Apple Rehab West Haven

Based on observations of the kitchen, review of policy and staff interviews, the facility failed to ensure staff obtained ice in a sanitary manner in the kitchenette where the ice machine was not operational and the facility failed to ensure items in the kitchen were dated and labeled, dented cans were discarded, temperatures were consistently taken/ documented, and cleaning schedules were signed off on. The findings include: 1. On 8/7/2025 at 9:14 AM an observation of the kitchen identified the ice machine in the right corner of the room was pad locked and the wall mounted scoop holder was empty in the presence of the federal surveyor in attendance. LPN #2 entered the nourishment room and opened the freezer took out an ice cube tray (1 of four), with non-gloved hands, filled the tray with tap water and placed the ice cube tray into the freezer portion of the nourishment room refrigerator) further observation identified none of the ice cube trays had covers. Food items in a cloth bag were on the freezer shelf above the open ice cube trays and were labeled with a resident name 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, review of facility policy and staff interviews for 2 of 5 residents (Resident #21 and Resident #29) reviewed for unnecessary medications, the facility failed to obtain consent from the resident's representative for psychotropic medications and informed the resident's representative in advance of risk and benefits of psychotropic medication usage. The findings included: 1.Resident # 21's diagnoses included anxiety disorder, dementia, and borderline personality disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was moderately cognitively impaired and required assistance of 2 or more helpers with showering, personal hygiene, upper and lower body dressing, and transfers. The MDS further identified Resident #21 had verbal behavioral symptoms directed toward others, and noted antipsychotics received on a routine basis. The Resident Care Plan (RCP) dated 6/13/25 identified psychiatric drug use and at risk for potential adverse effects 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 review, observations, facility policy review and staff interviews for the only resident reviewed for accidents (Resident #17) and 1 of 2 residents (Resident #17) reviewed for Activities of Daily Living, the facility failed to ensure staff updated the resident care plan after a fall and revise the care plan to reflect the resident's oral care needs and preferences and for 1 of 3 residents ( Resident #82) reviewed for respiratory care, the facility failed to revise and update care plan to reflect oxygen use and interventions. The findings included: 1.Resident #17's diagnoses included schizophrenia and dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was moderately cognitive impaired. The care plan dated 6/12 2025 with updated 7/22/2025 indicated Resident #17was at risk for falls due to newly admitted to the facility indicating Resident #17 fell on 5/24/2024, 2/7/2025, 4/19/2025 and 7/22/2025. Interventions included…

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, policy review and interview for 1 of 5 residents (Resident #17) reviewed for unnecessary medications, the facility failed to transcribe physician's order. The findings included:Resident #17's diagnoses included schizophrenia, dementia, and anxiety.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 had a Brief Interview of Mental Status (BIMS) score of 8 indicating moderate cognitive impairment and noted the resident required setup for eating. The assessment also noted the resident required partial/moderate assistance for dressing and transfers.The Resident Care Plan dated 7/22/25 identified Resident #17 had schizophrenia disorder and was at risk for changes in mood state and behaviors. Interventions included follow up by psychiatry group and to administer medications as ordered.The Psychiatry APRN progress note dated 7/28/25 at 6:53 AM identified Resident #17 was seen at the request of the facility for behavior disturbances, with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and interviews for 2 of 6 residents reviewed for abuse, the facility failed to ensure Resident #29 was provided care in a timely manner. The findings include: Resident #29 's diagnoses included unspecified dementia, Type 2 diabetes mellitus, chronic kidney disease.The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified Resident #29 was moderately cognitively impaired and required maximal assistance with toilet transfers and hygiene, the MDS also indicates Resident #29 has frequent urinary incontinence and occasionally incontinence of the bowel. The care plan dated 10/7/25 for Activities of daily living (ADLs). Interventions included assisting with preforming ADL as needed and transferring per physician's order. A physician's order dated 4/16/25 directed Resident #29 requires assistance of one staff for transfers.Observation on 8/7/2025 at 9:32 AM of Resident #29 requesting to use bathroom identified Nurse Aide (NA # 3)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 2 of 6 residents reviewed for abuse, the facility failed to ensure Resident #35 received audiology follow up for missing hearing aids. (sensory device). The findings include:Resident #35's diagnoses included unspecified hearing loss, adjustments disorder, and age-related physical debility.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #35 was moderately cognitively impaired and noted dependent for upper body dressing, personal hygiene and toileting hygiene.The care plan dated 7/11/25 identified Activities of Daily Living (ADL). Interventions included to ensure Residents#35 hearing aids are in daily and are functioning properly and to make audiology appointments as ordered/needed. A Missing Property form dated 7/25/25 indicated, Resident #35 hearing aids were missing. Resolution indicated Interdisciplinary team added Resident to the Audiology list for new hearing aids. Observation on 8/12/25 at 9:45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility policy and interviews for 1 of 3residents reviewed for respiratory care (Resident # 82), the facility failed to ensure the resident had current physician's order for oxygen therapy and for 1 of 3 residents reviewed for respiratory care (Resident #59), the facility failed to ensure that licensed staff appropriately evaluated a resident's oxygen as per professional standards during a potentially urgent medical situation. The findings included: 1.Resident # 82's diagnoses included acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 was cognitively intact and required supervision /set up assistance for personal hygiene, oral hygiene and partial assistance for bed mobility. A physician's order dated 5/16/25 directed to taper off oxygen gradually, maintaining oxygen saturation of >90 and to monitor every shift. A nurse's note 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 Number of residents sampled for unnecessary medications: 5Number of residents cited: 1 Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #21) reviewed for unnecessary medications, the facility failed to ensure physician was aware of a pharmacy consultant's recommendation for laboratory monitoring. The findings include: Resident #21's diagnoses included atrial fibrillation (irregular heartbeat), dementia, hypertension (high blood pressure), heart failure, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was moderately cognitively intact and required the assistance of 2 helpers for showering, personal hygiene, upper and lower body dressing, and transfers. The Resident Care Plan (RCP) dated 6/13/25 identified atrial flutter due to atrial fibrillation, an irregular heartbeat, at risk for heart failure. Interventions included to administer medications as ordered and adhere to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and facility policy for 2 out of 32 opportunities observed during medication administration for 2 out of 5 Residents (#8 and #54) resulting in a 7. % medication error rate, the facility failed to ensure residents were free from significant medication errors due to no medication available for use and utilizing expired over-the-counter medication. The findings include: Resident #8's diagnoses included spina bifida, paraplegia, and stage 4 pressure ulcer of the sacral region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was cognitively intact and required the assistance of 2 or more people with bed mobility, toilet hygiene, and transfers. Observations of medication administration on [DATE] at 9:38 AM with Licensed Practical Nurse (LPN #1) for Resident #8 identified the clotrimazole-betamethasone cream was not available in the facility. Interview with LPN#1 on [DATE] at 10:29 AM identified Resident #8's clotrimazole-betamethasone cream was not…

