Capitol City Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews for one (1) of 65 sampled residents, it was determined that facility staff failed to ensure that extra tracheostomy supplies were available at the bedside for a resident who is tracheostomy dependent. Resident #17. The findings included:A facility policy titled 'Tracheostomy Care' with a review date of 06/26/2025 documented, in part: 3b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu [manual resuscitator] bag easily accessible for immediate emergency care. A review of Resident #17's medical record revealed: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Respiratory Failure with Hypoxia, Tracheostomy Dependent, Aphasia and Seizure Disorder. A care plan dated 10/10/25 documented, in part: Focus: [Resident #17's name] has trach (tracheostomy) sz (size) 6 Shiley, sz 6.5 TC (tracheostomy collar) . Interventions: Keep extra trach tube and obturator at bedside. 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 record review and staff interviews, for one (1) of 65 sampled residents the facility staff failed to ensure nursing staff functioned with the appropriate competencies and skills to provide nursing and related services to assure resident safety as evidenced by the nurse's administration of a significant medication error. Resident #317 The findings included: Resident #317 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Dependence on Dialysis, Type 2 Diabetes Mellitus, End-Stage Renal Disease, Cerebrovascular Accident (Stroke), Dysphonia, and Need for Assistance with Personal Care. A review of Resident #317's medical record showed: A care plan initiated on 04/30/2025 that documented: [Name of Resident #317] has vision impairment/hearing impairment r/t (related to) blindness in the right eye and deafness in the left ear. Goal: [Name of Resident #317] will maintain optimal quality of life within limitations imposed by visual function through the next 90 days.…

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: Number of residents cited: Based on observation, record review, and staff interviews, the facility staff failed to establish a consistent location for the pharmacist's monthly medication review recommendations for each resident, thereby ensuring that the pharmacist's findings were available for review upon request. Resident #8 The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Epilepsy, Hypertension, Bipolar Disorder, Schizoaffective Disorder, Viral Hepatitis C, and Generalized Muscle Weakness. A review of Resident #8's medical record showed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE], which documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that Resident #8 had intact cognition. In addition, the assessment documented that the Resident had received the following medications during the last 7 days of the assessment: a hypoglycemic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews for two (2) of 65 sampled residents, the facility staff failed to ensure that food services accommodated one (1) resident's allergy to eggs and personal preferences for two (2) residents. Residents #89 and #67). Resident #89 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis, Type 2 Diabetes with Hyperglycemia, Discitis, End Stage Renal Disease, and Weakness. A review of Resident #89's medical record revealed the following: A physician's order dated 02/21/25 that stated: LCS/NAS (low concentrated sweets/no added salt) diet, regular texture, thin liquids consistency. A History and Physical assessment dated [DATE] at 12:00 AM that documented: .C . 2.Meds .Allergies: aspirin, codeine, and eggs. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating that the resident had intact cognition and the resident had 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.

Number of residents sampled: Number of residents cited: Based on residents' interviews, observation, and staff interviews, the facility staff failed to ensure residents received pm snacks. The findings included:A policy titled, Offering/Serving Bedtime Snacks with a review date of 08/15/25 instructed nursing staff to offer bedtime snacks to residents in accordance with resident's needs, preferences and requests on a daily basis.During the task of Resident Council meeting on 01/14/26 starting at 2:43 PM held with multiple residents from different units in the facility stated that they are not provided with pm snacks. Additionally, Resident #10 stated that they do have pm snacks for specific residents and their names are on the snack. The resident said that he can only get a pm snack if the resident who it is assigned to refuses it. During observations of kitchen on Unit 1 south and 3 south on 01/15/26 starting at 10:30 AM revealed multiple sandwiches with residents' names.During a face-to-face interview with the Administrator and Executive Director on 01/15/26 at approximately 3PM…

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.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, facility staff failed to prepare and distribute foods under sanitary condition, as evidenced by the following observations. The findings include:During a walkthrough survey in the kitchen on 01/06/2025 approximately at 9:30AM, the following observations were made: Cleaned and sanitized food contact utensils stored on rack that had no minimum 6 inches clearance from floor to prevent potential contamination at the manual dish washing area in the kitchen. There was no proper test kit provided to monitor food contact surface sanitizing solution concentration at the 3-compartment sink manual dish washing and for the sanitizing buckets. Single use coffee cups and lids left on floor under coffee making station. Food service director, Employee #20, was immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 01/06/2026, approximately at 10:00 AM, the above observations were acknowledged by Employee #20, Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that facility staff failed to show documented evidence that the facility's visitor logbook was retained with accuracy and documentation of gastrostomy management was lacking for one resident. (Residents #55 and #220). The findings included: Resident # 55 was admitted to facility on 04/03/2025 with diagnosis of diabetes mellitus, myocardial infarction, fluid overload, hypertension, osteoarthritis and congestive heart failure. Resident #55 reported to facility staff that on 04/07/2025, two hundred (200) dollars was missing from his room. He was residing on unit 2 South when this happened. On 02/06/2026 at 1:12 PM during an interview with Resident #55, in response to an inquiry regarding how he obtained the 200 dollars, he stated, my cousin [name] visited and gave it to me. A review of the visitor's logbook for 2south where the resident resided at the time showed that the pages were missing for the dates during 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 Number of residents sampled: Number of residents cited: Based on observations, record review, and staff interviews for one (1) of 65 sampled residents, the facility staff failed ensure no breaks in infection control by failing to wear proper personal protective equipment while providing incontinent care for a resident on Enhanced Barrier Precautions (EBP). Residents #3 The findings included: A facility policy entitled, Enhanced Barrier Precautions (EBP), reviewed and revised on 06/26/25, that documented: .Definitions: Enhanced Barrier Precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug -resistant organisms that employ targeted gown and glove use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.3. Implementation of Enhanced Barrier…

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.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, the facility staff failed to maintain essential kitchen equipment in good working condition as evidenced by the following:The findings include:During the initial walkthrough survey in the kitchen on 01/06/2026, the following observations were made: One (1) of one (1) the reach-in refrigerator in kitchen located next to the ice making machine was leaking condensate water inside its food storage chamber,The refrigerator referenced in above item #1 was missing light bulb cover inside its food storage chamber,Dish washing machine area - the spray hose storage hook was in poor repairDish washing machine area - atmospheric backflow preventer valve cover was in poor repairBroken garbage disposer attached underneath a food preparation sinkLeaking drainpipe under the food preparation sink at the cooklineThe ventilation exhaust hood in kitchen was missing grease trap pan and one grease filterFood service director, Employee #20, was immediately made aware of these findings and proceeded 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 Number of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet facilities.The findings include:During an environmental walkthrough of the facility on January 21, 2026, approximately between 10:30 AM and 2:00 PM, the following issues were identified out of 52 surveyed resident rooms on 1st, 2nd and 3rd floors of the facility building:Resident call lights were not functional in room [ROOM NUMBER]-A, 134-B, 132 - toilet room,152-A, 122-A and B, 106-A, 111-toilet room.Facility leadership was immediately made aware of these findings and proceeded to implement measures to address these issues.The observations were acknowledged by Employee #19, Maintenance Director, during a face-to-face interview on January 21, 2026, approximately at 2:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to equip corridors with firmly secured handrails.The findings include:During an environmental walkthrough of the facility on January 21, 2026, between 10:30 AM and 2:00 PM, it was observed that some of the handrails in 1-South unit corridors were not firmly secured to the adjacent wall, and the handrail near to room [ROOM NUMBER] was missing end cap.These observations were acknowledged by Employee # 19, Maintenance Director, approximately at 1:45 PM on 01/21/2026 approximately at 1:45 PM.

Number of residents sampled: Number of residents cited: Based on observations and interview, the facility staff failed to maintain an efficient pest control system as evidenced dead cockroaches were seen on floor at the cookline area in the kitchen.The findings include:1. Five (5) dead cockroaches observed under food preparation sink with leaking drainpipe at the cookline in the kitchen.Facility leadership was immediately made aware of these findings and proceeded to implement measures to address these issues.Employee # 20, Food Service Director, acknowledged the findings during a face-to-face interview on January 6th, 2026, at approximately 10:00 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, facility staff failed to follow a physician order with timeliness, as evidenced by the transfer of a resident to the emergency room for a higher level of care approximately three (3) hours after receiving the order for one of three sampled residents. Resident #20 The findings included: Resident #20 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Sacral Wound, Ambulatory Dysfunction, Diabetes Mellitus and Bipolar Disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident had a Brief Interview for Mental Status summary score of 13 indicating that the resident was cognitively intact. Additionally, the resident was coded for being dependent on staff for all activities of daily living and having an unstageable sacral pressure ulcer. A physical medicine and rehabilitation note dated 09/02/25 at 5:18 PM documented in part, Pt (patient) at bedside, alert some disorientation, asking about the location…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews for one (1) of 12 sampled residents, the facility staff failed to show accurate documentation for a resident who was dependent on staff for Activities of Daily Living care and ensured he was offered and provided a shower or bath on scheduled days as prescribed by the physician. Resident #1.Based on record review and staff interviews for one (1) of 12 sampled residents, the facility staff failed to show accurate documentation for a resident who was dependent on staff for Activities of Daily Living care and ensured he was offered and provided a shower or bath on scheduled days as prescribed by the physician. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Diabetes Mellitus, Peripheral Neuropathy, Lumbar Spine injury s/p (status post) Laminectomy and Spinal Fusion on Thoracic 11-L (Lumbar) 3 and chronic Lower Extremity Lymphedema.A review of Resident #1's medical record revealed:A physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) of eleven (11) sampled residents, facility staff failed to ensure that a care plan meeting was held or that a comprehensive care plan review was done at least quarterly (every 90 days) for one resident. Resident #11.The findings included:Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Hypertension and Major Depressive Disorder.Review of the resident's medical record revealed:A face sheet that showed the resident had a legal guardian.05/14/25 at 5:34 PM Care Plan Meeting Note: Readmission/Quarterly care plan meeting: IDT (interdisciplinary team) reviewed resident's plan of care, medication, diet, and EOL (end of life) planning. [Resident #11] is a LTC (long term care) resident. Code Status: DNR (do not resuscitate). Resident has no funeral arrangement in place. IDT will continue to monitor and assist.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of eleven (11) sampled residents, facility staff failed to ensure that the residents received medications as ordered by the physician. Residents #1 and #2.The findings included:Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Epilepsy, Cerebral Infarction, and Benign Neoplasm of Cerebral Meninges.Review of the resident's medical record revealed the following:An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognitive status.08/17/25 at 10:55 AM Nurses Note: - Positive for COVDI-19.- Nurse Practitioner (NP) made aware; ordered to transfer resident from room [ROOM NUMBER]A to room [ROOM NUMBER]A and for the resident to be on Paxlovid (antiviral medication to treat mild-to-moderate COVID-19) twice a day for 5 days. 08/17/25 at 11:09 AM Nurse Practitioner Progress Note: - Updated 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 observation, record review and staff interviews, for one (1) of eleven sampled residents, facility staff failed to minimize risks to a resident receiving intravenous (IV) therapy as evidenced by failing to label and date, as appropriate, the IV infusion tubing. Resident #1.The findings included:A facility policy titled, Intravenous Therapy dated 06/25/25 documented:- All IV tubing is to be labeled with date, time and initials.Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included: Epilepsy, Cerebral Infarction, and Benign Neoplasm of Cerebral Meninges.Review of the resident's medical record revealed the following:An Annual Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 09, indicating moderately impaired cognitive status.08/22/25 at 6:15 PM Nurse Practitioner Progress Note: - Blood culture results were reviewed.- Blood culture (both bottles): Staphylococcus hominis…

