt residue on the stove, and surrounding surfaces. c. A large amount of white and brown congealed buildup on the conventional oven doors. An interview on 3/17/25 at 10:30 AM with the FSD identified that kitchen staff only clean the outside/surface of the juice machine, but the facility use a contracted company for a comprehensive cleaning of the machine every 3 months and as needed. The FSD indicated that the company last serviced…

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 interviews, record review, and policy review, the facility failed to provide all staff with abuse and neglect training and failed to develop staff training for abuse that included federal components for abuse education. The findings included: 1. A review of abuse and neglect training documentation identified education was provided for new hires during orientation and during in-services that had occurred in May 2024, September 2024 and March 2025. Review of the sign-in sheets identified 31 employees had not received any abuse and neglect training (19% of the facility employees). Interview with the Administrator on 3/27/25 at 2:03 PM identified that the facility policy training program for abuse and neglect training directed all staff were in-serviced annually. Additionally, the Staff Development nurse was responsible for ensuring all employees received the mandatory in-service training on neglect and abuse. Interview and in-service signature record review with the Staff Development Nurse on 3/27/25 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.

Based on interviews, facility documentation review, and facility policy, the facility failed to develop a compliance and ethics program and failed to provide staff with compliance and ethics training. The findings included: Interview with the Administrator, Regional Registered Nurse (RN) #4, and Regional Registered Nurse (RN) #8 on 3/27/25 at 9:46 AM identified the facility did not have a compliance and ethics program and also did not have a compliance and ethics policy. It was further identified that compliance and ethics training is not part of new hire orientation or annual training. RN #4 and RN #8 stated there was a Code of Conduct policy, but this Code of Conduct is not communicated to the entire facility staff. The DNS was unavailable for interview. Although requested, a policy on Compliance and Ethics was not provided. The Code of Conduct policy failed to include the basic components of an ethics and compliance program including but not limited to: identification of a compliance officer or committee; how and who to report ethical concerns to; secure, confidential, and timely…

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 the clinical record, facility documentation, and facility policy for 3 of 6 residents, (Resident #42, Resident #43, and Resident #84) reviewed for abuse, for Resident #42 and #84, the facility failed to ensure that a resident-to-resident altercation, and for Resident #43 that a staff-to-resident altercation, involving physical mistreatment was properly reported according to policies, failed to implement policies to ensure a resident was protected from abuse, and failed to establish abuse procedures for coordination with the Quality Assurance and Performance Improvement (QAPI) program. The findings include: 1.a.Resident #42 had diagnoses that included dementia and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #42 had severe cognitive impairment with a Brief Interview of Mental Status, BIMS of 0 and was independent with ambulation. The Resident Care Plan (RCP) dated 10/23/24 identified Resident #42 had impaired thought process, and an ADL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #59) reviewed for unnecessary medications, the facility failed to review and revise the Resident Care Plan (RCP). The findings include: Resident #59's diagnoses included dementia, congestive heart failure, and bilateral sensorineural hearing loss. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had severe cognitive impairment, required set-up assistance with eating, required supervision with personal hygiene, and was independent with ambulation. The Resident Care Plan (RCP) in effect on 3/24/25 identified Resident #59 had a communication problem related to being severely hard of hearing. Interventions included discussing with the resident and his/her family concerns or feelings regarding communication difficulties and encouraging the resident to continue stating his/her thoughts. A review of social service progress notes and Resident 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 observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #4) reviewed for pressure ulcers, the facility failed to turn and reposition a resident with a pressure ulcer according to the physician's order. The findings include: Resident #4's diagnoses included dementia, generalized muscle weakness, anxiety and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment, was dependent on staff for toileting hygiene, personal hygiene, and transfers, and required maximum assistance for bed mobility. The MDS identified that Resident #4 had impairment on both sides of the upper and lower extremities and was always incontinent of urine and bowel. Additionally, the MDS identified that Resident #4 was at risk of developing pressure ulcers and had a pressure reducing device for bed, but did not have a current…