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

Based on observations, review of policy and staff interviews for 2 of 2 medication storage carts (Unit 2 [NAME] and Unit 3 East), reviewed for medication storage, the facility failed to label open medications and discard expired medications appropriately, and for 4 of 4 medication storage carts ( Unit 2 East and [NAME] Wings) reviewed for medication storage, the facility failed to appropriately complete the controlled substance shift-to-shift reconciliation sign off sheet. The findings include: A. Interview and observation with Registered Nurse (RN) #2 on 8/13/25 at 11:15 AM of unit 2-west medication cart identified the following: 1) Timolol Maleate Ophthalmic Solution 0.25%, 2 open bottles with no open date 2) Combigan Ophthalmic Solution, 1 open bottle with no open date 3) Dorxolamide Hydrochloride Ophthalmic Solution 2%, 1 open bottle with no open date 4) Infants Simethicone drops, 1 open bottle with not open date 5) Latanoprost Ophthalmic Solution, 1 bottle with open date of 6/6/25 6) Humalog/Lispro Kwik pen, 1 insulin pen with open date of 7/15/25 RN #2 at the time of the…

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

Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee included required participants during scheduled meetings, as evidenced by missing signatures from key committee members on multiple dates. The findings include: Review of QAA Committee sign-in sheets from 10/7/2024 through 7/1/2025 identified on 10/7/2024, the sign-in sheet was missing signatures from the Infection Preventionist, Director of Nursing, and Medical Director. On 4/1/2025, the sign-in sheet was missing the signature of the Infection Preventionist. During an interview on 8/13/2025 at 3:45 PM, the Administrator identified the QAA committee met at least quarterly as part of their quarterly medical staff meeting. The Administrator could not identify why, on 4/7/2024, the Infection Preventionist, Director of Nursing, and Medical Director did not attend the meeting, as he was not the Administrator of the facility at the time. Additionally, the Administrator indicated the Infection Preventionist had not attended the 4/1/2025 meeting as there was 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 observations, review of the clinical record, facility documentation, facility policy and interview for 1 of 2 residents (Resident #21) reviewed for pressure ulcers, the facility failed to ensure staff followed infection prevention and control practices during a wound dressing change for a resident with a pressure ulcer and the facility failed to ensure staff handled dirty linen in a sanitary manner in a shower area for 2 consecutive days, failed to ensure staff appropriately stored dirty linen bags in the laundry, failed to maintain clean wall fans and ceiling exhaust fans blowing toward clean linen areas, failed to maintain an adequate emergency linen supply, failed to maintain a clean, usable and easily accessible wash sink on the dirty side of the laundry, and failed to maintain a clean wash sink area with a wall surround on the clean side of the laundry and for the only resident reviewed for tube feeding (Resident #47), the facility failed to ensure that tube feeding was labeled correctly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, Review of the facility Infection Control Program, facility policy and interviews for 4 out of 5 residents reviewed for immunizations (Residents # 9, #63 # 67 #79), the facility failed to provide vaccines timely after consent was given and the staff failed to follow up with the responsible party of residents to offer vaccinations. The findings included: On 8/7/2025 starting at 02:00 PM and concluding at 4:30 PM the review of the facility infection control program was conducted by the surveyor with LPN #4, the Infection Preventionist, Corporate Nurse, RN #3 and the federal surveyor. A sample of 5 residents were reviewed for immunizations, and 4 out of the 5 residents were found out of compliance. 1. An interview and clinical record review for Resident #9 with LPN #4 identified a consent not signed with No, I refuse the annual influenza vaccine Pneumococcal vaccine and the Covid 19 vaccine. On the side of the consent form handwritten next to each vaccine type is written…