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, record review and staff interviews, for one (1) of eleven (11) sampled residents, facility staff failed to demonstrate competent nursing competencies and skills sets to provide safe nursing services as evidenced by a licensed nurse crushing resident medications that were labeled, Do not crush and without a physician's order. Resident #11. The findings included:A facility policy titled Medication Administration dated 06/11/25 documented:- Administer medication as ordered in accordance with the manufacturer specifications. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Hypertension and Major Depressive Disorder. Review of the resident's medical record revealed:A physician's orders dated 05/13/25 directed, Ferrous Sulfate (iron supplement) oral tablet 325 MG (milligrams), give 1 tablet by mouth one time a day related to Anemia.A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview…

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

Based on observation and staff interviews, facility staff failed to ensure that the medication error rate was less than 5%. The findings included: A facility policy titled Medication Administration dated 06/11/25 documented:- Administer medication as ordered in accordance with the manufacturer specifications.During a medication administration pass on unit 3 south on 08/26/25 at 9:00 AM with Employee #6 (Licensed Practical Nurse/LPN), two (2) medication errors were observed in five (5) opportunities, equaling a medication error rate of 40%. Employee #6 was observed crushing two (2) medications that had manufacturer labeled specifications to Do not crush on the blister packets. During a face-to-face interview at the time of the observation, Employee #6 was asked why she crushed the medications. Employee #6 stated, The resident gets all her medications crushed in applesauce because she has a swallowing issue and is on a thickened liquid diet. During a face-to-face interview on 08/26/25 at 9:34 AM, the findings were brought to the attention of Employee #7 (3 south Unit Manager) who…

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

Based on observations, record reviews and staff interviews, facility staff failed to implement infection control policies and procedures as evidenced by multiple staff observed not following posted personal protective equipment (PPE) requirements throughout the facility.The findings included: Review of the facility's Infection Prevention and Control Program dated 06/27/25 documented:- Staff include all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, and others who provide care and services to residents on behalf of the facility. - All staff are responsible for following all policies and procedures related to the infection control program.- All staff shall use PPE according to established facility policy governing the use of PPE. A facility tour was conducted on 08/22/25 starting at 4:26 PM with Employee #3 (Infection Preventionist). It should be noted that the facility was in a current outbreak with 16 residents positive for COVID-19. Employee #3 stated that unit 2 north was the designated COVID-19 unit. At the entrance of unit 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 11 sampled residents, facility staff failed to administer the COVID-19 immunization as ordered for Resident #7. The findings included:Review of the facility's Infection Prevention and Control Program dated 06/27/25 documented:- Residents and staff will be offered the COVID-19 vaccine when supplies are available to the facility.- The resident's medical record includes documentation that included each dose of COVID-19 vaccine administered, if the resident did not receive the COVID-19 vaccine, the reason(s) why. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes Mellitus, Congestive Heart Failure and Alzheimer's Disease. Review of the resident's medical record revealed the following: A face sheet that documented the resident's daughter as her responsible party (RP).An immunization record that showed that the last COVID-19 booster vaccine that Resident #7 received was on 09/14/22.A Significant Change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for one (1) of three (3) sampled residents, the facility staff failed to notify the State Agency of an allegation of abuse/neglect or injury of unknown origin within 24 hours of an incident involving Resident #1 who was found by staff with bloodied bed linens and with cuts to his right wrist from a disposable razor on [DATE]. The findings included: A review of the facility's policy titled Abuse, Neglect and Exploitation dated revised on [DATE] documented the following: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: Immediately, but not later than 2 hours after the allegation is made, If the events that cause the allegation involve abuse or result in serious bodily injury or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for one (1) of three (3) sampled residents, the facility staff failed to develop a comprehensive, person-centered care plan that documented the residents' use of a communication aid which the resident needed in order to communicate with others. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Paranoid Personality Disorder, Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction Without Residual Deficits, Adult Failure to Thrive and Hereditary Ataxia. A review of Resident #1's medical record revealed the following: A review of a document titled Speech Therapy SLP (speech language pathology) Discharge Summary date of service 04/25/24-07/10/24 documented the following LTG (long term goal) #1.0 Met on 06/04/24, Pt (patient) will increase communicative effectiveness from severely impaired to moderately impaired with use of trained strategies and use of aids. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) of nine (9) sampled residents, facility staff failed to ensure that reasonable accommodations for a room assignment was provided for a resident that did not endanger his health or safety as evidenced by placing Resident #2 (new admission), with a known history of physically aggressive behaviors toward other residents, in a room with Resident #1, also with a known history of physical aggression towards other residents and staff. The findings included: Resident #2 Background: Resident #2 was previously admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Metabolic Encephalopathy and Muscle Weakness. Review of the resident's medical record showed the following: A census tracking sheet that showed he resided on unit 3 south, room [ROOM NUMBER] bed B since 02/14/22. A Nursing Note dated 03/04/24 at 9:59 AM that documented: - Writer was informed that [Resident #2] pushed Resident #3 out of his wheelchair causing the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of nine (9) sampled residents, the facility's staff failed to provide a resident with written notice that a new roommate had been assigned to his room on 06/06/24. (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Schizoaffective Disorder, Anxiety, and Depression. A quarterly Minimum Data Set, dated [DATE] documented in part, the resident had a Brief Interview for Mental Status summary score of 15 indicating that the resident's cognitive status was intact. The resident was coded for having physical behaviors (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed toward others, verbal behaviors (e.g., threatening others, screaming at others, cursing at others) directed toward other, and rejection of care. Also, the resident was coded for using anti-psychotic medications on a routine basis. A care plan dated 05/01/24 documented in part, Focus area-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of nine (9) sampled residents, the facility failed to ensure that Resident #8 received appropriate treatment, services, care and management related to complications (clog) of his enteral feeding tube. The findings included: According to the National Institute of Health (NIH) - Gastrostomy tube (G-tube) malfunction is commonly encountered by nurses, physician assistants, nurse practitioners, and physicians in clinical practice. The team should have a working knowledge of how to handle G-tube problems and provide appropriate intervention and assistance in resolving the dysfunction. https://www.ncbi.nlm.nih.gov/books/NBK482422/ According to the Gastrointestinal Endoscopy Journal: - A common post Percutaneous Endoscopy Gastrostomy (PEG) complication is a clogged tube. - Occasionally, a clogged PEG tube can be opened with the administration of warm water, a canned carbonated beverage, or pancreatic enzymes. - We do not recommend the use of wires or brushes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of nine (9) sampled residents, the licensed nursing staff failed to demonstrate the appropriate competencies and skill sets to provide nursing services to assure resident safety and well-being of each resident. Resident #8. The findings included: According to the National Institute of Health (NIH) - Gastrostomy tube (G-tube) malfunction is commonly encountered by nurses, physician assistants, nurse practitioners, and physicians in clinical practice. The team should have a working knowledge of how to handle G-tube problems and provide appropriate intervention and assistance in resolving the dysfunction. https://www.ncbi.nlm.nih.gov/books/NBK482422/ According to the Gastrointestinal Endoscopy Journal: - A common post Percutaneous Endoscopy Gastrostomy (PEG) complication is a clogged tube. - Occasionally, a clogged PEG tube can be opened with the administration of warm water, a canned carbonated beverage, or pancreatic enzymes. - We do not recommend the use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility staff failed to have documented evidence that residents care plans (with goals and approaches to address resident needs) were reviewed for effectiveness and revised following each MDS assessment for 10 of 16 sampled residents. Residents' #1, #2, #4, #5, #6, #7, #8, #9, #11 and #12 The findings included: 1.Resident # 1 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia, Bipolar, and Psychosis. An Interdisciplinary Care Conference document revealed that the last care conference meeting was held on 05/18/23. A MDS transmittal sheet showed staff completed two assessments: an annual on 11/09/23 and a quarterly on 02/09/24. Resident #1's medical record, however, revealed that there was no documented evidence that the Interdisciplinary Team reviewed and revised the resident's care plan following the previously mentioned assessments. 2.Resident # 2 was admitted to the facility on [DATE] with multiple diagnoses including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility's staff failed to have documented evidence that a physician was notified of a safety concern with an order for hourly monitoring for one (1) of 16 sampled residents. (Resident # 8) The findings included: Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including Anoxic Brain Damage, Vascular Dementia, Psychotic Disorder with Delusions due to known Psychological Conditions. A Quarterly Minimum Data Set, dated [DATE] documented in part that the resident's Brief Interview for Mental Status summary score was 03, indicating severe cognitive impairment. The resident was coded for verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), rejection of care, and wandering. A review of physician dated 01/11/24 instructed, Hourly monitoring for resident for seizure. A nursing progress note dated 01/14/24 at 8:08 AM documented, Resident has been wandering from the hallway to 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 record review and staff interviews for one (1) of 16 sampled residents, facility staff failed to respect Resident #1's right to personal privacy when they searched her room and personal belongings without getting her permission to do so. The findings included: Resident #1 was admitted to the facility on [DATE]. The resident had multiple active diagnoses that included Schizophrenia, Bipolar Disorder, and Psychosis. A review of the Resident Smoking contract signed by Resident #1 and verbally acknowledged by the resident's responsible party on 02/02/23 documented in part, smoking material of residents requiring supervision with smoking should be maintained by staff. It should be noted the resident was not given a new contract after the smoking policy was revised on 08/30/23. A review of the Smoking policy dated 8/30/23, revealed the following policy statement: It is the policy of the facility to provide reasonable accommodations to residents who smoke, while maintaining a safe environment for all…