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 1 of 2 sampled residents (Resident #39) reviewed for positioning and mobility, the facility failed to ensure a pelvic positioning belt was applied per the physician's order. The findings include: Resident #39's diagnoses included Parkinson's disease, vascular dementia, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #39 was severely cognitively impaired, dependent with toileting, and required partial/moderate assistance with bed mobility and transfers. A Morse fall scale dated 1/20/25 identified Resident #39 had a history of falling and was a high risk for falls. The Resident Care Plan dated 3/3/25 identified Resident #39 was non-ambulatory, required assistance of 1 for transfers, and was a fall risk. Interventions included providing assistive and adaptive devices as ordered and to ensure proper positioning when sitting in a chair. An Occupational Therapy (OT #1) note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #57) reviewed for accidents and hazards, the facility failed to provide an assistive device and supervision with ambulation per the physician's order for a resident who was a high fall risk and for 1 of 3 sampled residents (Resident #84) reviewed for dementia care, the facility failed to provide supervision with ambulation at mealtime per the physician's order for a resident with dementia and dysphagia. The findings include: 1. Resident #57's diagnoses included dementia, muscle weakness, unsteadiness on his/her feet and a history of falling. A Morse fall scale evaluation dated 2/7/25 identified Resident #57 used an ambulatory aide (walker) and was a high risk for falling. A Physical Therapy (PT) evaluation and plan of treatment dated 2/7/25 identified Resident #57 was a fall risk and required supervision with a 2 wheeled walker as an assistive device. 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 interviews, record review, and facility policy for 1 of 3 sampled residents (Resident #96) reviewed for pressure ulcers, the facility failed to provide adequate hydration to a resident with a potential for a fluid deficit. The findings included: Resident #96's diagnoses included pressure ulcer of the sacral region, neuromuscular dysfunction of the bladder, and congestive heart failure (CHF). A Dietary Nutritional admission assessment dated [DATE] identified Resident #96's fluid intake goal was 1400-1700 ml per 24 hours. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #96 was cognitively intact, required set up for eating/drinking, and was dependent on staff for hygiene. Additionally, the MDS identified Resident #96 was on a diuretic (a medication that promotes fluid loss through urination). The Resident Care Plan dated 2/13/25 identified Resident #96 had a potential for a fluid deficit related to congestive heart failure, diuretic therapy, and bilateral lower extremity…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #50) reviewed for respiratory care, the facility failed to ensure a physician's order was in place when administering continuous oxygen. The findings include: Resident #50's diagnoses included pneumonitis, Congestive Heart Failure (CHF), pleural effusion, and resolved bronchitis and hypoxia (low oxygen). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 was severely cognitively impaired and was dependent with bed mobility, toileting, and transfers. The Resident Care Plan dated 1/5/25 identified altered cardiovascular status and anemia. Interventions included monitoring for shortness of breath and deterioration of respiratory status, monitor vital signs, and administer medications as ordered. Review of Resident #50's March 2025 Treatment Administration Record (TAR) identified a physician's order, beginning on 2/24/25 for Oxygen 0 to 4…

