Hebrew Center For Health And Rehabilitation

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 2 residents (Resident #57) reviewed for Advanced Directives, the facility failed to implement advanced directives according to the resident's expressed wishes and obtain written consent from the resident's health care representative, signed in the presence of two witnesses, for a do not resuscitate (DNR) order, as required by facility policy. The findings include:Resident #57 had diagnoses that included dementia, depression, and high blood pressure.A consent form dated [DATE] identified Resident #57 elected cardiopulmonary resuscitation (CPR) and all life saving measures.The physician's order dated [DATE] directed do not resuscitate (DNR), do not intubate (DNI), no tube feeding, and Registered Nurse (RN) pronouncement of death (despite Resident #57's wishes on [DATE] to be a full code).The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #57 had moderately impaired cognition, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, facility policy and interviews for 1 of 2 residents (Resident # 123) reviewed for abuse, the facility failed to ensure the resident was free from verbal and psychological abuse. The findings include Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8) who told the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident # 123), reviewed for abuse, the facility failed to ensure allegation of verbal abuse was reported to the appropriate state agency timely. The findings include: Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, facility policy and interviews for 1 of 2 residents reviewed for abuse, the facility failed to conduct an investigation regarding an allegation of verbal and psychological abuse. The findings include Resident #123's diagnoses included heart failure (unspecified), spontaneous rupture of extensor tendons in the right lower leg, and polyneuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #123 as cognitively intact and required substantial assistance with showering/bathing and bed mobility and was dependent for transfers. No behavioral concerns were noted. The care plan dated 8/11/25 identified Resident #123 had Activities of Daily Living (ADL). Interventions included: using a Hoyer lift, noted non-ambulatory status, and assistance with bathing and dressing. A review of the grievance log dated 9/27/25 identified Resident #123 had a complaint of poor customer service by a Nurse Aide (NA#8) who told 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 policy and staff interviews for 1of 3 sampled residents (Resident # 6), reviewed for pressure ulcer development and for care meetings, the facility failed to revised the resident's care plan regarding a change in condition in the resident' s pressure ulcer develop and failed to ensure resident care planning meeting was scheduled timely .The findings included: 2.a.Resident #6's diagnosis included a pressure ulcer, heart failure and acute embolism and thrombosis of the deep vein of the left upper extremity. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 had severe cognitive impairment and was at risk for pressure ulcer but had no pressure ulcers. A Third Eye Health Note dated 11/10/2025 at 12:59 AM by the on-call Advanced Practice Registered Nurse (APRN) on 11/09/2025 at 3:47 PM indicated notification of a pressure injury to the left heel and an order for a dressing and a pressure-relieving boot were provided. 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 clinical records, facility documentation, facility policies, observation, interviews, for 1 of 2 residents (Resident #17) reviewed for respiratory care, the facility failed to ensure an RN assessment was conducted when the resident had a change in respiratory status. The findings include: Resident #17's diagnoses included atherosclerotic heart disease, type 2 diabetes, and vascular dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had a Brief Interview of Mental Status (BIMS) score of two (2) indicative of severe cognitive impairment, required maximal assistance with personal hygiene, and moderate assistance with rolling left and right. The Resident Care Plan (RCP) dated 10/16/2025 identified Resident #17 had a communication problem and expressive aphasia. Interventions included anticipating and meeting needs, allowing adequate time for responses, not rushing the resident, and asking yes/no questions when appropriate. The RCP failed to include 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 clinical record, observations, facility policy, and interviews for 1 of 2 residents (Resident #17) reviewed for positioning/mobility, the facility failed to apply a right upper extremity splint per the physician's order, for a resident with contractures. The findings include: Resident #17 diagnoses included hemiplegia and hemiparesis of the right side, contracture of the right hand and right wrist, and vascular dementia.A physician's order dated 8/27/2021 directed to apply a right palm guard between 6 AM and 8 AM up to 8 hours for prevention of contractures to the right hand and check skin prior to and following application. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Interview of Mental Status (BIMS) score of two (2) indicative of severe cognitive impairment, did not display behaviors of rejection of care, and required maximal assistance with personal hygiene, upper and lower body dressing.The Resident Care Plan (RCP) dated 10/16/2025…