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 medication and treatment administration, the facility failed to notify a provider of medication and treatment omissions following an abdominal burn that the resident sustained in the facility. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) score of three (3) indicative of severely impaired cognition and required setup assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/10/25 identified Resident #1 had skin abnormalities due to coffee that was spilled on his/her abdomen on 3/9/25 resulting in a second-degree burn (damage to the outer layer of skin and part of the underlying layer).…

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 medication and treatment administration, the facility failed to ensure that medications and treatments were administered per physician's orders. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and required setup assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/10/25 identified Resident #1 had skin abnormalities due to coffee that was spilled on his/her abdomen on 3/9/25 resulting in a second-degree burn (damage to the outer layer of skin and part of the underlying layer). Interventions included to ensure that a secured lid is in…

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 medication and treatment administration, the facility failed to ensure complete and accurate documentation of a resident record when medications and treatments were not signed off when administered/completed. The findings include: Resident #1's diagnoses included dementia with behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of three (3) indicative of severely impaired cognition and required setup assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 2/14/25 identified that Resident #1 has impaired memory, recall and decision-making skills related to dementia. Interventions included to offer medications as ordered, be aware of the effectiveness and side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who required emergency services and transfer to the hospital, the facility failed to conduct an complete and accurate assessment at the time the resident was noted to have a change in condition. The findings include: Resident #1's diagnoses included dementia, dysphagia (difficulty swallowing), and gastroesophageal reflux disease (GERD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life and was dependent on staff for all activities of daily living. The Resident Care Plan dated 1/3/25 identified Resident #1 had a potential for aspiration, asthma, and GERD. Interventions directed to assist with meals, check vital signs and lung sounds for any signs of aspiration, keep the resident in an upright position for thirty (30) minutes after meals, keep head of bed elevated, monitor for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who had a change in condition and required transfer to the hospital, the facility failed to monitor and implement interventions until Emergency Medical Services arrived and failed to give a thorough hand off report. The findings include: Resident #1's diagnoses included dementia, dysphagia (difficulty swallowing), and gastroesophageal reflux disease (GERD). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life and was dependent on staff for all activities of daily living. The Resident Care Plan dated 1/3/25 identified Resident #1 had a potential for aspiration, asthma, and GERD. Interventions directed to assist with meals, check vital signs and lung sounds for any signs of aspiration, keep the resident in an upright position for thirty (30) minutes after meals, keep head of bed…

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 review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse and neglect, the facility failed ensure the resident was free from misappropriation. The findings include: Resident #1 was admitted with diagnoses that included cardiomyopathy and muscle weakness. A 5-day MDS dated [DATE] identified Resident #1 had moderately impaired cognition. A resident care plan (RCP) dated 7/7/2024 identified Resident #1 had impaired memory, recall and decision-making skills. RCP directed to offer gentle reminders, offer one step at a time directions and to support /reassure if anxious. A facility reportable event form dated 9/6/2024 identified that on 8/22/2024, Resident #1 was accompanied by NA #1 to an appointment and Resident #1's credit card was given to NA #1 to pay for transportation. The report indicated NA #1 used Resident #1's credit card to purchase her own personal items. The facility summary 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 clinical record reviews, facility documentation, facility policy, and interviews for one (1) of two (2) sampled residents (Resident #2) who had indwelling urinary catheters, the facility failed to ensure the resident attended scheduled outpatient urology appointments and maintain accurate documentation in the clinical record of when the appointments were canceled, missed or rescheduled. The findings include: Resident #2's diagnoses included quadriplegia and neuromuscular dysfunction of the bladder. The admission record identified Resident #2 was responsible for him/herself. A physician's order dated 3/4/23 directed indwelling foley catheter #16Fr with 10cc balloon. The resident care plan dated 4/3/23 identified Resident #2 had an indwelling catheter and was at risk for urinary tract infections (UTI's). Interventions directed to conduct catheter care as ordered and as needed, medications as ordered, observe for sediment, cloudy, bloody, scant or foul-smelling urine and report to the physician, and 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 reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who required social service assistance, the facility Social Worker failed to maintain the resident's dignity and respect during a verbal altercation with the resident. The findings include: Resident #2's diagnoses included post-traumatic stress disorder, anxiety disorder, depression, and history of alcohol dependence. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily living. The Resident Care Plan dated 11/16/23 identified Resident #2 had a diagnosis of depression, was impulsive and could direct anger at others. Interventions directed to encourage Resident #2 to seek staff assistance if having difficulty with another resident, re-direct him/her if a mood change was noted, offer clear and simple explanations, and minimize information overload, report changes in mental status,…