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 the only sampled resident, (Resident #66), reviewed for hemolytic treatment, the facility failed to ensure appropriate communication occurred between the hemolytic treatment center and the facility. The findings include: Resident #66's diagnoses included end stage renal disease, dependence on hemolytic treatment, and anemia. A physician's order dated 1/19/25 directed to send Resident #66 to hemolytic treatments 3 times per week. On the resident's return, staff were to record the resident's hemolytic center weight from the communication book to ensure consistency. The admission Minimum Data Set assessment dated [DATE] identified Resident #66 was cognitively intact and required partial moderate assistance with personal hygiene, dressing, bed mobility, transfer, and toileting, and required set up assistance with eating. Additionally, Resident #66 was receiving hemolytic treatment. A. The Resident Care Plan dated 1/25/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews for 2 of 6 sampled residents reviewed for accidents (Resident #57 and Resident #84), the facility failed to ensure staff competency related to electronic medical record (EMR) use. The findings include: 1. Resident #57's diagnoses included dementia, muscle weakness, unsteadiness on feet and a history of falling. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 was severely cognitively impaired and required supervision or touch assistance for transfers, toileting, and bed mobility. The MDS indicated use of a mobility device/walker. The Resident Care Plan dated 3/2/25 identified Resident #57 had limited physical mobility, a self-care performance deficit, and a risk for falls. Interventions included ambulation and transfers with supervision and a 2 wheeled walker in the room and hallways, provide supportive care and assistance with mobility as needed, and assistance of 1 for bathing, dressing, and toileting. An interview, observation, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #66) reviewed for hemolytic treatments, the facility failed to provide appropriate packaging for medication being sent with a resident for hemolytic treatments and failed to assess a resident for self-administration of medication. Additionally, the facility failed to ensure narcotic keys for the medication cart were safely kept with the charge nurse, failed to ensure bimonthly narcotic audits were conducted, and failed to ensure narcotics for destruction in the Director of Nursing (DNS) office were stored appropriately. The findings include: 1. Resident #66's diagnoses included end stage renal disease, dependence on hemolytic treatment and anemia. A Physician's order dated 1/17/25 directed to send hydralazine (lowers blood pressure) 100 milligrams 1 tablet on Monday, Wednesday and Friday with Resident #66 to his/her hemolytic treatments. A physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 11 sampled residents (Resident #48) observed in the east dining area during meals, the facility failed to provide adaptive equipment as identified on the meal ticket. The findings include: Resident #48's diagnoses included Parkinson's disease, severe dementia with anxiety, and adult failure to thrive. The annual Minimum Data Set assessment dated [DATE] identified Resident #48 was severely cognitively impaired and required substantial maximum assistance with eating and was dependent on staff for personal hygiene, dressing, toileting, bed mobility, and transfer. The Resident Care Plan dated 1/23/25 identified Resident #48 had a dementia diagnosis which could affect appetite/intake, has a history of significant weight loss, is taking psychotropic medications which can affect appetite/intake, and used adaptive equipment to help with independent eating. Interventions included diet as ordered, provide…

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, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and to ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include: The facility administration failed to: Ensure the State Agency was notified, in a timely manner, of reportable events Ensure allegations of abuse were investigated timely and thoroughly Ensure staff accused of abuse were removed from the schedule timely Ensure residents were provided with an environment free from involuntary seclusion. Ensure medications were administered timely and according to professional standards. Ensure narcotics were properly stored and bimonthly narcotic audits were performed. Ensure the clinical record was complete and accurate. Ensure staff received adequate training per federal guidelines. Ensure residents were provided with a sufficient number of clean bed and bath linens. Ensure care plans…