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 staff interviews for 1 of 2 residents reviewed for elopement risk (Resident #10), the facility failed to replace a resident's expired Wander Guard per facility policy for a resident at risk for elopement. The findings include: Resident #10 was admitted on [DATE] with diagnoses that included dementia and stroke.A nursing admission assessment dated [DATE] identified Resident #10 had cognitive and hearing impairment.An elopement risk evaluation dated [DATE] identified Resident #10 was at risk for elopement related to a history of wandering/elopement, being cognitively impaired, and having the physical ability to leave the building. Interventions included applying a wander device.A physician's order dated [DATE] directed to check the placement of the Wander Guard device. The order also indicated the specific serial number of the device assigned to Resident #10 and noted an expiration date of 10/2025. The physician's order did not indicate 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 clinical records, facility documentation, facility policy, and interviews for the one sampled resident (Resident #12) reviewed for dialysis, the facility failed to monitor fluid intake for a resident on fluid restrictions. The findings include:Resident #12 had diagnoses that included hypertensive stage 5 chronic kidney disease, renal agenesis, and dependence on renal dialysis.A physician's orders dated 5/30/2025 directed a fluid restriction of 1500 milliliters (ml) per day and document intake of fluids in the plan of care (POC) every shift.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Interview of Mental Status (BIMS) score of 14 indicative of intact cognition, required supervision for eating and drinking, and was receiving dialysis.The Resident Care Plan (RCP) dated 11/15/2025 identified Resident #12 had renal failure and required dialysis. Interventions directed to encourage/provide intake of fluids throughout the day and monitor/evaluate…