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 the record review and staff interview, for one (2) of 16 sampled residents, the facility's staff failed to follow the Abuse policy by not: (1) reporting an incident of resident-to-resident abuse (fire incident) immediately but not later than 2 hours to the Administrator or the State Survey Agency. This is evidenced by the Administrator stating that he received notification of a residents mattress being lit by another resident on the following Monday 04/22/24 at 9:00 AM, 34 hours after the incident. In addition, the State Survey Agency was notified of the incident approximately 46 hours later; And (2) Interviewing all who might have knowledge of the allegation of resident-to-resident abuse. (Resident #1 and Resident #6) The findings included: Review of the facility's Abuse, Neglect, and Exploitation policy last revised, 01/04/2024, stipulated, immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the record review and staff interview, for one (2) of 16 sampled residents, the facility's staff failed to follow the Abuse policy by not: (1) reporting an incident of resident-to-resident abuse (fire incident) that had the potential to affect all residents immediately but no later than 2 hours after the allegation to the Administrator and the State Survey Agency. And (2) Interviewing all who might have knowledge of the allegation of resident-to-resident abuse. (Resident #1 and Resident #6) The findings included: Review of the facility's Abuse, Neglect, and Exploitation policy last revised, 01/04/2024, stipulated, immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1. The facility staff failed to report an incident of resident-to-resident abuse (fire incident) immediately to the Administrator or State Survey Agency. This is evidenced by the Administrator receiving notification approximately 34…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 16 sampled residents, the facility staff failed to take appropriate corrective action after Resident #6 used his cane to assault Resident #8 on 02/08/24. As a result, Resident #6 used his cane again to assault Resident #7 on 03/26/24. The findings included: Resident #6 was admitted to the facility on [DATE]. The resident had a history of Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Unspecified Psychosis Disorder, Generalized Anxiety, Unspecified Intracranial Injury with Loss of Consciousness, and Disorder of Brain. A nursing note dated 02/08/24 at 9:19 PM documented, Physical Aggresssion Initated: At about 4pm it was reported that the resident stated that he hit one female. Resident was asked if he hit someone? Resident said, Yes I hit her because she comes to my room to steal my stuff. She thinks I am playing with her and I am not. I hit her with my cane so that she would not come again to my room. Resident was educated on not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for three (3) of 16 sampled residents, the facility staff failed to develop a comprehensive care plan that (1) addressed safety measures for Resident #6 who used a cane inappropriately in the past. (2) addressed Resident #8's order for hourly monitoring (3) included Resident 5's physician orders for up in chair as tolerated and out of bed as tolerated in the care plan interventions. (Residents' #5 , #6, and #8) The findings included: 1. Resident #6 was admitted to the facility on [DATE]. The resident had a history of Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Unspecified Psychosis Disorder, Generalized Anxiety, Unspecified Intracranial Injury with Loss of Consciousness, and Disorder of Brain. An Annual Minimum Data Set, dated [DATE] documented in part the resident had a Brief Interview for Mental Status summary score of 13 indicating the resident was cognitively intact. The resident was coded for: no impairments with upper and lower extremities,…

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 a record review and staff interview, the administration failed to effectively and efficiently maintain a safe environment for all residents. This is evidenced by: (1) The staff to include the DON not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Administrator. (2)Resident #7 not protected from an altercation with Resident #8 following an investigation of a similar incident involving Resident #8 on 02/08/24. The facility's census on the first day of the survey was 287. The findings included: 1. The administration failed to effectively and efficiently maintain a safe environment for all residents. As evidenced by staff to include the DON (Employee #2) not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Facility Administrator. Resident #1 was admitted to the facility on [DATE] and had a medical history that included Schizophrenia, Bipolar Disorder, and Psychosis. A review of the facility's Abuse,…

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 a record review and staff interview, the governing body failed to ensure that the Abuse, Neglect, and Exploitation Policy was implemented. This is evidenced by: (1)The staff to include the DON not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Administrator. (2) Resident 6's two resident-to-resident abuse investigations not including interviews with all who might had knowledge of the incidents. (3) Resident #7 not being protected against abuse from Resident #8 following an investigation of a similar incident involving Resident #8 on 02/08/24. The facility's census on the first day of the survey was 287. The findings included: 1. The governing body failed to ensure that the Abuse, Neglect, and Exploitation Policy was implemented by the staff to include Employee #2 (DON) not reporting a fire incident immediately, but not later than 2 hours to the Survey State Agency or the Administrator. Resident #1 was admitted to the facility on [DATE] and had 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 a record review and staff interview, the Administration staff failed to ensure that their current Facility assessment dated [DATE] included services to competently care for residents who are smokers. The facility's census on the first day of the survey was 287. The findings included: A review of the smoking policy dated 08/30/23 documented in part, It is the policy of the facility to provide reasonable accommodations to residents who smoke, while maintaining a safe environment for all residents, visitors, and staff . A review of the Facility's Assessment date 02/01/24 revealed under section General Services they indicated that they would Identify Hazard and risk for Residents. The document, however, failed to identify what hazards and risk they were referring to. Additionally, the facility's assessment failed to include services provided to ensure the safety and well-being of smokers, other residents, staff, and the facility. A Master Smoking List dated 04.29.24 showed 86 residents that reside in 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 record review and staff interview, for two (2) of 16 samples residents, the facility staff failed to ensure: Resident 5's Medication Administration Record showed what the resident received and Resident #8's care plan contained accurate information. The findings included: 1.Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia and Muscle Weakness. 1a. A physician order dated 10/28/23 directed, Abilify Maintena Intramuscular Prefilled Syringe 400 milligrams inject 2 milliliters intramuscular 400 milligrams one time a day on the 28th day of month. A review of the October 2023 Medication Administration Record revealed on 10/28/24 at 9:00 AM a nurse signed her initials indicating that she administered Abilify. A physician order dated 01/08/24 directed, Abilify Maintena Intramuscular Prefilled Syringe 400 milligrams inject 2 milliliters intramuscular 400 milligrams one time a day starting on the 8th of every month for Schizophrenia. A physician order dated 02/24/24…

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's staff failed to have an effective Quality Assurance and Performance Improvement Plan (QAPI). This is evident by the plan's failure to address residents with behaviors or outline safety measures for staff to follow to ensure residents did not possess smoking paraphernalia outside of the designated smoking area. The facility's census on the first day of the survey was 287. The findings included: During the QAPI plan interview conducted on 05/02/24 at approximately 10:00 AM , the plan dated 01/26/23 documented in part, Plan - Smoking Patio Monitoring .Goal- residents will be monitored on smoking patio facility standards .Active Plan- resident will be reminded in residents council meeting that no resident is to have a lighter in their possession . Addition the QAPI binder lacked documented evidence of a plan to address residents with challenging behaviors. During a face-to-face interview on 05/02/24 at 10:34 AM, Employee # 1 (Administrator) and Employee # 17 (QAPI Nurse) reviewed the plan and stated that it was the current 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.

Based on observation, staff interview and family interview, the facility staff failed to ensure a resident's bed control did not have exposed encased wires for one (1) of 16 sampled residents. (Resident #11) The findings included: A State Agency Compliant Intake Form DC~12694 dated 04/09/24 documented in part, The control to the bed has exposed wires is often on the floor . An observation on 04/29/24 at approximately 10:00 AM showed Resident # 11's handheld bed controller was wrapped around the resident's left side bedrail. Wires encased in different color lining were observed coming from the bottom of the controller. The controller was operational, and no exposed wires were visible. During a face-to-face interview on 04/29/24 at 11:00 AM, Employee #22 Interim Maintenance Supervisor stated that after the surveyor informed him of the resident's bed control, he immediately changed it. According to the employee, nurses had not notified him about the bed controller.

Based on record reviews, policy reviews and staff interviews, the Administrative staff's actions, inactions, and decisions contributed to deficient practices as evidenced by failure to ensure that established policies and procedures were implemented. The resident census on the first day of the survey was 287. The findings included: 1. In the area of 42 CFR§ 483.45, Pharmacy Services, the Administration staff failed to ensure that Resident #8 was free of a significant medication error. On 07/19/23, a significant medication error occurred when Employee #9 (Registered Nurse/RN), administered ear drops to right eye of Resident #8, resulting in a chemical burn. Cross Reference 42 CFR§ 483.45, Pharmacy Services, F760. 2. In the area of 42 CFR§ 483.25, Quality of Care, the Administration failed to ensure that: Resident #8 received medications as ordered by the physician; Resident #4 received treatment and care in a timely manner in accordance with professional standards of practice after a sexual assault by Resident #3; and that Resident #10's hospital discharge instructions were followed.…

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, record review and staff interview, the Governing Body failed to ensure that established policies regarding the management and operation of the facility were followed and implemented related to: Quality of Care and Significant Medication Errors. The resident census on the first day of the survey was 287. The findings included: 1. In the area of 42 CFR§ 483.45, Pharmacy Services, facility staff failed to ensure that Resident #8 was free of a significant medication error. This failure resulted in actual harm to Resident #8 on July 19, 2023. Cross Reference 42 CFR§ 483.45, Pharmacy Services, F760. 2. In the area of 42 CFR§ 483.25, Quality of Care, facility staff failed to ensure that: Resident #8 received medications as ordered by the physician; Resident #4 received treatment and care in a timely manner in accordance with professional standards of practice after a sexual assault by Resident #3; and that Resident #10's hospital discharge instructions were followed. Cross reference 42 CFR§ 483.25, Quality of Care, F684. During a face-to-face interview on 08/25/23 at…

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

Based on record reviews, and staff interviews, the facility failed to ensure that the comprehensive Quality Assurance and Performance Improvement (QAPI) plan was implemented to correct identified deficiencies related to quality of care and significant medication errors. The resident census on the first day of the survey was 287. The findings included: 1. Review of the facility's most recent Recertification Survey that ended on 03/10/23 showed that the facility was cited for the following deficiencies: F684 - Quality of Care and F760 - Residents Are Free of Significant Medication Errors. An onsite revisit survey was conducted on 06/16/23 to determine compliance for the deficiencies cited during the 03/10/23 survey due to the facility alleging compliance as of 06/09/23. The onsite revisit determined the facility remained out of compliance. The facility submitted a plan of correction for the 06/16/23 revisit survey and alleged compliance as of 07/06/23. The facility's accepted plan of correction for F760 included the following: -Licensed nurses (RN/LPN) will be educated by nurse…

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 reviews and staff interviews, facility staff failed to operate and provide services in compliance with applicable Federal and State regulations as evidenced by failing to have a Licensed Independent Clinical Social Worker (LICSW) to provide direct supervision of Licensed Graduate Social Workers (LGSW). The census on the first day of the survey was 294. The findings included: Under 22B DCMR 3229.1, The facility shall provide social services to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. During a face-to-face interview on 11/14/23 at 1:00 PM, Employee #6 stated that when a resident reports an allegation of abuse to her, she then reports it to her supervisor. When asked if she reported Resident #1's allegation of abuse to her supervisor, Employee #6 stated, No. I don't have a direct supervisor right now to report to. During a review of the Social Services department human resource files on 11/15/23, it was noted that Employee #6, #7 (Social Worker) and #8 (Social Worker) had active Licensed Graduate Social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 12 sampled residents, facility staff failed to provide Resident #4's representative written information that specified the state bed-hold policy to include the number of bed hold days. The findings included: Review of the facility policy Bed hold Notice for Hospital Transfer . documented, .Upon an acute transfer to the hospital, it is out policy to contact the resident/agent as soon as possible to discuss bed holds and duration . Resident #4 was admitted to the facility on [DATE] with diagnoses that included: Mixed Receptive-Expressive Language Disorder, Dysphagia and Contractures. Review of Resident #4's medical record revealed a face sheet that showed Resident #4 had a responsible party (RP)/guardian. An Annual Minimum Data Set (MDS) dated [DATE] showed facility staff coded: rarely/never makes self understood and rarely/never understood others; severely impaired cognitive skills for decision making; required extensive assistance of two persons for 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 record review and staff interview, for three (3) of 12 sampled residents, facility staff failed to ensure that 1. Resident #8 received medications as ordered by the physician, 2. Resident #4 received treatment and care in a timely manner in accordance with professional standards of practice after a sexual assault by Resident #3, and 3. Resident #10's hospital discharge instructions were followed. (Residents' #8, #4, and #10) The findings included: Review of the facility policy Medication Administration last revised on 05/10/23 documented, .Medications are administered by licenses nurses . as ordered by the physician and in accordance with the professional standards of practice, in a manner to prevent contamination or infection . obtain and record vital signs, when applicable or per physician orders. When applicable hold medication for those vital sounds outside the physician prescribed parameters . 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Type 2…