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 1 of 3 sampled residents (Resident #4) reviewed for pressure ulcers, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn prior to personal care, for 1 of 5 sampled resident units (for Resident #96, Resident #404, and Resident #407) reviewed for infection control practices, for Resident #96, failed to implement the appropriate precautions for an active Multi-Drug Resistant Organism (MDRO) and failed to perform appropriate hand hygiene during wound care for Resident #404, failed to ensure appropriate PPE was worn upon entering the resident's room and failed to implement appropriate precautions for an active MDRO, and for Resident #407 failed to ensure appropriate hand washing for a resident with an active MDRO. The findings include: 1. Resident #4's diagnoses included dementia, generalized muscle weakness, anxiety, and hypertension. The quarterly Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was safely transferred in the mechanical lift resulting in minor injuries on two (2) separate occasions. The findings include: Resident #1 had diagnoses including morbid obesity, chronic pain, muscle weakness, difficulty in walking, localized edema to the bilateral lower extremities and depression. The Resident Care Plan (RCP) dated 2/17/22 identified that Resident #1 had an alteration in Activities of Daily Living (ADLs) related to difficulty walking and generalized weakness post hospitalization for dyspnea (shortness of breath), pulmonary edema (excess fluids in the lungs), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and lymphedema (swelling cause by a lymphatic system blockage) with interventions that included providing assistance as needed and Physical Therapy (PT) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for wounds, the facility failed to ensure the resident care plan identified an actual skin impairment that required treatment. The findings include: Resident #1's diagnosis included end stage renal disease (ESRD), sepsis, diabetes mellitus, heart failure and history of cellulitis to the left lower limb. Nursing Clinical admission Documentation dated 10/7/23 identified Resident #1 had no skin lesions. A Nurse's note dated 10/10/23 completed by Licensed Practical Nurse, LPN #1 identified Resident #1 had four (4) soft scabbed areas to the left shin with no drainage noted. The shin was swollen,and the peri wound was red. The Advanced Practice Registered Nurse (APRN) was updated, and a new treatment was prescribed for Medi honey to the scabbed areas followed by non-woven gauze with Kling (wrap) to secure. A physician's order dated 10/10/23 directed to apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who were reviewed for wounds, the facility failed to ensure a wound assessment or evaluation was completed for a resident who developed a skin impairment. The findings include: Resident #1's diagnosis included end stage renal disease (ESRD), sepsis, diabetes mellitus, heart failure and history of cellulitis to the left lower limb. Nursing Clinical admission Documentation dated 10/7/23 identified Resident #1 had no skin lesions. A Nurse's note dated 10/10/23 completed by Licensed Practical Nurse, LPN #1 identified Resident #1 had (4) soft scabbed areas to the left shin. No drainage was noted. The shin was swollen, peri wound red. The Advanced Practice Registered Nurse (APRN) was updated, and a new treatment was prescribed for Medi honey to the scabbed areas followed buy non-woven gauze with Kling (wrap) to secure. A physician's order dated 10/10/23 directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for a change in condition, the facility failed to ensure complete neurological assessments were completed timely for a resident after an unwitnessed fall. The findings include: Resident #1's diagnoses included diabetes mellitus, dementia, seizures, anxiety disorder, and depression. The annual Minimum Data Set (MDS) form dated 5/10/2023 identified Resident #1 had severe cognitive impairment and was independent for bed mobility, transfers, and locomotion. The Resident Care Plan (RCP) dated 5/17/2023 identified an alteration in ADLs performance. Interventions directed to assist as needed and provide assistive/adaptive device: walker/wheelchair. A reportable event form and investigation dated 8/5/2023 at 11:30 PM identified Resident #1 was observed on the floor in his/her room and was lethargic, weak, and confused, and indicated he/she was going to the bathroom. RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews for one of one resident (Resident # 65) reviewed for dementia care, The facility failed to ensure that the resident and or the resident representative was informed in advance of the risk and benefits of a psychotropic medication and failed to obtain a consent before initiation of a psychotropic medication. The findings include. Resident # 65's diagnosis included adjustment disorder with mixed anxiety and depressed mood, Post-Traumatic Stress Disorder (PTSD), unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and suicidal ideation. A psychiatric consultation note dated 3/18/2021 directed to add Trazadone(antidepressant) 25 Milligrams (MG) every 6 hours as needed for anxiety/sleep. A physician's order dated 6/18/2021 directed the use of Trazadone 75 MG at bedtime. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 was moderately cognitive impairment and required set up for bed mobility, eating and showering. The 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 review, review of facility documentation and interview for 1 of 2 sampled residents (Resident #36), the facility failed to provide evidence that recommendations were followed in accordance with professional standards. the findings included: Resident #36 was admitted on [DATE] with diagnoses included transient ischemic disorder, anxiety disorder, personality disorder, adjustment disorder with depressed mood, and unsteadiness with walking. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #36 had a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicating no cognitive impairment. Resident #36 required extensive assistance of one staff member with transfers, and partial assistance of one staff member with toileting and activities of daily living (ADL). The Pre-admission Screening and Resident Review (PASRR) consult provided dated 2/8/22 identified the need for weekly individualized counseling, physical therapy (PT) and…