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 observations, interviews, and review of facility policy the facility failed to ensure medication carts were locked when left unattended and medications, including narcotics were properly secured. The findings include:1. Observation on 1/08/2026 at 6:01 AM identified an unattended, unlocked medication cart in the hallway on the Three North unit outside of the data closet.Interview with Licensed Practical Nurse (LPN) #8 on 1/08/2026 at 6:04 AM identified that he did not lock the medication cart before entering a resident room at the opposite end of the hallway to provide routine care. LPN #8 indicated he did not push the lock hard enough. LPN #8 identified the medication cart contained narcotics. LPN #8 stated he was aware of the facility policy requiring medication carts to be locked when not in use, not in view, or unattended, and that narcotic medications require double locking for safety. 2. Observation on 1/08/2026 at 6:22 AM identified an unattended, unlocked medication cart in the hallway on the Four North hallway. A packet of medication, labeled with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, facility documentation, facility policies, observation, interviews for 1 of 2 residents (Resident #104) reviewed for diagnostic testing, the facility failed to ensure test results were provided to the physician timely. The findings include:Resident #104 had diagnoses that included a coagulation defect and a thyroid nodule.A physician specialist consult report dated 8/26/2025 directed to obtain a thyroid ultrasound next week, a CT scan of the thorax in 6 months, and to return for a follow-up visit in 3 months.The physician's orders dated 8/26/2025 directed to obtain a thyroid ultrasound with confirmation of booking.The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #104 had mild cognitive impairment.Review of Resident #104's radiology thyroid ultrasound report dated 8/27/2025 at 4:41 PM identified that the exam was completed on 8/27/2025 at 4:41 PM and the results were provided to the facility on 8/27/2025 at 8:50 PM. The radiology report indicated 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, observations, and interviews for 1 of 1 resident (Resident #168) reviewed for dental, the facility failed to obtain outside resources for routine dental service to meet the resident's needs. The findings include:Resident #168 was admitted to the facility in March 2022 with diagnoses that included chronic pain and chronic obstructive pulmonary disease. The physician order dated 1/14/25 directed a dental evaluation. The quarterly MDS dated [DATE] identified Resident #168 had moderate cognition and was able to eat independently. The physician order dated 6/2/25 directed for a regular diet with no salt packets. The RCP dated 6/9/25 identified Resident #168 was dependent on staff for physical needs. Interventions directed to provide a regular diet, assist with meals as needed, and honor food preferences as able. Review of the dental note written by RDH #1 (dental hygienist) dated 7/22/25 at 1:59 PM identified Resident #168 was seen for 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 observations, review of facility policy, and interviews, the facility failed to ensure garbage and refuse were disposed of properly. The findings include:a.Observation and interview on 1/6/2026 at 12:00 PM with the Director of Dietary #1 of the refuse areas identified the following: The door/lid of the dumpster was observed to be open with garbage and debris on the ledge of the entrance/opening of the dumpster, including food residual, purple gloves, food wrappers, and straws. There was also a pale yellow-brown sludge-like substance on the ledge. Garbage and debris were noted around and under the dumpster on the ground, including purple gloves, clear gloves, Styrofoam cups and bowls, a full container of apple sauce, multiple empty containers of apple sauce, food leftovers, and white bags containing garbage. The Director of Dietary #1 identified the kitchen was responsible for maintaining the garbage. The Director of Dietary #1 stated he brought shovels in so he could clean up the garbage around the dumpster. The Director of Dietary #1 indicated that the garbage keeps…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility documentation, facility policy, observations, and interviews for 3 of 8 residents (Resident #15, Resident #115, and Resident #123), reviewed for infection control, the facility failed to properly place a soiled Personal Protective Equipment (PPE) bin (Resident #15) in the resident's room and failed to wear appropriate PPE during direct care (Resident #115 and Resident #123). The findings included: 1.Resident #15's diagnosis included Enterocolitis due to Clostridium Difficile(C-Diff). A significant change in status Minimum Data Set (MDS) dated [DATE] identified Resident #15 had mildly impaired cognition. A physician's order dated 12/08/2025 directed to provide Contact/enteric precautions for C-Diff. The RCP dated 12/31/2025 identified Resident #15 had a C-Diff infection with interventions including to initiate contact-enteric precautions on acute onset of diarrhea, provide medications as ordered, observe bowel movements for changes and report to the physician. 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 clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for abuse, the facility failed to ensure residents (Resident #1 and #2) were free from mistreatment. The findings include: a. Resident #1's diagnoses included depression and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was alert and oriented, had no behaviors and required supervision for bathing and toilet use and moderate assistance for transfers and toilet use. The Resident Care Plan (RCP) dated 8/31/2024 identified Resident #1 required assistance with self-care. Interventions directed two (2) half rails/mobility bars up for assistance with bed mobility, toilet use and transfer assist of two (2). Review of Facility Reportable Event Form identified on 9/15/2024 at 10:15 AM Resident #1 was alert and oriented, and alleged a NA hit him/her in the left eye with a towel and slammed the railing down on his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident#1) who was reviewed for an allegation that a nurse aide spit on the resident's food and fed the resident the meal, the facility failed to ensure Resident #1 was not abused or mistreated by facility staff. The findings include: Resident #1's diagnoses included dementia, dysphagia, and depression. The significant change Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life and was totally dependent on staff for all activities of daily living including eating. The Resident Care Plan dated 5/23/24 identified Resident #1 had a self-care deficit and was unable to independently provide any care for him/herself. Interventions directed one (1) staff member for feeding and two (2) staff members for hygiene, dressing, bathing, toileting, and transfers. The nurse's note dated 6/16/24 at 10:00 AM identified one (1) 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, review of facility documentation and policies, and interviews for one of five sampled residents (Resident #4) reviewed for an allegation of resident-to-resident physical abuse, Resident #4 was not free from physical abuse when Resident #4 was punched in the back by Resident #5 while walking in the hallway. The findings include: Resident #4's diagnoses included Alzheimer's disease, insomnia, and cognitive communication deficit. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #4 rarely or never made decisions regarding tasks of daily life, difficulty focusing attention, disorganized thinking, and required minimal assistance of staff with getting in and out of the bed and chair and ambulating. Resident #5's diagnoses included bipolar disorder, dementia, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #5 rarely or never made decisions regarding tasks of daily life and required supervision or touching…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of verbal abuse, the facility failed to ensure an allegation of abuse was reported within two (2) hours to the administrator or designee. The findings include: Resident #1's diagnoses included dementia, and osteoporosis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life and was dependent on staff for most activities of daily living. Review of the Facility Reported Incident form dated 5/23/24 at 10:45 AM identified a staff member allegedly overhead a nurse aide tell Resident #1 to shut up on 5/10/24 at 10:00 AM. Interview and review of the Facility Reported Incident with the Director of Nursing (DON) on 6/13/24 at 12:00 PM identified an Occupational Therapist, OT#1, was the staff member that overheard the incident on 5/10/24 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 review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the clinical record was complete and accurate to include complete documentation of meals and personal care provided. The findings include: Resident #1's diagnoses included dysphagia (difficulty swallowing), traumatic brain injury, and legal blindness. The admission MDS dated [DATE] identified Resident #1 was alert, oriented, and was dependent with assist of two (2) for all ADL's (activities of daily living) and required assistance for eating. The Resident Care Plan (RCP) dated 12/19/2023 identified Resident #1 had dysphagia and an ADL self-care performance deficit and activity tolerance. Interventions directed to provide feeding/dining assistance as needed and to provide two (2) staff for all care. 1. Review of Resident #1's Documentation Survey Report identifying ADL's including eating identified the following…