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

Based on staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failure to identify areas for improvement and to develop and implement corrective and preventive actions. The resident census during the survey was 343. The findings included: Facility staff failed to identify areas for improvement and to develop and implement corrective and preventive actions for the deficiencies as follows: Under§483.10, F 584 Safe/clean/comfortable/ Homelike Environment Under §483.12, F600 Freedom from Abuse, Neglect, and Exploitation Under §483.25(b)(1) F686Treatment/Services to Prevent/Heal Pressure Ulcers Under §483.25(d)(2), F689 Free of Accident Hazards/ Supervision/Devices Under §483.45 F 760 Residents Free of Significant Med Errors On 3/10/23 at approximately 2:30 PM, a face-to-face interview was conducted with Employee #5 (Director of Quality Improvement) regarding Quality Assurance and Performance Improvement (QAPI). Employee #5 stated, The committee met…

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, record review, resident interview, and staff interview, for one (1) of 19 sampled residents whose personal funds are managed by the facility, the facility's staff failed to adhere to generally accepted accounting principles when acting as a manager (representative payee) for the resident's personal funds (social security benefits). (Resident #229). The findings included: Resident #229 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, [NAME] Cardia, and Muscle Weakness. A review of Resident #229's electronic medical record revealed a business office general note dated 11/22/22 at 11:57 that documented, Presented resident with NOMNC (Notice of Medicare Non-Coverage). Explained to the resident how her Medicaid benefits work in LTC (long term care) facility. She stated she does not want her money coming to the facility and refused to sign the direct deposit form. It was explained to her the facility will apply to be rep [representative]…

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, record review, and staff interviews for 8 of 105 sampled residents, facility staff failed to: 1. ensure that residents or their family members were provided information to formulate an Advance Directive and 2. ensure that current copies of the Advance Directives were in the resident's medical record. (Residents' #286, #101, #272, #29, #158, #10, #53, and #247). The findings included: 1. Resident #286 was admitted to the facility on [DATE] with multiple diagnoses that included Paraplegia, Morbid Obesity, Hypertension, Type 2 Diabetes, Peripheral Neuropathy and Muscle Weakness. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #286 had a Brief Interview for Mental Status score of 11 indicating the resident had a moderately impaired cognitive status and Functional Status for Activities of Daily Living indicating 2-person physical assistance for bed mobility, transfer, locomotion on and off unit, dressing, toilet use and personal hygiene. Review of Resident #286's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that facility staff failed to provide the housekeeping services necessary to maintain a safe, clean, and comfortable environment, as evidenced by 1. torn privacy curtains in eight (8) of 52 resident's rooms, 2. soiled exhaust vents in 15 of 52 resident's rooms, 3. trash thrown throughout the facility parking lot between February 21 and [DATE], 4. two (2) of two (2) overly packed trash cans in the facility parking lot, and 5. expired dental items in the dental office. The findings include: During an environmental walk-through of the facility on February 23, 2023, between 1:30 PM, and 4:00 PM, and on February 24, 2023, between 10:35 AM and 12:00 PM the following were observed: 1. Privacy curtains in resident rooms #106, #147, #158, #159, #160, #257, #307, and #330 were observed torn. 2. Exhaust vents were noted to be soiled in the bathroom of resident rooms #143, #152, #159, #217, #227, #228, #250, #308, #315, #329, #333, #337, #348, #351, and #352. 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.

Based on observations, record review, resident interview and staff interview, the facility's staff failed to ensure residents were able to file grievances anonymously and receive written decisions regarding their grievances. The findings included: Review of a policy tilted, Resident and Family Grievances dated 02/02/22 documented, .A grievance may be filed anonymously .In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. Multiple observations of the facility including six units, common areas, and dining areas from 02/10/23 to 03/02/23, revealed there were no physical mechanisms (for example, a drop box) for residents to anonymously file a grievance. A review of the facility's Grievance Book revealed a document titled Compliant Tracking Log for February 2023. There were ten (10) grievances listed in the grievance log. According to the log, eight (8) of the 10 grievances had been resolved.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for (3) of 105 sampled residents, the Inter Disciplinary Team (IDT) failed to conduct quarterly care planning conferences for Residents #29, #150, and #60. 1. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Schizophrenia, Acquired Absence of Right Leg Below Knee, and Acute Kidney Failure. A review of the medical record revealed the face sheet noting Resident #29 was his/her own responsible party. The following care plan meeting notes were noted: -02/10/22 at 11:17 AM, IDT (Interdisciplinary Team) reviewed plan of care, goals and interventions up to date for [Resident #29] Representative ( .) invited but unable to attend. -04/14/22 at 1:19 PM, IDT reviewed plan of care goals and interventions up to date with [Resident #29]. [Resident #29] is alert and oriented to self, place and time with intermittent confusion. He is incontinent of both bladder and bowel he needs 1 staff limit assist with ADL (Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for five (5) of 104 sampled residents, the facility's staff failed to follow physician orders or acceptable standards of practice evidenced by failing to 1. provide Resident #56's daily mouth care, resulting in extensive oral thrush (yeast infection), 2. provide Resident #130's two-person assistance with incontinent care, 3. provide Resident #493's left-hand wound treatment, 4. ensure straws were not provided to Resident #51 as ordered, and 5. offload Resident #113's bilateral heals per physician's order. (Residents #56, #51 #130, #493, and #113). The findings included: 1. Review of Resident #56's medical record showed that Resident #56 was admitted to the facility on [DATE] with diagnoses including: Tracheostomy, Chronic Respiratory Failure, Gastrostomy Status, Anoxic Encephalopathy, Traumatic Brain History and Persistent Vegetative State. Further review revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview…

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, record review, resident and staff interview for five (5) of 105 sampled residents, facility staff failed to provide food at appropriate temperatures for consumption, and that met residents preferences (Residents #143, #251, #79, #197, and #231, The findings included: 1. Resident #143 was admitted to the facility on [DATE] with multiple diagnoses that included: Cerebral Infarction, Muscle Weakness, Hypertension, Hyperlipidemia, Anemia and Gastro-Esophageal Reflux Disease. Review of Resident #143's medical record revealed a Care Plan dated 11/23/18 that documented Interventions/Tasks - Update food preferences PRN (as needed). Review of Resident #143's medical record revealed a Care Plan dated 03/13/19 that documented Interventions/Tasks - Diet: Regular. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #143 had a Brief Interview for Mental Status score of 15 indicating the resident had an intact cognitive status and a Functional Status for Activities of Daily…

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

Based on observations and staff interview, facility staff failed to distribute and serve foods under sanitary conditions as evidenced by foods such as puree Salisbury Steak, puree peas, and from the regular menu, mashed potatoes that tested below 135 degrees Fahrenheit (F). The findings include: Lunch food temperatures were inadequate and failed to test at 135 degrees Fahrenheit (F) or more during a food tray test on January 4, 2023, at approximately 1:00 PM, on three (3) of five (5) observations. Pureed menu Salisbury steak tested at 133.3 degrees Fahrenheit (F), and pureed peas tested at 131.3 degrees. Regular menu Salisbury steak tested at 135 degrees F, Mashed potatoes tested at 134 degrees F and peas tested at 137.8°F. Employee #7 acknowledged the findings on February 21, 2023, at approximately 1:45 PM