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

Based on observation of the kitchen, review of facility documentation, facility policy review, and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and the facility failed to ensure the dishwasher water temperatures were consistently documented and failed to ensure food was handled in accordance with infection control standards. The findings included: An observation on 10/31/21 at 10:05AM with the Food Service Director (FSD) of the kitchen identified the following: 1 A large amount of white and brown congealed buildup on the front and side of oven. 2. A large amount of brown congealed buildup behind the stove where the floor meets the wall and behind the side counter where the floor meets the wall. An interview on 10/31/22 at 10:05 AM with the FSD identified the facility used to have a contracted company who provided more comprehensive cleaning services. The facility has not utilized the cleaning company for approximately 6 months. The FSD further indicated that although the staff should have ensured the cleaning of the stove 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 Facility Assessment review, facility documentation review and interviews, the facility failed to ensure that the Facility Assessment was updated yearly. The findings include: An interview on 10/31/2022 with the Director of Maintenance who stated that he was asked to find the Facility Assessment. The Director of Maintenance further indicated he could only find the Facility assessment dated 2018. The Maintenance Director also indicated that it was the Administrator's responsibility to maintain the Facility Assessment and indicated that the old administrator left last month, and the Interim administrator (Administrator #1) last day was today. A review of the facility's Facility Assessment on 10/31/22 failed to reflect that yearly Facility Assessments had been conducted for 2020, 2021 and 2022, Interview on 10/31/2022 with Administrator #1 in the presence of Maintenance Director identified she did not know if the Facility Assessment Form presented to surveyor from 2018 was the most up to date. Administrator 1 indicated her last day was today and the new Administrator was due 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.

Based on facility documentation review, facility policy review and interviews, the facility failed to ensure the Medical Director consistently attended the quarterly QA meetings to maintain an effective and comprehensive Quality Assurance and Performance Improvement (QAPI) program. The findings include: On 11/02/22 at 12:52 PM an Interview with Administrator #2 and the Director of Nursing (DNS) during a reviewed the QAPI meeting agenda for 10/27/2022 shared minutes and meeting attendees. The DNS indicated that the Medical Director does not attend quarterly QA meetings consistently from 1/2022 to 10/27/22. She further indicated although the Medical Director does not attend all the QA meetings, she provides an update to the Medical Director of the quarterly minutes when he comes to the building. The DNS was unable to provide signature sheets from 1/2022 to 10/27/22 of the Medical Directors attendances at the QA quarterly meetings. Interview with the Medical Director on 11/2/22 at 4:00 PM identified he does not attend the scheduled QA meetings at the facility. The Medical Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of facility policy and interviews, the facility failed to document the completion of the legionella mitigation steps as per the facility plan and for 1 sampled resident ( Resident # 12) who utilized a urinary device, the facility failed to store the device in a bag to prevent the spread of infection and for 1 resident ( Resident # 35) who utilized oxygen, the facility failed to store the oxygen and label tubing in the manner that was sanitary and prevent the spread of infection and or 1 of 2 residents ( Resident # 54) reviewed for reviewed for Respiratory Care, the facility failed to ensure that appropriate infection control practices were followed for storage of respiratory equipment .The findings included: An Environmental Assessment and Procedure document dated January 2019 identified the facility posed a medium risk to promote growth of legionella and the mitigation steps in part were outlined to include: 1. Hot water storage area: hot water should be maintained at or above 140…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility policy and interviews, the facility failed to obtain written signatures for consent or refusal of required vaccinations for 5 of 5 residents) reviewed for vaccinations (Resident #21, #25, #47, #63) and for (Resident #76 the facility failed to provide documentation of screening for eligibility and education provided for pneumococcal vaccination within accordance to facility practice and policy. The findings included: 1. a. Resident #21 was admitted to the facility on [DATE]. A Preventative Health report with a run date of 11/1/22 at 3:24 PM identified that from 3/8/22 to 11/1/22, Resident #21 refused the pneumococcal vaccination on 3/14/22. The report also identified that Resident #21 had received a COVID 19 booster shot at the facility on 4/11/22. b. Resident #25 was last admitted to the facility on [DATE]. A Preventative Health report with a run date of 11/1/22 at 5:46 PM identified that from 3/7/15 to 11/1/22, Resident #25 received the influenza vaccination…