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 review, and interviews, the facility failed to ensure the chemical sanitizing solution was monitored to ensure the manufacturer's recommended sanitization concentrations. The findings include: Observation during an initial tour of the kitchen on 11/15/23 at 9:45 AM with the Dietary Director identified that the facility utilized a QAC (Quaternary Ammonium Chloride) chemical-based sanitizing solution for sanitizing and utilized red sanitizing buckets for the wiping cloths. During the observation, the kitchen was identified to be a kosher kitchen, with separate areas of meat and dairy preparation. One red sanitizing bucket was observed to be in use in the meat area of the kitchen. Immediately following this observation, a request was made to the Dietary Director to provide the testing logs for 2023 for the QAC sanitizing solution for the red sanitizing buckets. The Dietary Director identified that the facility did not keep a log of the test strips for the sanitizing solution of any of the sanitizing buckets. The Dietary…

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 review, and interviews for one of two sampled residents (Resident #101) reviewed for hospitalization, the facility failed to document and monitor bowel movements (BM) in accordance with the facility bowel regimen policy. The findings include: Resident #101 's diagnoses included heart failure, chronic pain syndrome, rheumatoid arthritis, and gastroesophageal reflux disease (GERD). The admission MDS assessment dated [DATE] identified Resident #101 had moderate cognitive impairment, required extensive assistance for bed mobility, toilet hygiene and transfers. The assessment further identified the resident was always incontinent of bowel and was not on a bowel training program. The physician's order dated 6/23/23 directed to administer Milk of Magnesia (MOM) suspension 400mg/5ml (laxative) and give 30ml by mouth as needed for constipation daily if no BM after six shifts. The care plan dated 6/23/23 identified Resident #101 had a self-care deficit related to weakness,…