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident interview, and staff interviews for six (6) of 104 sampled residents, the facility's staff failed to ensure resident's records contained accurate documentation. (Residents #132, #93, #101, #313, and #492.) The findings included: 1. The facility's staff failed to ensure Resident #313's Nutritional Intake Summary forms dated 02/07/23 to 02/09/23 accurately documented foods consumed or not consumed by the resident. Resident #313 was admitted to the facility with multiple diagnoses including: Dementia, Parkinson, Stage 4 Sacral Pressure Ulcer, and Anxiety. A review of the resident's medical record revealed a nurse practitioner's progress note dated 02/06/23 at 1:36 PM that documented, Was asked to see pt (patient) for slight wt (weight loss), poor po intake. She does not open her mouth at times and sometimes holds food in mouth . Plan .obtain a 3 day food diary .will evaluate after food diary review. Will discuss with family regarding PEG if po (by mouth) intake not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for four (4) of 105 sampled residents, the facility's staff failed to maintain Infection Control and Prevention Practices during wound care, dressing changes, and medication administration. (Residents #587, #76, #75, and #313. In addition, the facility failed to ensure trash and used personal protective equipment was disposed of properly. The findings include: 1. Resident #587 was admitted to the facility on [DATE] with multiple diagnoses including: Third Degree Burns of Trunk and Surgical Aftercare following Surgery on the Skin. A review of a care plan dated 02/08/23 documented, Focus area- Actual skin impairment r/t (related to) second and third degree burn to bilateral lower extremities (Left/right). The care plan listed several interventions including monitor for s/s (signs and symptoms) of infections .treatment as the affected side as ordered . A review of a physician order dated 02/09/23 documented, Aquaphor Advanced Therapy External Ointment . cleanse wound 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 record review and staff interview, for six (6) of 98 sampled residents, facility staff failed to ensure that residents were offered influenza and pneumococcal immunizations. Resident #73, #132, #184, #248, #311 and #324 The findings include . All adults need immunizations to help them prevent getting and spreading serious diseases that could result in poor health, missed work, medical bills, and not being able to care for family. All adults need a seasonal flu (influenza) vaccine every year. Flu vaccine is especially important for people with chronic health conditions, . and older adults. Additionally, over 60 percent of seasonal flu-related hospitalizations occur in people 65 years and older. As we get older, our immune systems tend to weaken over time, putting us at higher risk for certain diseases. This is why, in addition to the seasonal flu (influenza) vaccine and Td or Tdap vaccine (tetanus, diphtheria, and pertussis), you should also get .Pneumococcal conjugate vaccine (PCV15 or PCV20), which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for ten (10) of 98 sampled residents, facility staff failed to ensure the residents were provided COVID-19 immunization according to the Centers for Disease Control (CDC) recommendation and manufacturer specifications as appropriate (Residents #55, #73, #76, #77, #184, #248, #291, #311, #324 and #327). The findings included: Guidance from the Centers for Disease Control (CDC) titled: The Benefit Of Getting COVID-19 Vaccine, last updated 12/22/2022, documented: -Vaccine consent or assent for a COVID-19 vaccine is given by LTC [long-term care] residents (or people appointed to make medical decisions on their behalf, called a medical proxy) and documented in their charts per the provider's standard practice. Residents who receive a COVID-19 vaccine (or their medical proxy) also receive a fact sheet before vaccination. The fact sheet explains the risks and benefits of COVID-19 vaccination. There are many benefits of getting vaccinated against COVID-19. Prevents serious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interview, for one (1) of 105 sampled residents, the facility's staff failed to notify a resident's family regarding use of medications (Depakote and Exelon). (Resident #74.) The findings included: Resident #74 was admitted to the facility with multiple diagnoses including Paranoid Schizophrenia, Anxiety and Dementia with other Behavioral Disturbances. Review of Resident #74's medical record revealed the following: A physician's order dated 11/29/22 directed, Depakote Delayed Released 50 MG (milligrams) - give 1 tablet via g-tube (gastrostomy tube) two times a day for mood disorder. An Annual Minimum Data Set, dated [DATE] showed facility staff coded: short-term and long-term memory problems, unable to recall the current season, location of room, staff name and faces; received anti-anxiety medications. Physician's orders dated 01/10/23 directed: Depakote Delayed Released 50 MG (milligrams) - give 1 tablet via g-tube two times a day for mood disorder Exelon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 105 sampled residents, the facility failed to ensure a resident's family was provided information to schedule zoom calls for virtual visitation from 11/31/22 to 03/09/23 (Resident #60). The findings included: Resident #60 was re-admitted to the facility on [DATE] with multiple diagnoses including Hemiplegia, Cerebral Infarction, and Morbid Obesity. A review of two documents titled Resident Virtual Visit Schedule revealed virtual visits were conducted at 11:00 AM on 07/15/22 and 11:00 AM on 11/30/22. The visit on 7/25/22 documented it was conducted with the complainant, and that they were present. A review of a complaint received by the state agency (DC-11471) on 1/09/23, .I live in North Carolina and I'm unable to see [pro-[NAME]] on a daily basis, but I used to be able to video chat with [pro-[NAME]] regularly. The last time I saw [pro-[NAME]] on video was October 21, 2022, through Skpe [sp] .Every time I call the recreational department to set up 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 record reviews, family interviews, and staff interview for one (1) of 104 sampled residents, the facility's staff failed to notify a resident's family of the resident's significant unplanned weight loss of 5.2 percent from 11/12/22 to 12/21/22 [40 Days]. The findings included: Resident #313 was admitted on [DATE] with multiple diagnoses including Dysphasia, Lewy Body Dementia, Parkinson's Disease, and Stage 4 Sacral Pressure Ulcer. A review of a nutritional assessment dated [DATE] documented, Resident new admit . wt. (weight) 105 LBS (pounds) at lower end of norm[normal] for bmi (body mass index), resident has puree diet. Rec (recommend) SLP (speech therapy) for best consistency .currently beinf [being] fed by staff] . Review of an admission Minimum Data (MDS) assessment dated [DATE] documented, under the Cognitive Skills for Daily Decision-Making section, the resident was coded as 3 indicating the resident was severely impaired (never/rarely made decisions). Additionally, the resident was coded 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 record reviews and staff interviews for one (1) of 105 sampled residents, facility staff failed to implement its policies and procedures for investigating allegations of abuse, neglect, and injuries of an unknown source. (Resident #237) The findings included: A review of the facility's policy titled Abuse Neglect and Exploitation with a revision date of 09/20/22, documented .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include .focusing the investigation on determining if abuse, neglect, exploitation and or mistreatment has occurred, the extent and cause and providing complete and thorough documentation of the investigation .Reporting/Response The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency and to all other required agencies .within specified timeframes . 1. Facility staff failed to report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for one (1) of 105 sampled residents, facility staff failed to report an injury of an unknown source timely to the State Agency per its policies and procedures. (Resident #237) The findings included: A review of the facility's policy titled Abuse Neglect and Exploitation with a revision date of 09/20/22, documented .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include .focusing the investigation on determining if abuse, neglect, exploitation and or mistreatment has occurred, the extent and cause and providing complete and thorough documentation of the investigation .Reporting/Response The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency and to all other required agencies .within specified timeframes . Resident #237 was admitted to the facility on [DATE] 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 record review, family interview, and staff interview, for one (1) of 104 sampled residents, the facility's staff failed to develop a baseline care plan for Resident #74. The finding included: Resident #74 was admitted on [DATE] with multiple diagnoses including Anemia Muscle Weakness, and Dysphagia. A review of the resident's medical record including progress notes, care plans and assessments lacked documented evidence that staff developed a baseline care plan for Resident #74. A review of a document titled, Interdisciplinary Care Conferences lacked documented evidence a care plan conference meeting was held 48 hours after Resident #74's admission date of 11/28/22. According to the document, the first care plan conference was held on 01/31/23, and the resident's daughter signed the document to indicate she attended. During an interview with Resident #74's daughter (responsible party) on 2/13/23 at 5:00 PM, she reported that the facility staff did not inform her what care was being provided for 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 observations, record reviews, and staff interviews, facility staff failed to develop/implement care plans for (2) of 105 sampled residents. (Residents #131 and #53) The findings included: 1. Facility staff failed to develop a care plan that addressed Resident #131's short-term memory deficit. Resident #131 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Dementia, Bipolar Disorder, and Alcohol Abuse. A Review of Resident #131's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the facility staff coded the resident as having a moderate cognitive impairment and no impairment in the upper or lower extremity. The facility staff coded the resident as having no behavioral symptoms. A Psychological Services Supportive Care progress note dated 07/28/22 at 8:21 AM documented, .Met with patient today at the request of the facility after he was assaulted by another resident .Asked patient what happened between he and the other resident. Patient stated…

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, record review and staff interview for one (1) of 105 sampled residents (231), facility staff failed to follow physician's orders to provide weekly skin assessments for a resident who is bedridden and totally dependent of care as evidenced by a pressure ulcer to the sacrum that facility staff first discovered and documented at an unstageable level. The findings included: Resident #231 was admitted to the facility on [DATE] with multiple diagnoses that included: Vascular Dementia, Cognitive Communication Deficit, Muscle Weakness, End Stage Renal Disease, Malignant Neoplasm of Lung, Heart Failure, Cerebral Infarction, Dysphagia and Type 2 Diabetes. Review of Resident #231's medical record revealed a Care Plan dated 12/24/21 that documented Focus - [Resident's name] has actual impairment to skin integrity r/t multiple wounds . Interventions/Tasks - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident and staff interviews for one (1) of 105 sampled residents, the facility's staff failed to ensure that Resident #51's environment was free of accident hazards by 1. not removing drinking straws from the resident's meal tray, 2. having two portable space heaters in the clean linen area of the facility, and several cracks from the concrete driveway and sidewalk, located at the entrance of the facility, that presented a tripping hazard. The findings included: 1. Review of Resident #51's medical record revealed that the Resident was admitted to the facility on [DATE] with diagnoses including: Dysphagia (difficulty swallowing), Neuroleptic Induced Parkinsonism, Cerebral Infarct, Seizures, and Dementia. Review of a physician's order dated 01/05/23 documented, Regular diet, pureed texture, nectar thick consistency, No straws. Review of a Speech Language Pathology (SLP) Evaluation and Plan of Treatment dated 01/06/23 documented: .Thin Liquids -Straw - .Mild, clinical s/s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, family interview and staff interviews, for one (2) of 104 sampled residents, the facility's staff failed to adequately monitor a resident's nutritional status and obtain after admission and at least monthly thereafter to help identify and document potential weight loss or weight gain. (Residents #313 and #60) The findings included: A review of the policy titled, Weight Monitoring dated 02/01/22, instructed, A weight monitoring schedule will be developed upon admission for all residents: weights should be recorded at the time of obtained . newly admitted residents -monitored weekly for 4 weeks. Resident with weight loss- monitor weight weekly . All others- monitor weight monthly .A significant change in weight is defined as 5% in weight in 1 month (30 days) . Resident #313 was admitted on [DATE] with multiple diagnoses including Dysphagia, Lewy Body Dementia, Parkinson Disease, and Stage 4 Sacral Pressure Ulcer. A review of a care plan with an initial date of 11/11/22…

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 medical record and staff interview, for one (1) of 102 sampled residents, the facility's staff failed to ensure Resident #313 was seen by a physician or nurse practitioner at least once every 30 days for the first 90 days after admission. The findings included: Resident #313 was admitted to the facility on [DATE] with multiple diagnoses including: Dementia, Stage 4 Sacral Pressure Ulcer, Hypertension, Muscle Weakness, and Bradycardia. A review of an admission Minimum Data Set, dated [DATE] documented the resident had an entry [admission] date of 11/11/22. A review of Resident #313's physician progress notes, nurse practitioner progress notes, and history and physical dated from 11/11/22 to 01/31/23 revealed there was no documented evidence that a physician or nurse practitioner saw the resident in December of 2022. During a face-to-face interview on 03/06/23 at approximately 12:45 PM, Employee #39 (Nurse Practitioner) stated that Resident #313's was assigned to her caseload. The employee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 105 sampled residents, facility staff failed to show documented evidence that a pharmacist performed a monthly medication review for Resident #150, from 01/23/23 through 02/23/23. (Resident #150) The findings included: Review of the facility policy titled Medication Regimen Review with a revision date of 02/01/22 documented, .The pharmacist shall document either manually or electronically, that each medication regimen review has been completed. The pharmacist shall document either that no irregularity was identified or the nature of any identified irregularities .Written communications from the pharmacist shall become a permanent part of the resident's medical record . 1. Resident #150 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Unspecified Dementia. A review of the medical record revealed an Minimum Data Set…

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

Based on observations and interview, it was determined that facility staff failed to maintain resident call system in good working condition as evidenced by the failure of the call bell system to operate correctly in two (2) of 52 resident rooms. The findings include . During an environmental walkthrough of the facility on February 23, 2023, between 1:30 PM and 4:00 PM, and on February 24, 2023, between 10:35 AM and 12:00 PM, call bells in two (2) of 52 resident's rooms (#244 and #338) did not initiate an alarm when tested. These findings were acknowledged by Employee #6 on February 23, 2023, at approximately 4:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility staff failed to ensure: (1) Medication Regimen Reviews were conducted at least once a month by a licensed pharmacist for seven (7) of 82 sampled residents; and (2) failed to ensure a licensed pharmacist included a resident's complete medical record when conducting the drug regimen review for one (1) of 82 sampled residents. Residents' #5, #77, #98, #205, #210, #211, #244, and #283. The findings included: 1. Facility staff failed to conduct a monthly Medication Regimen Review (MRR) for Residents' #5, #98, #205, #210, #211, #244 and #283. A. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Bipolar Disorder and Major Depressive Disorder. Review of the comprehensive care plan revealed the following: A focus area, [Resident Name] is on 9+ (plus) medications and at risk for adverse reaction r/t (related to) polypharmacy revised on 03/11/2021 had the following interventions, Review resident's medications with MD (medical…

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, facility staff failed to update the Facility Assessment to reflect the facility's current operations. The resident census on the first day of survey was 315. The findings included: The resident alpha census on the first day of survey, 12/06/2021, revealed that 315 residents were in the facility. The facility has a licensed bed capacity of 360 residents. Review of the Facility Assessment 2020 document revealed the following: On page 28 of 29, Person involved in completing assessment listed: Name of the former Licensed Nursing Home Administrator, last date at the facility 10/19/2020 and former Chief Operating Officer Name, last day of operations 08/31/2020. Upon request of an updated facility assessment, the surveyor was provided a copy of the Facility Assessment Review and Update 2021. Review of this document showed the following: Staff type (page 6) showed, Type of Staff: Administration -6 Business Office - 2 Medical Records - 2 Admissions - 2 Nursing- as needed to accommodate occupancy Dining Services- contracted Rehabilitation -…

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, record review and staff interviews, facility staff failed to maintain infection prevention and control to prevent the transmission of communicable diseases and infections as evidenced by: (1) not preparing and serving foods under sanitary conditions, (2) not wearing personal protective equipment (PPE) properly, (3) to follow clean technique when suctioning one (1) of 82 sampled residents and (4) ensure the medication room on Unit 3 South was kept in sanitary manner and (5) improper hand hygiene during medication administration. Resident #283. The findings included: Review of the policy entitled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures revised 07/2020 documented, . While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including . appropriate use of PPE (personal protective equipment) . staff wear facemasks at all times while in the facility . staff wear eye protection during any 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.

Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by six (6) of six (6) resident shower rooms throughout the facility with marred floors. The findings included: During an environmental walkthrough of the facility on December 15, 2021, at approximately 11:00 AM, the floor in six (6) of six (6) resident's shower rooms were marred in several areas on the following units: 1 North, 1 South, 2 North, 2 South, 3 North and 3 South. These observations were acknowledged by Employee #5 during a face-to-face interview on 12/22/2021, at approximately 9:30 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for five (5) of 82 sampled residents, facility staff failed to develop care plans with goals and approaches to address: one (1) resident's use of behavioral health services; one (1) resident's use of a perm-a-cath; and one (1) resident who sustained a fall; additionally, facility's staff failed to implement care plan interventions for one (1) resident's use of a scoop mattress and one (1) resident's use of psychoactive medications. Residents' #24, #161 #205, #229 and #290. The findings included: 1. Facility staff failed to develop care plans with goals and approaches for Resident's #24, #229, and #290. A. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses including Major Depressive Disorder. Review of the physician's order dated 03/06/2021 instructed, Psych (psychiatric) consult and treat. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: In section C (Brief Interview for Mental Status) - 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 observation, record review, resident and staff interviews, for three (3) of 82 sampled residents, facility staff failed to: (1) administer Midodrine (used to treat low blood pressure) to a resident in accordance with the physician's order, (2) follow a consult receive/obtain pumps to treat a resident with lymphedema, (3) ensure a resident received reading glasses as prescribed. Residents' #98, #174 and #210. The findings included: 1. Facility staff failed to administer Midodrine (used to treat low blood pressure) to Resident #98 in accordance with the physician's order. Review of the Physician's order directed, Midodrine HCI 5 mg give 1 tablet by mouth two times a day for Hypotension hold for SBP (systolic blood pressure) greater than 110 & DBP (diastolic blood pressure) greater than 60 Review of the Medication Administration Record for November 2021 revealed that the facility's licensed nursing staff signed in the designated location to indicate that Resident #98 received Midodrine on 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 82 sampled residents, facility staff failed to ensure one (1) resident had an physician's order in place to treat a pressure ulcer located on the resident's right buttock and failed to follow physician orders for a Stage 4 (sacral) pressure ulcer for one (1) Resident. Residents' #211 and #229. The findings included: 1. Facility's staff failed to follow physician's orders for Resident #211's Stage 4 (sacral) pressure ulcer. Resident #211 was re-admitted to facility on 04/09/2021 with multiple diagnoses including Stage 3 Pressure Ulcer in Sacral Region, Stage 4 Pressure of Left Buttocks, Unspecified Open Wound at Abdominal Wall .The resident also has a history of Generalized Muscle Weakness, Kidney Failure, Hypertension . Review of a Quarterly MDS dated [DATE] showed the following: In section C (Brief Interview for Mental Status) - the resident had a summary score of 13 indicating that the resident was intact cognitively. In section I (Active Diagnoses) -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure that one (1) resident with limited mobility received restorative nursing services as needed to help promote optimal safety and independence and in accordance with their comprehensive person-centered care plans. Residents' #124 The findings included: Review of the policy entitled, Restorative Nursing Services, revised 07/2020 documented, Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Resident #124 was admitted to the facility on [DATE] with diagnoses that included: Arthritis, Pressure Ulcer of Left Heel, Heart Failure, Hypertension, Peripheral Vascular Disease and Renal Insufficiency Review of the admission Minimum Data Set (MDS) dated [DATE] showed the resident was coded with a Brief Interview for Mental Status (BIMS) summary score of 14 indicating she was cognitively intact. Under Section G (Functional Status), the resident 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 observation, record review, and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to: (1) ensure that a resident's environment was free of accidents, (2) implement interventions to reduce hazard and risk to prevent a resident from accidental falls and (3) provide adequate supervision in accordance with the plan of care. Residents' #61, #249 and #402. The findings included: 1. Facility staff failed to ensure Resident #61's environment was free of accidents/hazards by not providing adequate supervision as evidenced by failure to have 2 persons assist with toileting and bed mobility as directed in the plan of care. Resident #61 was admitted to the facility on [DATE] with diagnoses that included: Repeated Falls, Mild Cognitive Impairment, , Muscle Weakness, And Morbid Obesity. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C (Cognitive Patterns) facility staff coded resident as having a Brief Interview for Mental Status (BIMS) summary score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to establish parameters to determine when to administer pain medications to Resident #98. The findings included: Resident #98 was admitted to the facility on [DATE] with multiple diagnoses that included: Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Multiple Pressure Ulcers. Review of the Physician's order directed: 09/24/2021 Oxycodone (narcotic used to treat pain) HCI (hydrochloride) 5 mg (milligram) give 1 tablet by mouth every 6 hours for pain and multiple wound 10/01/2021 Tylenol Extra Strength 500 mg give 2 tablet by mouth every 8 hours for pain 10/13/2021 Tylenol 325 mg give two tablets by mouth every day and evening shift for Pain management give 30 minutes prior to wound dressing According to the Medication Administration Record for October 13- 31 2021 the facility nursing staff signed in the designated area indicating that Resident #98 received Tylenol extra strength 500 mg, Tylenol 325…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure that a resident did not receive Tylenol (pain reliever) in excessive doses and failed to ensure that a resident did not receive Midodrine (low blood pressure medication) in accordance with the physician's order. Resident #98. The findings included: According to the Tylenol for health care professional- manufactures specifications, Professional Discretionary Dosing: To help encourage the safe use of acetaminophen, in 2011, the makers of Tylenol ® lowered the labeled maximum daily dose for single-ingredient Tylenol ® Extra Strength (acetaminophen) products sold in the US from 8 pills/day (4000 mg) to 6 pills/day (3000 mg). The dosage interval also changed from 2 pills every 4 to 6 hours to 2 pills every 6 hours. If pain or fever persists at the total labeled daily dose, healthcare professionals may exercise their discretion and recommend up to 4000 mg/day.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, for one (1) of 82 sampled residents, facility staff failed to provide an outside resource for routine dental services to meet a resident's needs. Resident #205. The findings included: Review of the policy entitled, Dental Services revised 12/2006 documented, Routine and 24-hour emergency dental services are provided to our residents through: . referral to community dentist or referral to other health care organizations that provide dental services . Resident #205 was admitted to the facility on [DATE] with diagnoses that included: Contracture of Muscles, Quadriplegia, Morbid Obesity and Unspecified Psychosis. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status summary score of 15, indicating intact cognitive response. In Section L (Oral/Dental Status): mouth or facial pain, discomfort or difficulty with chewing, no. During 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 and staff interview, facility staff failed to prepare and serve foods under sanitary conditions as evidenced by dietary staff in the kitchen with no hair net and no beard net, 400 of 400 food serving trays that were soiled and/or damaged, and one (1) of one (1) soiled tilt skillet. The findings included: During a walkthrough of dietary services on 12/06/2021, at approximately 8:30 AM, the following were observed: 1. A dietary staff was observed with no hair net and no beard net. 2. Approximately 400 of 400 food serving trays were soiled and/or damaged. 3. One of one tilt skillet was soiled with cooked food residue. These observations were acknowledged by Employee #4 during a face-to-face interview on 12/22/2021, at approximately 9:30 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for four (4) of 82 sampled residents, facility staff failed to maintain medical records on each resident that were complete and accurately documented. Residents' #1, #126, #290 and #298. The findings included: 1. Facility staff failed to accurately document in on Resident #1's medical in two (2) of two (2) occurrences. Resident #1 was re-admitted to the facility on [DATE] with the following diagnoses: Muscle Wasting, Atrophy Not Elsewhere Classified Right Upper Arm and Pressure Ulcer of Sacral Region Stage 4, Vascular Dementia with Behavioral Disturbance, Hemiplegia or Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Aphasia, and Seizure Disorder. A. Review of the most recent Admission/readmission Screener dated 11/29/2021 for Resident #1, lacked documented evidence that facility staff completed the musculoskeletal and skin integrity sections of the form. B. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents and three (3) employees, facility staff failed to provide COVID-19 immunization per regulations and manufactures specifications and failed to maintain compliance requirements for COVID-19 vaccination employees. Resident #GG2. The findings included: The number of doses needed depends on which vaccine you receive. To get the most protection: Two (2) Pfizer-BioNTech vaccine doses should be given 3 weeks (21 days) apart, two (2) Moderna vaccine doses should be given 1 month (28 days) apart and Johnson & Johnsons [NAME] COVID-19 vaccine requires only one dose. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html#:~:text=The%20number%20of%20doses%20needed,than%20the%20recommended%20interval. 1. Facility staff failed to administer COVID-19 immunization as required for Resident #GG2 in accordance with Centers for Disease Control (CDC) and manufacturer guidelines. Resident GG#2 was admitted to the facility on [DATE] with multiple…