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 abuse the facility failed to ensure that resident was free from mistreatment. The findings include: Resident #1 's diagnoses included diabetes, anxiety, and depressive disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1, was alert and oriented and required maximal assistance for personal hygiene and ADLs. The Resident Care Plan (RCP) dated 2/28/2024 identified Resident #1 had history of abuse allegations. Interventions directed psychiatric service to follow, visits to follow up on allegation, watch for signs of mental distress, increased anxiety, and/or change in mood state and report to resident's physician/APRN. A physician's order dated 2/21/2024 directed physical therapy three (3) times per week for four (4) weeks (therapeutic exercises, orthotics, prosthetics, therapeutic activities, and wheelchair management). 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 resident (Resident #24) reviewed for non-pressure skin condition, the facility failed to notify the physician and the resident representative when significant changes occurred, and for 1 of 2 residents (Resident #26) reviewed for pressure ulcers, the facility failed to notify the physician and the resident representative when Resident #26 developed 2 new pressure ulcers, and for 1 residents (Resident #52) reviewed for nutrition, the facility failed to notify resident representative of a weight loss and new orders, and for 1 of 2 residents (Resident #42) reviewed for hospitalization, the facility failed to notify the physician when the resident began to have hallucinations, and for 1 of 12 residents (Resident #69) reviewed for quality of care, the facility failed to notify the physician or the resident representative when Resident #69's blood pressure was low, and for 1 of 2 residents (Resident #49) reviewed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a home like environment. The findings include: a. Random Observation on 12/6/23 identified the following: 3rd floor center ceiling air condition units soiled in appearance. 3rd floor corridor ceiling fans (2 identified) dust covered and visibly soiled. room [ROOM NUMBER] - radiator near door dented, air mattress placed on bed - not hanging on bed, tape on bureau door, one side of shared bureau missing its lock, plate lopsided on wall-hole exposed, hole near baseboard, baseboard in disrepair. room [ROOM NUMBER] - baseboard in disrepair, door stop hole near baseboard, floor unclean, bureau drawer in disrepair. room [ROOM NUMBER] - perimeter around baseboard soiled with discoloration, wire hanging loosely from wall, wooden block approximately 12 x 3 on floor, various residual holes in wall possible previous wall hangings. room [ROOM NUMBER] - baseboard behind bed B is detached, venetian blind wand to expose room to natural light was on the floor…

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 5 residents (Resident 59) reviewed for unnecessary medications, the facility failed to monitor blood pressure and pulse according to the physician ordered parameters, and for 1 resident (Resident 86) reviewed for accidents, the facility failed to complete neurological vital signs, according to their policy, after 2 unwitnessed falls, and for 1 resident (Resident #24) reviewed for edema, the facility failed to follow the physician's orders for ted stockings, failed to complete a comprehensive RN assessment timely, and failed to follow the physician's order for weights, and for 1 of 2 residents (Resident #26) reviewed for pressure ulcers, the facility failed to follow the policy for weekly body audits and failed to have a complete a comprehensive assessment of 2 new pressure ulcers, and for 1 of 12 residents (Resident #67 and 69) reviewed for quality of care, the facility failed to follow…

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, review of facility policy and interviews, the facility failed to maintain a clean and sanitary kitchen environment. The findings include: a. During the brief initial kitchen tour, with the Food Service Director on 11/28/23 at 10:52 AM the following was identified. Dirt, grime, and debris were observed on the floors and walls. Two floor fans observed in the kitchen were covered with dust and debris, as lunch was being prepared by the dietary staff. b. During the kitchen tour with the Food Service Director on 11/29/2023 at 1:35 PM the following was identified. The entryway to the kitchen on the dining room side was observed with heavy black/brown/white debris in both corners of the door on the floor. Dietary Aide #2's hair was sticking out in the front and on the sides of his head covering. Paper-like products on the floor with debris, along with a blue glove and other debris under the food prep area tables (packages of cups, lids, dust, and grime). Personal lunch box and drink tumbler on a food prep station, along with covid test cards and masks. Black grime 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, review of the clinical record, facility documentation, facility policy, and interviews the facility stored clean supplies on the dirty linen carts, failed to ensure that the staff maintained appropriate infection control precautions related to Covid 19 antigen testing, failed to ensure infection surveillance monitoring was completed per facility policy, failed to ensure that environmental rounds were completed at least quarterly per facility policy, failed to have an established infection control committee, failed to report Covid 19 outbreaks to the state agency, and failed to maintain mechanisms of tracking Covid-19 outbreaks reported to the state agency. The findings include: 1. Observation on 11/29/23 at 6:30 AM on the third floor east side identified a 2-bin dirty linen cart in the hallway with a partially opened bag of briefs on the bottom shelve under the dirty linen bag, a stack of clean disposable wash cloth on top of the dirty linen hamper lid, and a new box of large gloves that was opened. The lid was missing on the hamper side with the dirty briefs…