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 two of two sampled residents (Resident #151 and Resident #212) with overdue physician's orders and progress notes, the facility failed to ensure physician's orders and visits were documented, signed, and dated in a timely manner. The findings include: 1. Resident #151was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), type 2 diabetes, and congestive heart failure (CHF). The quarterly MDS assessment dated [DATE] identified Resident #151 was moderately cognitively impaired and required supervision with dressing and toileting, and limited assistance with personal hygiene and transfers. A review of Resident #151's physician's orders on 11/22/23 at 11:00 AM identified that the last signed physician's orders were dated 6/18/23, which indicates the date the orders were last reviewed. The orders identified that they would be in effect for the next sixty days, which means 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 observations, facility documentation, facility policy review, and interviews, the facility failed to ensure that medications maintained in the medication storage carts and the medication storage rooms were labeled properly, and failed to ensure that IV fluid medications were maintained in a manner to ensure integrity of the medications and for one sampled resident (Resident #573) who had ordered IV (intravenous) medication, the facility failed to ensure the IV medication was labeled with the date, time, and initials of the nurse administering the medication. The findings include: 1. Observation on 11/15/23 at 12:17 PM with LPN #1 identified that the medication cart located on the 2 North unit contained a blister card that contained two white tablets. The blister card was partially torn and did not contain a label that identified the name of the medication, the dose, the frequency of use and the resident's name. Interview with LPN #1 at the time of the observation identified she was unable to identify…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, and interviews for two of two sampled residents (Residents #73 and #146) reviewed for dining, the facility failed to honor the resident's preferences by omitting items on the room meal trays. The findings include: 1. Resident #73's diagnoses included anemia, coronary artery disease, and heart failure. The admission MDS assessment dated [DATE] indicated Resident #73 was cognitively intact and independent with eating. The care plan dated 10/4/23 identified Resident #73 had unspecified anemia with interventions that included increase dietary iron through red meat and green vegetables. The care plan also identified that the resident had a potential risk for nutrition-related problems with an intervention to monitor food and beverage intake. A physician's order dated 10/11/23 directed a regular diet for Resident #73. An interview with Resident #73 on 11/15/23 at 11:51 AM indicated that the resident's meal trays frequently arrived incomplete. The resident also indicated…

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 two of five sampled residents (Residents #274 and #275) reviewed influenza and pneumococcal vaccinations, The facility failed to obtain the vaccine history and provide influenza and pneumococcal immunizations in a timely manner. The findings include: Resident #274 was admitted to the facility on [DATE] with diagnoses that included heart disease, posthemorrhagic anemia, and polyneuropathy. Resident #274's admission MDS assessment dated [DATE] identified intact cognition, and not up to date with the following vaccinations: influenza, pneumococcal, and COVID-19. Review of the immunizations in the electronic medical record (EMR) identified Resident #274, was tested for tuberculous on 11/5/23, and no additional vaccination information was identified. Resident #275 was admitted to the facility 11/6/23 with diagnosis that included diabetes type 2, dementia, and hypertension. The electronic medical record (EMR) for Resident #275 indicated no…

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 an allegation of mistreatment, the facility failed to ensure Resident #1 was treated with dignity and respect. The findings include: Resident #1's diagnoses included bipolar disorder, vascular dementia with agitation, schizoaffective disorder, depression, and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of life, required limited one (1) person assistance with getting in and out of the bed and chair transfers, extensive one (1) person assistance with toileting and personal hygiene, was independent when ambulating and utilized a walker and wheelchair for mobility. The resident care plan dated 5/22/23 identified a behavior problem related to dementia and schizoaffective disorder. Interventions included administer medications as ordered, attempt distractive activity when…

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 #3) who were reviewed for resident-to-resident abuse, the facility failed to ensure the resident was free from inappropriate sexual conduct by another resident. The findings include: Resident #2's diagnoses included dementia with other behavior disturbances. The resident care plan dated 8/2/23 identified Resident had a behavior problem. Interventions directed to monitor for targeted behaviors, to anticipate and meet the resident's needs, provide opportunity for a positive interaction, stop and talk with the resident as passing by, explain all procedures and allow time to adjust, if reasonable, discuss behavior, explain/re-enforce why behavior is inappropriate and/or unacceptable, intervention as necessary, remove from situation, monitor for target behaviors and psychiatric evaluation. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had poor…