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, record review and staff interviews, for one (1) of 82 sampled residents, the facility staff failed to provide a resident with dignity by not covering the resident's urinary catheter collection bag. Resident #249. The findings included: Resident #249 was admitted to the facility on [DATE] with multiple diagnoses including: History of Prostate Cancer, Benign Prostatic Hyperplasia, Catheter -Associated Urinary Tract Infection and Stage 3 Sacral Wound. A review of Resident #249's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status summary score of 12, indicating mild cognitive impairment. In Section H (Bladder and Bowel), A, indicating the presence of an indwelling urine catheter. A review of the physician's orders directed the following: 11/01/2021, Change Foley catheter bag weekly one time a day every 14 days. 11/02/2021, Empty urine bag when 1/3 to 1/2 full and record amount. 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 observation, record review and family and staff interview for two (2) of 82 sampled residents, facility staff failed to provide one (1) resident with safe and appropriate transportation for a doctor's visit; and provide a one (1) resident with an operable cell phone that was replaced by the facility. Residents' #24 and #283. The findings included: 1. The facility staff failed to provide Resident #24 with an operable cell phone that was replaced by the facility. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses including: Acute Kidney Failure and Dependence on Renal Dialysis. Review of the resident's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] that coded the following: In Section C (Cognitive Status), a Brief Interview for Mental Status summary score of 14, indicating the resident was intact cognitively. In Section I (Active Diagnoses), the resident was coded for Renal Insufficiency, Renal Failure or End-Stage Renal Disease . In section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 82 sampled residents, the facility's contracted Behavioral Facilitator failed to provide privacy for a resident receiving telehealth psychological (counseling) services. Resident #24. The findings included: Resident #24 was admitted to the facility on [DATE] with multiple diagnoses including Major Depressive Disorder. Review of the Quarterly Minimum Data Set, dated [DATE] revealed the following: In Section C (Cognitive Status), a Brief Interview for Mental Status summary score of 14, indicating the resident was intact cognitively. Review of the medical record showed the following: A service agreement with the contracted company providing psychological services dated 03/01/2021 that lacked documented evidence what services were to be provided by the Behavior Facilitator. 03/06/2021 [physician's order] - Psych (psychiatric) consult and treat 11/01/2021 [Nurse Practitioner Progress Note] Report resident refused most of her medication and scheduled dialysis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 82 sampled residents, facility staff failed to show evidence that residents or their representatives were able to formulate an advance directive. Residents' #1, #249 and #298. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Hypertension, Peripheral Vascular Disease, Major Depressive Disorder, Anxiety and Seizure Disorder. A review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 99, indicating resident was unable to complete the interview. Review of the electronic and paper health record lacked documented that facility staff provided Resident #1's representative (guardian) with an opportunity to formulate an advances directive. During a face-to-face interview on 12/13/2021 at 1:45 PM, Employee #7 (1 North Unit Social Worker), acknowledged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for one (1) of 82 sampled residents, the facility's staff failed to ensure a resident was free from physical abuse from an employee. Resident #230. The findings included: Resident #230 was admitted to the facility on [DATE] with multiple diagnoses including: Nicotine Dependence, Unspecified Psychosis, Adjustment Disorder with Disturbance of Conduct, Anxiety, Lumbar Spondylolysis, Lack of Coordination, Obesity . Review of the Quarterly Minimum Data Set, dated [DATE] revealed the following: In section C (Brief Interview for Mental Status) - revealed a summary score of 13 indicating the resident was cognitively intact. In section E (Behavior) the resident was coded as a 1, indicating that Resident #230 exhibited verbal behavioral symptoms toward others e.g. threating, screaming or cursing for one (1) to three (3) days during this assessment period. In section I (Active Behaviors) - the resident was coded for Anxiety Disorder, Depression, and Psychotic Disorder (other than…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to implement their written policies and procedures on abuse and neglect of residents by failure to report allegations and actual abuse of residents immediately and to conduct thorough investigations for allegations. Residents' #1, #205 and #230. The findings included: Review of the facility's Abuse Investigation and Reporting Policy with a revision date of 07/2017 documented the under the Reporting section, . All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee to the following .agencies .Adult Protective Services (where state law provides jurisdiction in long-term care) . The facility's Abuse Policy revised on 12/10/2018 documented, . It is the policy of this facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse . All alleged incidents involving abuse, neglect and exploitation or mistreatment .will…

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, record review and staff interviews, the facility staff failed to ensure that alleged violations involving abuse and neglect or mistreatment, were reported immediately for two (2) of 82 sampled residents. Residents' #205 and #230 The findings included: Review of the facility's Abuse Investigation and Reporting Policy with a revision date of 07/2017 documented the under the Reporting section, . All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee to the following .agencies .Adult Protective Services (where state law provides jurisdiction in long-term care) . The facility's Abuse Policy revised on 12/10/2018 documented, . It is the policy of this facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse . All alleged incidents involving abuse, neglect and exploitation or mistreatment .will be reported immediately to the facility Administrator .Appropriate state survey agencies and 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 record review and staff interviews for one (1) of 82 sampled residents, the facility staff failed to ensure a thorough investigation was conducted of an allegation of neglect. Resident #1. The findings included: A review of the facility's abuse policy revised on 12/20/2018 states the following: . Investigation Written statements from all staff present during and/or involved in the incident will be submitted to the nursing supervisor before change of shift. These statements will be submitted with the supervisor's written summation of the incident . It is the Administrators ultimate responsibility to assure that all alleged abuses are reported, investigated immediately, and policy and procedures are followed. Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia or Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Muscle Wasting and Atrophy Not Elsewhere Classified Right Upper Arm, Vascular Dementia with Behavioral Disturbance and Pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for one (1) of 82 sampled residents, the facility's staff failed to provide the hospital with required documentation when transferring a resident. Resident #283. The finding included: Review of the facility's, Hospital Transfer Checklist documented, These forms must accompany all hospital transfers and must be documented in transfer progress note individually . care plan . Resident #283 was admitted to the facility on [DATE] with multiple diagnoses including: Persistent Vegetative State, Personal History of Tracheostomy, Contracture of Multiple Muscles, Traumatic Brain Injury, Encephalopathy . Review of the medical record revealed a nursing progress note dated 10/26/2021 at 9:19 AM that documented, Resident was notes early this morning at about 7:25 AM with rapid breathing, vital signs O2 (oxygen) 98%, temperature 106.1, HR (heart rate) 62 to 190, respiration 45, B/p (blood pressure) 155/55 .NP (Nurse Practitioner) ordered .neb (nebulizer) treatment .at 8:30 AM 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, record review and staff interview, for one (1) of 82 sampled residents, the facility staff failed to notify a resident and their representative of the transfer/discharge and the reasons for the move in writing. Resident #290. The findings included: Resident was admitted to the facility on [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Hypertension, Neuralgia and Neuritis, Unspecified Mood Disorder . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] Under Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 08, indicating resident had moderate cognitive impairment. A review of the Nurses Progress note dated 7/16/2021 at 22:12 showed Resident #290 had a fall on 07/16/2021. Dr [name] was made aware with new order given to transfer the resident to the nearest ER (emergency room) via 911 for further evaluation status post fall with head…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, for three (3) of 82 sampled residents, the facility staff failed to provide information about the facility's bed hold policy. Residents' #1, #117 and #283. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Hypertension, Peripheral Vascular Disease, Hemiplegia or Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] that facility staff coded the resident in the following manner: Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 99, indicating resident was unable to complete the interview. A physician's order on 10/31/2021 directed: N.P. [Nurse Practitioner's name] transfer resident to [Name of local hospital] for a dislodged PEG-tube. A nurse's progress on 10/31/2021 at 6:49 AM revealed, During routine rounds @ 11 pm, resident peg-tube was observed lying on the floor . N.P ordered Transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) out of 82 sampled residents, facility staff failed to accurate code the Minimum Data Set (MDS) assessment for Resident #161. The findings included: Resident #161 was admitted to the facility on [DATE] with the following diagnoses: Human Immunodeficiency Virus (HIV), Unspecified Protein-Calorie Malnutrition, Hemiplegia and Hemiparesis following Cerebral Infarction and Dysphagia. Review of the Quarterly (MDS) Minimum Data Set, dated [DATE], revealed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 08, indicating moderately impaired cognition. In Section G (Functional Status), upper extremity and lower extremity was coded as, 2 indicating impairment both on sides. In Section J (Health Conditions) J1800 Has the resident had any falls since admission/entry or reentry or the prior assessment is coded as 0 indicating no. Review of the nursing progress note dated 07/03/2021 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to conduct a Pre-admission Screening and Resident Review (PASARR) for Resident #251. The findings included: Resident #251 was admitted to the facility on [DATE] with multiple diagnoses that included: Unspecified Psychosis, Anxiety Disorder and Mild Cognitive Impairment. Review of Resident #251's electronic and paper health record on 12/13/2021 lacked documented evidence that the facility staff conducted a PASARR. During a face-to-face interview conducted on 12/13/2021 at 10:34 AM, Employee #8 (Social Services Director) acknowledged the finding and stated, The PASARR is done on admission. I talked to the admissions coordinator and they don't seem to have one for him (Resident #251). I will do one for him today.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for two (2) of 82 sampled residents, the facility staff failed to: (1) update the care plan to address a resident calling 911 and (2) update a residents care plan to include goals and approaches to address pressure ulcer/injury. Residents' #205 and #400. Findings included: 1. Facility staff failed to update Resident #205's care plan after she called 911. Resident #205 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Psychosis, Contracture of Muscles, Quadriplegia, and Morbid Obesity. Review of the comprehensive Care Plan revealed: Focus area, [Resident Name] has behavioral issues calls 911 . called 911 on 12/2/19, 12/25/19 and 1/7/19, last revised on 06/29/2021. 11/04/2021 at 8:01 PM (Nurses Note) . Resident called 911 herself without informing the nurse. 911 crew arrived around 5:45 pm. Resident left the facility around 6:03 pm to [Hospital Name] . 11/05/2021 (Physician's Order) Resident transfer to [Hospital Name] due to 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 record review and staff interview, for one (1) of 82, sampled residents, facility staff failed to record the residents discharge plan in the active clinical record for Resident #194. The findings included: Resident #194 was readmitted to the facility on [DATE] with diagnoses that include, Hypertension, Diabetes Mellitus, Aphasia, Cerebrovascular Accident (CVA), Hemiplegia, Cerebral Edema, and Encounter for Attention to Gastrostomy. The admission Minimum Data Set, dated [DATE] in Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score was left blank. However, the resident was coded as moderately impaired under Section C1000, Cognitive Skills for Daily Decision Making. In Section Q (Participation in Assessment and Goal Setting) Q0100 Participation in Assessment was coded as yes for family or significant other participated in assessment. Q0300 Resident's Overall Expectation is coded as resident expects to be discharged to the community. Q0400 Discharge Plan is coded as 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, interviews and record reviews, the facility's staff failed to ensure a resident who is totally dependent on staff received services to maintain good grooming and personal hygiene for one (1) of 82 sampled residents. Resident #283. The findings included: Resident #283 was admitted to the facility on [DATE] with multiple diagnoses including Traumatic Brain Injury, Persistent Vegetative State, Contracture of Muscle and Anoxic Encephalopathy . Review of a Quarterly Minimum Data Set, dated [DATE] showed the following: In section C (Cognitive Patterns), the Brief Interview for Mental Status summary score was blank In Section G (Functional Status) - the resident was coded for being totally dependent on the physical assistance of one staff member for personal hygiene. In section I (Active Diagnoses) - the resident was coded for Chronic Respiratory Failure, Personal History of Traumatic Brain Injury, and Encephalopathy . Review of the Activities of Daily Living (ADLs), Supporting policy with 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 record review, resident and staff interview, for one (1) of 82 sampled residents, the facility's staff failed to ensure a resident received an optometry assessment and an assistive device to maintain vision. Resident #210. The findings included: Resident #210 was admitted to the facility on [DATE] with multiple diagnoses that include: Acquired Absence of Right Leg above the Knee, Acquired Absence Left Leg above the Knee, and Diabetes Mellitus Type 2. Review of the Quarterly Minimum Data Set, dated [DATE], showed in Section C (Cognitive Patterns), a Brief Interview for Mental Status summary score of 15, indicating intact cognition. During a face-to-face interview conducted on 12/07/2021 with Resident #210, the Resident stated, I had glasses, but they were lost .I told the staff. Review of medical record revealed an Optometry Consult dated 11/20/2020 which documented in the section entitled Chief complaint decreased vision was circled and lost readers The section entitled Assessment and Plan documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure a resident's supra-pubic catheter drainage bag was positioned below the level of the bladder. Resident #211. The findings included: Review of the policy, Urinary Catheter Care Policy with a revision date of September 2014 instructed staff to, . position the urinary bag below the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #211 was re-admitted to facility on 04/09/2021 with a history Neuromuscular Dysfunction of Bladder. During three (3) observations on 12/06/2021 from 10:43 AM to 1:35 PM, Resident #211 was observed lying in bed with her supra-pubic indwelling catheter drainage bag positioned at the same level of her bladder. The tubing was observed collecting urine and not draining into the drainage bag. Review of the medical showed the following: 04/09/2021 [physician's order] - Foley catheter care every…