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 interview for 3 of 5 residents (Resident #26, 46, and 80) reviewed for immunizations, the facility failed to ensure that the resident and/or resident representative was educated on and offered Covid 19 vaccinations. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included iron deficiency anemia, adjustment disorder, and failure to thrive. The quarterly MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required the assistance of one to two staff members with transfers, eating, and toilet use. A review of Resident #26's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed Covid 19 immunization status with Resident #26. The clinical record review identified a blank Covid 19 vaccination consent form located in Resident #26's paper chart. 2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included…

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 facility documentation, and interviews the facility failed develop, implement, and maintain an effective training program for all staff. The findings include: Interview with the Staff Development Nurse, (RN #2) on [DATE] at 11:00 AM indicated she was responsible to do all the education and competencies at the facility for all the staff. RN #2 indicated she had not done any mandatory education in 2022 or 2023 for existing staff and she had not done any competencies with the existing nursing staff in 2022 or 2023. RN #2 indicated she could not find any documentation or records that education had been completed in 2022 and 2023 prior to her starting in that position. RN #2 indicated she had only done education and competencies with the new hire and did not do it with anyone else. Review of the Facility assessment dated [DATE] identified staff were assigned to units based on training, education, and competencies to best care for the residents. Staff training, education, and competencies: Annual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for the 1 resident (Resident #53) reviewed for activities of daily living, the facility failed to promote dignity while dining. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated 7/3/23 directed Resident #53 to be assisted 1:1 for self-feeding of all meals due to decreased bilateral upper extremity function. Resident is to be provided built-up spoon and fork with curve. Hot drinks to be provided in [NAME] spill proof straw due to decreased grip strength, with meals. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, required supervision with eating, was dependent for bathing, personal hygiene, and was on a therapeutic diet. The care plan dated 11/1/23 identified Resident #53 required staff assistance with ADL's. Interventions included…

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 resident (Resident #67) reviewed for care planning, the facility failed to invite the resident to participate in the quarterly care plan meetings. The findings include: Resident #67 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver and abdominal distention. The admission MDS assessment dated [DATE] identified Resident #67 had intact cognition and required maximum assistance with care and was dependent on staff for transfers. Review of the resident care plan sign in sheets dated 4/14/22 - 9/28/23 identified the following. a. A care plan meeting was held 7/21/22, however, the resident care plan sign in sheet identified Resident #67 had not signed in as attending. Review of the nursing and social service notes dated 7/15/22 - 7/25/22 did not reflect Resident #67 was invited to participate in his/her resident care plan meeting or had refused to attend. b. The clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interview for 1 of 3 residents (Resident #22), who was discharged from the facility with Medicare A days remaining, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to the resident upon his/her discharge. The findings include: Resident #22 was admitted to the facility on [DATE] on Medicare A. Facility documentation, provided to the survey team on 11/28/23, identified Resident #22 was discharged home on [DATE] with Medicare A benefit days remaining. Interview with the RN #1 on 11/29/23 at 11:00 AM identified facility staff have looked, and they cannot find the NOMNC that had been provided to Resident #22 upon his/her discharge. Although requested, the facility could not determine if a Notice of Medicare Non-Coverage (NOMNC) had been provided to Resident #22 upon his/her discharge from the facility.