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, facility policy review, and interviews for facility infection control review, for one of three residents (Resident #3) reviewed for respiratory care, the facility failed to ensure respiratory items were dated and stored in accordance with accepted practices, and for one sampled resident (Resident #28) observed for precautions, the facility failed ensure staff attempted to redirect a resident when they were observed in a common area, and for twelve observed residents, (Residents #50, #138, #151, #154, #114, #197, #202, #18, #54, #116, #137 and #188), the facility failed to ensure residents wore face masks and were socially distanced in accordance with accepted practices when in common areas. The findings include: a. Resident #3's diagnoses included heart failure and atrial fibrillation. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition, required limited staff assist for activities of daily living and did not use oxygen. 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, facility policy review, and interviews for one sampled resident (Resident #91) reviewed for dining, the facility failed to ensure a resident who required one to one staff assistance with meals was not left alone with a meal. The findings include: Resident #91's diagnoses included dysphagia. Physician's order dated 7/13/2021 directed to administer a mechanical soft dysphagia level 3 texture, mildly thick consistency. The speech therapist's note dated 7/20/2021 directed that Resident #91 required one to one (1:1) staff assistance for meals/feeding for swallowing safety with caregivers implementing compensatory swallowing strategies consistently. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #91 had severely impaired cognition and required one-person physical assistance with eating. The care plan dated 8/9/2021 identified a chewing/swallowing difficulty related to dysphagia. Interventions directed to ensure Resident #91 was seated upright at 90…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, and facility policy review, for two of four residents (Resident #60 and #266) reviewed for accidents, the facility failed to ensure neurological checks were completed after a fall, and for one sampled resident (Resident #17) reviewed for care and services, the facility failed to ensure an RN assessment was completed timely. The findings include: a. A 5-Day Minimum Data Set (MDS) dated [DATE] identified that Resident #60 had severe cognitive impairment, required extensive assistance of two staff for bed mobility and transfers. A care plan dated 4/12/2021 identified that Resident #60 was at risk for falls due to history of falls, poor safety awareness and psychotropic medication use. Interventions directed to monitor vital signs as ordered and to provide last rounds, check for comfort and in continence at end of 11-7 shift. Review of the Medication Administration Record for May identified that Resident #60 was on Aspirin Low dose 81…

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 six residents (Resident #71) reviewed for nutrition, the facility failed to ensure staff acted upon recommendations timely for a resident who received dialysis. The findings include: Resident #71's diagnoses included end stage renal disease with renal dialysis. The nursing care plan dated 7/12/2021 identified Resident #71 required hemodialysis. Interventions directed to send communication forms with Resident #71 to dialysis, adjust the plan of care as needed upon return from dialysis, and to provide diet and supplements as ordered. An admission Minimum Data Set (MDS) dated [DATE] identified Resident #71 had moderately impaired cognition and received dialysis. Review of the dialysis consultation report form dated 8/9/2021 identified that Resident #71's albumin (serum protein) level on 7/14/2021 was optimal but was trending downward from 4.6 grams per decilitre (gdL) (normal reference levels are 3.5 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, observations, facility documentation review, facility policy review, and interviews for one of two residents (Resident #3) reviewed for respiratory care, the facility failed to ensure a physician's order was obtained for a resident who required use of oxygen, and the facility failed to ensure a sign was posted to alert oxygen was in use. The findings include: Resident #3's diagnoses included heart failure, hypertension, and atrial fibrillation. The quarterly MDS dated [DATE] identified Resident #3 had moderately impaired cognition, required limited staff assist for activities of daily living and did not use oxygen. The Resident Care Plan (RCP) dated 9/14/2021 identified a self-care deficit and hypertension. Interventions directed to assist with care, administer medications as ordered and to monitor for side effects. Nurse's note written by the ADNS dated 9/27/2021 at 10:24 AM identified at approximately 9:30 AM Resident #3 was unresponsive to verbal stimuli an was awakened with…

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