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 facility documentation, facility policy and interviews, the facility failed to ensure essential kitchen equipment was maintained in safe working condition. The findings include: Invoice for services performed dated 8/29/22 noted a problem with the control board with the display board being replaced. Recommendations were made at that time to replace the dishwasher. A quote dated 9/22/22 noted the cost of a new dishwasher. An observation on 10/31/22 at 10:05AM with the FSD identified the rinse cycle display on the high temperature dishwasher read 112 degrees. The company who services the facility dishwasher was called out after experiencing a problem with the control panel where temperature readings were displayed. The company came out and determined there was not an issue with the rinse temperatures, only in the display reading during the rinse cycle. Subsequent to surveyor inquiry, purchase order dated 11/2/22 for a new dishwasher was placed with a delivery date of 11/17/22. An interview on 11/03/22 at 1:31 PM with the Director of Maintenance identified all previous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident # 54) reviewed for skin conditions, non-pressure, the facility failed to ensure that the care plan comprehensive and individualized with goals and interventions to reflected the resident's psoriasis skin condition. The findings include: Resident #54's diagnoses included psoriasis and Type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 had no cognitive impairment and required extensive assistance of one person for bed mobility, transfer, toileting, bathing, and personal hygiene. Additionally, the assessment identified the resident was at risk for pressure ulcer but did not have any unhealed pressure ulcers. The care plan dated 8/21/2022 identified a problem due to a fungal rash to bilateral groin, interventions included : to ensure skin is clean and free from moisture and to provide treatment as ordered. The care plan further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of policy and staff interviews for 1 sample resident (Resident # 337) reviewed for infection, the facility failed to monitor the resident's Vancomycin trough level according to the professional standard when resident was receiving intravenous (IV) Vancomycin medication. The findings include: Resident #337 diagnoses included sepsis, cellulitis of left lower limb, osteomyelitis, type 2 diabetes mellitus, non-pressure chronic ulcer of other part of right foot and Methicillin susceptible staphylococcus aureus infection. The physician's order dated 10/10/22 directed to administered Vancomycin reconstitute solution 1.25 gram once a day intravenously every evening. The Resident Care Plan (RCP) dated 10/10/22 identified Resident #337 required intravenously antibiotic related to gangrene. Intervention included: administered IV antibiotic per physician ordered, follow regimen when caring for IV site and laboratory per physician order. The admission Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy and interviews, for 1 of 2 residents reviewed for pressure ulcers (Resident #76), the facility failed to consult the dietician regarding a new pressure area within 7 days per facility policy. The findings include: Resident #76 was admitted with diagnoses that included vascular dementia without behavioral disturbance and displaced intertrochanteric fracture of right femur. A quarterly MDS assessment dated [DATE] identified Resident # 76 was severely cognitively impaired requiring extensive assistance of 2 staff members for bed mobility and extensive assistance of 1 staff member for personal hygiene. Additionally, the quarterly MDS dated [DATE] identified Resident #76 was at risk for development of pressure ulcers/injuries and indicated the resident did not have any unhealed pressure ulcers/injuries. The care plan reviewed on 7/27/22 identified that Resident #76 was at risk for skin breakdown-skin tears-abrasions-bruising secondary to fragile skin, at risk…