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 #20) reviewed for communication, the facility failed to follow up on the resident's complaint of lost hearing aids. The findings include: Resident #20 was admitted to the facility with diagnoses that included mild cognitive impairment and hard of hearing. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition and had moderately impaired hearing and did not have hearing aids. Additionally, resident requires extensive assistance with care. The care plan dated 3/20/23 identified resident was hearing impaired. Interventions included to offer audiology consultation as needed and gain his/her attention before attempting to communicate to resident. Review of the April and May 2023 MAR's and TAR's identified staff was not signing that the residents hearing aids were being applied in the morning and removed in the evening. Review of the nurse's notes and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 5 residents (Resident #80) reviewed for preadmission screening and resident review (PASARR), the facility failed to ensure a Level 1 PASARR screening was completed prior to admission to the facility. The findings include: Resident #80 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, and vascular dementia. The annual MDS dated [DATE] identified Resident #80 had severely impaired cognition and delusions as a potential indicator of psychosis, in the last 7 days. The care plan dated 8/31/23 identified Resident #80 had a disruption in cognitive operations and activities, had exhibited compulsive/delusional behaviors, and could be accusatory, at times. Interventions included discussing with the resident alternative ways to express emotion and release physical tension, involve the resident in treatment planning and decision making, and consulting psychiatric services, as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #53) reviewed for rehabilitation and restorative services, the facility failed to develop a comprehensive care plan that included interventions for refusals of care and refusals of specialized rehabilitation services and for 1 of 3 residents (Resident #54) reviewed for pressure ulcers, the facility failed to develop a comprehensive care plan following the onset of a new pressure ulcer. The findings include: 1. Resident #54 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, hemiplegia, and gastrostomy status. The nursing admission assessment dated [DATE] identified Resident #54 had bilateral heel deep tissue injuries, an ulcer to the back of the head, and a stage 3 pressure ulcer to the coccyx. Special treatments included skin prep to the bilateral heels and daily dressing changes to the back of the head and coccyx. The nursing admission 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 review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #53 and 67) reviewed for activities of daily living, the facility failed to conduct quarterly resident care conferences and/or invite the resident to attend the meetings. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. Review of the resident care plan sign-in sheet identified a resident care conference was held on 3/22/23. The quarterly MDS dated [DATE] identified Resident #53 had intact cognition, was always incontinent of bowel and bladder, required supervision with eating, was dependent for bathing, personal hygiene, rolling left to right, laying to sitting, and was on a therapeutic diet. The care plan dated 11/1/23 identified Resident #53 was admitted to the facility for short term rehabilitation (STR) after being hospitalized for STR. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #451) reviewed for accidents, the facility failed to administer medications according to professional standards of practice to prevent a medication error, and as a result, a medication that the resident had an allergy to was administered. The findings include: Resident #451 was admitted to the facility on [DATE] with diagnoses that included Sjogren syndrome, anxiety disorder, chronic pain. Further, Resident #451 had an allergy to acetaminophen. The admission MDS dated [DATE] identified Resident # 451 had intact cognition, with supervision needed for bed mobility, transfers, locomotion and dressing. A physician's order dated 10/17/22 directed to administer Oxycodone 5mg daily for pain for 10 days as needed, expiring on 10/27/22. The nurse's note dated 10/28/22 at 6:16 AM by RN #5 identified Resident #451 was given Oxycodone-Acetaminophen (Percocet) about 12:10 AM instead of Oxycodone 5mg…

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 resident (Resident #20) reviewed for communication, the facility failed to assist the resident to replace hearing aids when they were lost. The findings. Resident #20 was admitted to the facility with diagnoses that included mild cognitive impairment and hearing impairment. The quarterly MDS dated [DATE] identified Resident #20 had moderately impaired cognition, moderately impaired hearing and did not have hearing aids Additionally, the resident required extensive assistance with care. The care plan dated 3/20/23 identified the resident was hearing impaired. Interventions included to offer audiology consultation as needed and gain his/her attention before attempting to communicate to resident. Review of the MAR and TAR's dated 4/1/23 - 5/31/23 identified nurses were not documenting if hearing aids were being applied or removed daily. Review of the nurse's notes and physician progress notes dated 4/1/23 - 5/31/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 3 residents (Resident #26, 49 and 54) reviewed for pressure ulcer, the facility failed to follow the policy for Braden Scale assessments, failed to have treatments in place for a new pressure ulcer, failed to follow the air mattress manufacturer's recommendations, failed to complete weekly wound assessments by a registered nurse including wound documentation, failed to complete weekly body audits, failed to accurately complete weekly body audits, and failed to implement appropriate preventative measure. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included failure to thrive and deep vein embolism and thrombosis. The physician's order dated 4/24/23 directed to complete a Braden Scale on admission and every week for 4 weeks, (5/1, 5/8, 5/15 and 5/22/23). The care plan dated 4/27/23 identified the Braden Scale was to be completed on admission and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 resident, (Resident #46) reviewed for range of motion, the facility failed to complete nail care on a resident with contracted hands to keep nails short. The findings include: Resident #46's diagnoses included vascular dementia, cerebral infarction with right sided body paralysis. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition and was totally dependent with the assist of two for bed mobility, dressing and personal hygiene. The care plan dated 9/26/23, identified Resident #46 was dependent on staff for activities of daily living. Interventions included, assisting with skin care, mouth care and incontinent episodes. Observation on 11/30/23 at 12:34 PM identified Resident #46's hands appeared contracted, were closed fisted and the left hand pointer fingernail was long and jagged, with black debris under the nail. The surveyor was unable to visualize the other…

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 7 of 7 residents (Resident #9, 27, 48, 50, 51, 61, and #66) reviewed for accidents, the facility failed to provide supervision of the residents during the fire drill, and for 1 of 9 residents (Resident #29) reviewed for accidents, the facility failed to ensure that 1:1 supervision was provided to a resident with an identified aspiration risk, and for the only sampled resident (Resident #53) reviewed for activities of daily living, the facility failed to ensure medications were not left unsecured in the resident's room. The findings include: 1a. Resident #9 was admitted to the facility with diagnoses that included stroke with hemiplegia, dementia, and anxiety. The quarterly MDS dated [DATE] identified Resident #9 had severely impaired cognition and required total assistance with care. The care plan dated 10/20/23 identified Resident #9 was at risk for falls. Interventions included having the call light in reach…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #52 and 53) reviewed for nutrition, for Resident #52, the facility failed to do weights per policy and physician order and for Resident #53 the facility failed to ensure the meals received were in accordance with the ordered therapeutic diet. The findings include: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and quadriplegia. Review of the weight record dated [DATE] identified Resident #52 weighed 128 lbs. A physician's order dated [DATE] directed to provide 1:1 assistance with feeding. The admission MDS dated [DATE] identified Resident #52 had severely impaired cognition and required maximum assistance with eating. Review of the weight record dated [DATE] identified Resident #52 weighed 133.8 lbs., (a 5.8 lbs. increase from the previous weight dated [DATE]). Review of the weight record dated [DATE] identified 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 observation, review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #69) reviewed for enteral feeding, the facility failed to ensure the resident received care and services to prevent complications (infection). The findings include: Resident # 69 was admitted to the facility on [DATE] with diagnoses that included Glucose-6-Phosphate Dehydrogenase (G6PD), right leg below knee amputee, and hypotension (low blood pressure). Resident #69 also had a court appointed conservator. The admission MDS dated [DATE] identified Resident #69 had moderately impaired cognition, required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #69 receives nutrition via feeding tube. The care plan dated 7/24/23 identified a concern with enteral feeding with interventions that include to care for insertion site as ordered and to watch for sign and symptoms of intolerance such as abdominal pain, nausea, diarrhea, constipation,…

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 facility documentation, and interviews, the facility failed to ensure that the DNS did not serve as the RN supervisor. The findings include: Review of DNS job description dated 9/25/23 identified he/she was to plan, organize, develop, and direct the overall operations of the nursing services department in accordance with current federal, state, and local standards and regulations and as directed by the Administrator. Interview with the DNS on 12/7/23 at 8:20 AM indicated that she was required to act as the day supervisor on 11/20/23 from 7:00 AM - 4:00 PM and was responsible to do any RN assessments as needed. The DNS indicated there are times when she has had to supervise, and other times the ADNS will supervise. Review of the schedules dated 11/15/23 - 12/2/23 identified the DNS acted in the capacity of the day supervisor on 11/16, 11/20, 11/24, 11/27, 11/29, 11/30, and 12/1/23 for the 7:00 AM - 3:00 PM shift, and she leaves the facility each day about 4:00 PM, even if she was the supervisor…

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 interview, for 1 of 5 residents (Resident #80) reviewed for unnecessary medications, the facility failed to identify and monitor target behaviors for a resident receiving an antipsychotic medication since admission, over 8 months. The findings include: Resident #80 was admitted to the facility on [DATE] on an antipsychotic medication with diagnoses that included dementia with psychotic disturbance, major depressive disorder, anxiety and bipolar disorder. Physician's order dated 4/6/23 directed to administer Olanzapine (antipsychotic medication) 5mg daily for behaviors. Physician's order dated 4/18/23 directed to discontinue Olanzapine (antipsychotic medication) 5mg daily for behaviors. Physician's order dated 4/20/23 directed to administer Depakote (medication used to treat some psychiatric conditions) 500mg every evening for mania. Physician's order dated 4/21/23 directed to administer Depakote 250mg daily for mania, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #26, 45, 46, and 80) reviewed for immunizations, the facility failed to ensure that the resident and/or resident representative was educated on, or offered influenza and/or pneumococcal vaccinations. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included iron deficiency anemia, adjustment disorder, and failure to thrive. The quarterly MDS dated [DATE] identified Resident #26 had moderately impaired cognition and required the assistance of one to two staff members with transfers, eating, and toilet use. A review of Resident #26's clinical record on 12/1/23 failed to identify any documentation that the facility reviewed pneumococcal immunization status with Resident #26. The clinical record review identified that Resident #26 had a consent status of to be determined for the Pneumovax 23 vaccine. Further review of Resident #26's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for the 1 resident (Resident #53) reviewed for activities of daily living, the facility failed to provide a dependent resident with weekly showers. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, type 2 diabetes mellitus, anxiety disorder, morbid obesity, and spondylosis. A physician's order dated 3/7/23 directed staff to provide a shower every Saturday on the 7:00 AM - 3:00 PM shift. Review of the TAR's dated 9/1/23 through 12/6/23 failed to identify Resident #53 refused showers, the documentation identified showers were given weekly on the scheduled shower days, Saturday 7:00 AM - 3:00 PM. Review of the nurse's note dated 9/1/23 through 9/30/23 identified a progress note dated 9/2/23 indicating Resident #53 refused a shower/bed bath twice, this shift. Review of the nurse's notes dated 10/1/23 through 12/6/23 failed to identify Resident #53 refused scheduled showers or…