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 review, facility policy and interviews for 1 resident (Resident # 14) reviewed for hospitalizations, the facility failed to obtain a physician order for an increase in oxygen therapy for a resident experiencing a change in condition according to standards of practice and facility policy. The findings include: Resident #14 was admitted with diagnoses that included end stage small cell lung cancer, chronic obstructive pulmonary disease (COPD) and diabetes mellitus Type II. The MDS 5-day assessment dated [DATE] identified Resident #14 had moderate cognitive impairment and required total assist with personal care. The care plan dated 10/6/22 identified Resident #14 was at risk for altered respiratory status related to history of chronic obstructive pulmonary disease (COPD) and hypoxia. Interventions included: to administer oxygen as ordered, assess and record for signs of impaired gas exchange, to monitor oxygen saturation per physician order and to position upright for optimal breathing. 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 policy and interviews for one resident (Resident # 14) reviewed for hospitalizations, the facility failed to ensure a complete and accurate clinical record for a resident who experienced a change of condition and for one sampled resident ( Resident # 65), reviewed for dental, the facility failed to ensure the resident's dental visit was uploaded to the clinical record within accordance to facility practice. The findings included: 1. Resident #14 was admitted on with diagnoses that included end stage small cell lung cancer, chronic obstructive pulmonary disease (COPD) and diabetes mellitus Type II. The 5-day MDS assessment dated [DATE] identified Resident #14 had moderate cognitive impairment and required total assist with personal care. The care plan dated 10/6/22 identified Resident #14 was at risk for altered respiratory status related to history of chronic obstructive pulmonary disease (COPD) and hypoxia. Interventions included: to administer oxygen 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.

Based on facility documentation review, facility policy review and interviews, the facility failed to maintain an effective, comprehensive, data driven Quality Assurance and Performance Improvement (QAPI) program. The findings include: On 11/02/22 at 12:52 PM an Interview with Administrator #2 and the Director of Nursing (DNS) during a reviewed the QAPI meeting agenda for 10/27/2022 shared minutes and meeting attendees. The DNS indicated that the Medical Director does not attend quarterly .The DNS further indicated that a while back it was noted there was an uptick in the number of falls. The DNS further indicated that since falls were addressed in QAPI, falls had been reduced dramatically and the facility is continuing to use the audits. However, the facility was unable to share evidence of follow-up on QAPI issues regarding fall prevention and statistical data to monitor the effectiveness of the plan. The facility policy named Quality Assurance and Performance Improvement/Corporate Compliance Program dated 9/2020 indicated in part the facility would establish and maintain a…

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

Based on facility documentation review, facility policy review, and interviews the facility failed to ensure that the QAPI committee tracked, analyzed, and acted on data obtained. The findings include: On 11/02/22 at 12:52 PM an Interview with Administrator #2 and the Director of Nursing (DNS) indicated that they had noticed an uptick in resident falls and since brought to QAPI Falls have been dramatically reduced and they continue to complete audits. The facility was unable to share evidence of follow-up on QAPI issues that require Follow-up and documentation. The facility policy named Quality Assurance and Performance Improvement/Corporate Compliance Program dated 9/2020 indicated in part that the facility would establish and maintain a Quality Assurance and Performance Improvement program (QAPI) by utilizing information and data to define and measure goals.