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 abuse, the facility failed to ensure the residents were free from mistreatment, and failed to ensure alternate access to a visitor was offered. The findings include: Resident #1 was admitted with diagnoses that included polyneuropathy, chronic obstructive pulmonary disease (COPD) and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as alert and oriented, and required supervision with one (1) person for transfers and ambulation in the room. A Resident care plan (RCP) dated 7/20/2023 identified Resident #1 was impulsive and could not always control behaviors directing anger towards others by speaking loudly. Interventions directed if observed becoming angry to assist to another area, avoid information overload and for Resident #1 to call for assistance if another resident directed their anger towards her/him. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one of three residents (Resident # 6) reviewed for abuse, the facility failed to review and revise the resident's care plan after and allegation of abuse regarding staff to resident. The findings include: 1.Resident #6 was admitted on [DATE] with diagnoses that included personality disorder, adjustment disorder and type II diabetes mellitus. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was without cognitive impairment and was independent with locomotion on and off the unit with the utilization of a wheelchair. The Resident Care Plan (RCP) dated 7/30/21 identified Resident #6 could be physically and verbally aggressive with impulsiveness. Interventions included: to not express anger or impatience verbally or with physical movements which would likely increase confusion and agitation, to be cognizant of not approaching the resident's personal space and to do not make unrealistic…

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, observations, review of facility policy and interviews for one of two residents (Resident #1) reviewed for vision and hearing, the facility failed to ensure the resident received and maintained assistive devices to maintain hearing abilities. The findings include: Resident #18's diagnoses included dementia with behavioral disturbances, depressive episodes, anxiety disorder and Parkinson's disease. The quarterly MDS assessment dated [DATE] identified Resident #18 had severe cognitive impairment and required extensive assistance of one-person physical support for dressing, difficulty hearing and noted the resident required hearing aids. The care plan identified the resident has a hearing deficit. Hearing aids are broken, and new mold ordered. See Audiology Consultation on 4/26/19 updated . Hearing device in place until new hearing aids in. Interventions include: to refer resident for an audiology evaluation as needed, to get resident's attention before speaking, face…

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 resident (Resident #46) reviewed for accidents, the facility failed to follow physician's order for the resident's transfer status to prevent a potential accident. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, a history of falling, left sided homonymous bilateral field defects, neurologic neglect syndrome, left foot drop and obesity. The care plan dated 3/8/21 identified a need for staff assistance with Activities of Daily Living (ADL) and a risk for falls. Interventions directed to follow physician transfer orders and to encourage the resident to ask and wait for staff assistance for transfers. The quarterly MDS assessment dated [DATE] identified Resident #46 had intact cognition, was incontinent of bowel and bladder and required 2 persons physical assistance with transfers. The 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 review of the clinical record, observations, facility policy, and interviews for one resident (Resident #272) reviewed for pain management, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice related to pain management and in accordance with the physician's orders. The findings include: Resident #272 was admitted to the facility on [DATE] with diagnoses that included polyneuropathy, pain in right hip, bilateral osteoarthritis of knee, cervical disc degeneration, rheumatoid arthritis. The care plan dated 10/8/21 identified a risk for pain/discomfort. Interventions directed to provide pain medication as ordered and to observe the resident for signs/symptoms associated with pain. The admission MDS assessment dated [DATE] identified Resident #272 had intact cognition, was occasionally incontinent of bowel and bladder and required assist of 1 with transfers. A physician's order 2:45 P.M. dated 10/13/21 directed to give Ultram 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.

Based on observation of the facility medication storage of the Emergency Medication Box (Ebox), review of facility policy and interviews, the facility failed to ensure medications were labeled in accordance with professional standards. The findings include: Observations on 10/15/21 at 10:15 A.M. identified 2 medications were found to be expired in the Emergency Medication Box (Ebox). A review of medications in the Ebox on the second floor indicated 19 pills in blister packs labeled Diazepam 5 MG, with an expiration date of 7/2021. Additionally, in the medication Ebox 13 pills in blister packs labeled Morphine 15 MG were noted to have an expiration date of 8/2021 and noted was a used vial of multiuse Tuberculosis vaccine with an expiration date of 7/6/2021. Interview with RN #2 at that time of the observation on 10/15/21 identified she did not check the expiration dates and indicated she was not aware of how often the medication Ebox should be check for expired medications. Interview with DNS at 10:23 A.M. identified the facility did not have a schedule for checking expired…

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, observations, review of facility policy and interviews for one resident (Resident #18) reviewed for dental, the facility failed to provide emergency dental services. The findings include: Resident #18's diagnoses included dementia with behavioral disturbances, depressive episodes, anxiety disorder and Parkinson's disease. The care plan for ADL dated 11/11/20 identified Resident #18's dentures are chipped. Interventions included: to offer to assist the resident with placing and removing dentures each day. Offer to assist the resident with cleaning and soaking dentures overnight with nightly care. Dentist as ordered/needed. Additionally, the care noted resident wears dentures: to please provide good mouth care and make sure the residents dentures are given to him/her daily and assist with mouth care as needed. Please ensure the resident's dentures are cleaned daily and are available to me each day. Further review of the resident's care plan failed to identify a care for…

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