Based on observations, facility policy and interviews during the initial tour of the Dietary Department, the facility failed to discard expired refrigerated food and failed to ensure a sanitary environment. The findings include: During the initial kitchen tour of the Dietary Department on 12/16/19 at 10:10 AM with the Food Service Director (FSD) the following was identified: sour cream that expired on 12/2/19, low fat cottage cheese that expired on 11/8/19, and non-fat cottage cheese that expired on 12/11/19. Additionally, the cooking hood baffles were coated in grease and black debris and located above a cheese sauce that was cooking on the stove. The hot water steam feed pipe to the steamer, that was no longer functioning, was coated with grease and hanging black debris located above the griddle that had been used, according to the FSD, for breakfast. The ceiling above the cooking area was stained and dirty with dark debris. The paint was noted to be peeling above the food preparation counter with bare areas where the paint had come off. In the corner, by the hand washing sink 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, review of facility documentation, policy review, and interviews for one of three sampled residents (Resident #35) who was reviewed for an allegation of mistreatment, the facility failed to ensure the allegation of mistreatment was reported to the administrator and state agency at the time the incident occurred. The findings include: Resident #35's diagnoses included chronic obstructive pulmonary disease, anxiety, major depression, and multiple sclerosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #35 had no memory recall deficits, was alert and oriented to the year, month and day, exhibited no behavioral symptoms, required extensive assistance of one (1) person with toilet use, personal hygiene and dressing, was non-ambulatory and utilized a wheelchair for mobility on and off the unit. The Resident Care Plan dated 8/27/19 identified Resident #35 had an alteration in activity of daily living related to physical status. Interventions directed 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, a clinical record review, a review of the facility documentation, a review of the facility policy, and interviews for one sampled resident (Resident #75), the facility failed to consistently document intake and output for a resident who had a suprapubic catheter and received tube feedings, and for one sampled resident (Resident #85), the facility failed to appropriately label dressings following a dressing change. The findings include: a. Resident # 75 diagnoses included Parkinson's disease neurogenic bladder and obstructive uropathy. The annual Minimum Data Set (MDS) dated [DATE] identified moderate cognitive impairment, extensive assistance of 2 staff for bed mobility and transfers, extensive assistance of one person for dressing and toileting, total dependence for personal hygiene and had an indwelling catheter. A physician order dated 11/1/19 directed to administer Jevity 1.2 240 cubic centimeters (cc) bolus feeds every 3 hours between 6:00 AM and midnight and free water flushes of 100…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, policy review, and interviews for one of three sampled residents (Resident #22) who was dependent on staff for transfers in and out of the bed via a mechanical lift, the facility failed to provide appropriate supervision of the mechanical lift to prevent an accident with an injury. The findings include: Resident #22's diagnoses included vascular dementia, Alzheimer's disease, major depressive disorder, psychotic disorders with hallucinations and delusions, and chronic pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #22 had some difficulty with making decisions regarding tasks of daily life, difficulty focusing attention, disorganized thinking and required extensive two (2) person assistance with turning and repositioning when in bed and personal hygiene, was totally dependent on two (2) person assistance with transfers in and out of the bed and chair, was non-ambulatory, utilized a wheelchair for mobility, 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, a clinical record review, a review of facility documentation, staff interviews, and a review of facility the policy, for one sampled resident (Resident #6) reviewed for weight loss, the facility failed to implement dietary recommendations and/or failed to follow physician orders and/or failed to reweigh the resident in accordance with the facility policy. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included feeding difficulties, hypokalemia, major depressive disorder, constipation, generalized muscle weakness, and a Vitamin D Deficiency. A physician order dated 9/1/19 directed to provide a snack at bedtime and document the percentage taken. A physician order dated 9/4/19 directed to obtain weekly weights. A physician order dated 9/10/19 directed to re-weigh Resident #6. The September 2019 weight log identified on 9/3/19 a recorded wight of 146.4 pounds (lbs), the weight on 9/5/19 was 138.6 lbs which identified a weight loss of 5.33%. 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, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #85) reviewed for infections, the facility failed to identify a discrepancy in the measurement of a Percutaneously Inserted Central Catheter (PICC). The findings include: Resident #85 was re-admitted to the facility on [DATE] with diagnoses that included osteomyelitis of the ankle and right foot, Methicillin Resistant Staphylococcus Aureus infection (MRSA), Diabetes and Schizophrenia. A physician's order dated 11/27/19 directed to measure the right upper extremity PICC external catheter length and arm circumference with dressing changes on Wednesday on the 7:00 AM to 3:00 PM shift and as needed. The Resident Care Plan (RCP) dated 11/27/19 identified a Percutaneously Inserted Central Catheter (PICC) line in place to provide IV antibiotic therapy. Interventions included to administer IV medications per the physician's order, change the dressing per 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.