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, record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to ensure a resident received their prescribed diet of pureed texture. Resident #161. The findings included: Resident #161 was admitted to the facility on [DATE] with the following diagnoses: Dysphagia, Unspecified Protein-Calorie Malnutrition and Human Immunodeficiency Virus (HIV). Review of the care plan revealed a focus area, [Resident Name] needs a therapeutic diet . initiated on 06/22/2021 had the following intervention, Diet as ordered .Puree. Review of the physician's order dated 09/14/2021 directed, . Pureed texture diet Review of the Quarterly (MDS) Minimum Data Set, dated [DATE], revealed that facility staff coded the following: In Section C (Cognitive Patterns), Brief Interview for Mental Status summary score of 08, indicating moderately impaired cognition. In Section G (Functional Status), Eating is coded as extensive assistance and one-person physical assist In Section K…

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, record review and staff interview, two (2) of 82 sampled residents, the facility's staff failed to: ensure an ambu [artificial manual breathing unit] bag (used to deliver positive pressure ventilation to any patient with insufficient or ineffective breaths) was easily accessible for a resident; and to follow physician's orders to show of titrating/monitoring a residents oxygen saturation. Residents' #283 and #298. The findings included: 1.Resident #283 was readmitted to the facility on [DATE] with multiple diagnoses including: Chronic Respiratory Failure, Tracheostomy, Personal History of Traumatic Brain Injury, Contracture of Multiple Muscle . Review of the Quarterly Minimum Data Set, dated [DATE] showed the following: In section C (Cognitive Pattern) - this section was blank In section I (Active Diagnoses) - Chronic Respiratory Failure, Personal History of Traumatic brain Injury, Encephalopathy . In section O (Special Treatment, Procedures and Programs)- the resident was coded for…

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

Based on record review and staff interview, facility staff failed to reconcile narcotics in two (2) of two (2) occurrences. The findings included: 1. During an observation on 12/06/2021 at 8:52 AM of Unit 1 North, Team 1 Medication Cart, review of the facility's document entitled, Controlled Drug Count Verification form revealed that on the date 12/06/2021 at 7:00 AM, only one nurse signed to performing the shift count for reconciling narcotics (the off going nurse did not sign). During a face-to-face interview at the time of the observation, Employee #9 (1 North Unit Manager) stated, She (the off going nurse) had an emergency and had to leave. 2. During an observation on 12/08/2021 8:45 AM of unit 1 North, Team 1 Medication Cart, review of the facility's document entitled, Controlled Drug Count Verification form revealed that on the date 12/07/2021 at 11:00 PM, only one nurse signed to performing the shift count for reconciling narcotics (the off going nurse did not sign). During a face-to-face interview at the time of the observation, Employee #9 (1 North Unit Manager)…

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

Based on observation and staff interview, facility staff failed to: (1) discard of expired medications and dietary supplements and (2) initial and date medications after opening. The findings included: 1. Facility staff failed to discard of expired medications and dietary supplements. A. During an observation on 12/08/2021 at 8:55 AM, on unit 1 North, Team 1 Medication Cart, the following was observed: one (1) Insulin vial with the expiration date of 11/21/2021. During a face-to-face interview conducted at the time of the observation, Employee #9 (1 North Unit Manager), acknowledged the findings and stated that she would discard the item. B. During an observation on 12/08/2021 at 11:45 AM of unit 1 North's Medication Storage Room, the following was observed: four (4) intravenous (IV) bags of medication with the expiration date of 11/21/2021, one (1) IV start kit with the expiration date of 05/31/2021; and four (4) sterile dressing change kits with the expiration date of 10/31/2021. During a face-to-face interview conducted at the time of the observation, Employee #9 (1 North Unit…

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

Based on observations and staff and resident interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on three (3) of six (6) observations. The findings included: During a food test tray assessment on 12/07/2021, at approximately 1:45 PM, hot foods such as ham (116 degrees Fahrenheit), cabbage (133 degrees Fahrenheit), and roasted potatoes (134 degrees Fahrenheit), tested below the minimum required temperature of 135 degrees Fahrenheit (F). During a face-to-face interview with Resident #124 on 12/08/2021 at 11:30 AM, she stated the food is cold and is not good. During a face-to-face meeting with Resident Council members on 12/13/2021 at 2:00 PM, the residents stated, The meals are cold, the food does represent community preferences, we get cereal with no milk and tea bags with no hot water. These observations were acknowledged by Employee #4 (Dietary Supervisor) during a face-to-face interview on 12/22/2021, at approximately 9:30 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, for one (1) of 82 sampled residents, the facility staff failed to provide a resident with occupational therapy. Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia or Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Muscle Wasting, and Atrophy Not Elsewhere Classified Right Upper Arm. Review of the medical record revealed: Physician's Orders: 11/29/2021 Consult: PT/OT/SLP (physical therapy/occupational therapy/speech therapy), may treat and evaluate as needed. 11/29/2021 Occupational therapy eval (evaluate) and treat as needed. A review of Resident #1's medical record lacked documented evidence that the facility provided the resident with occupational therapy after her re-admission to the facility on [DATE]. During a face-to-face interview conducted on 12/22/2021 at 12:25 PM, Employee #14 (Acting Director of Rehabilitative Services), stated, Everyone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 82 sampled residents, facility staff failed to conduct COVID-19 testing for a resident exposed to COVID-19 who subsequently tested positive for COVID-19 as well. Resident #GG1. The findings included: . Residents with close contact with someone with SARS-CoV-2 infection, regardless of vaccination status, should have a series of two viral tests for SARS-CoV-2 infection. In these situations, testing is recommended immediately . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031062858 During a face-to-face interview conducted on 12/20/2021 at 9:46 AM with Employee #3 (Infection Preventionist), he revealed that the resident in room [ROOM NUMBER] bed B had been transferred to the emergency room (ER) on 12/18/2021 for seizures. Upon testing at the ER, that resident was found to be COVID-19 positive. Resident #GG1 (350 bed A) was placed on droplet/contact isolation on 12/18/2021 for exposure to COVID-19. When asked if Resident #GG1…

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

Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by: kitchen hood baffles that were not securely attached, three (3) of three (3) drainpipes from the three-compartment sink that extended into a floor drain, one (1) of one (1) walk-in refrigerator and walk-in freezer with missing slats, and a plumber's snake that was stuck in a drain located near the three-compartment sink. The findings included: 1. Kitchen hood baffle filters were loose and were not firmly secured. 2. Three (3) of three (3) drainpipes from the three-compartment sink extended into the drain with no air gap. 3. One (1) of one (1) walk-in refrigerator was missing two (2) slats and one (1) of one (1) walk-in freezer was missing one (1) slat. 4. A plumber's snake (used to unclog drains) was observed stuck into a drain located next to the three-compartment sink. These observations were acknowledged by Employee #4 during a face-to-face interview on 12/22/2021, at approximately 9:30 AM.

Based on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells in three (3) of 58 resident's rooms that did not emit an alarm when tested. The findings included: During an environmental walkthrough of the facility on 12/15/2021, at approximately 11:00 AM, call bells in three (3) of 58 resident's rooms failed to alarm when tested (resident's room #'s 255, #258 and #236). These observations were acknowledged by Employee #5 during a face-to-face interview on 12/22/2021, at approximately 9:30 AM.

Based on observations and staff interview, facility staff failed to store and prepare foods under sanitary conditions as evidenced by inadequate internal temperatures in one (1) of one (1) walk-in freezer, four (4) of four (4) soiled convection ovens, one (1) of five (5) missing slat in one (1) of one (1) walk-in refrigerator and a broken outer temperature gauge in one (1) of three (3) reach-in refrigerator. Findings included . During a walkthrough of dietary services on February 9, 2020, at approximately 7:20 AM, the following were observed: 1. Internal temperatures in one (1) of one (1) walk-in freezer fluctuated between 30 degrees Fahrenheit (F) and 38 degrees F between 7:22 AM and 9:30 AM. Food items such as mixed vegetables and French fries were still frozen but approximately 15 of 15 one-serving containers of ice cream were melted and discarded. No other foods were affected as the walk-in freezer was repaired soon thereafter. 2. Four (4) of four (4) convection ovens were soiled throughout with burnt food deposits. 3. One (1) of five (5) slats was torn off in one (1) of one (1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview for five (5) of 11 sampled residents, whose personal funds are managed by the facility, the facility's staff failed to follow generally accepted accounting principles when depositing a money order made out to one (1) resident and to ensure five (5) residents who have Resident Fund Management System (RFMS) accounts gave the facility staff authorization to manage their funds. Residents' #187, #112, #116, #181 and #238 Findings include . 1. Review of the medical record for Resident #187 showed that she was admitted to the facility on [DATE] with diagnoses that included Hypertension and End-Stage Renal Disease. A review of the admission Minimum Data Set [MDS] dated 9/23/2019, showed Section C [Cognition Patterns] C1000 Cognitive skills for daily decision making were recorded as 15 which indicated that the resident was cognitively intact. During a face-to-face interview with Resident #187, on February 10, 2020, at 2:58 PM, she stated that the facility cashed a money…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, facility staff failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by stained ceiling tiles in nine (9) of 60 resident's rooms, soiled exhaust vents in six (6) of 60 resident's rooms, broken door closures in three (3) of 180 resident's rooms and a bed bumper board observed on the floor in one (1) of 60 resident rooms. Findings included . During an environmental walkthrough of the facility on February 10, 2020, between 10:35 AM and 3:30 PM the following were observed: 1. Ceiling tiles were stained in nine (9) of 60 resident's rooms including rooms #104, #120, #136, #202, #205, #208, #210, #235, #243. 2. Exhaust vents were soiled with dust in resident room ##209, #251, #305, #349, #355, #359, six (6) of 60 resident's rooms. 3. Door closures to the entrance door in resident rooms #104, #204 and #249 failed to function as intended and a trash bag was used to keep the door in place, three (3) of 180 resident's rooms. 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for five (5) of 75 sampled residents, the facility's staff failed to update Care Plans for : (1) one (1) resident, who fell during care; (2) 1 to 1 monitoring for safety for one (1) resident; (3) two (2) residents, who had a resident-to-resident verbal interaction; and (4) one (1) resident's dialysis information (Residents' #81, #235, #246, #297 and #322). Finding include . 1.The facility's staff failed to update Resident # 81's Care Plan after he fell during care. Resident #81 admitted to the facility on [DATE], with diagnoses that included: Diabetes Mellitus, Hypertension, Hyperlipidemia, Cerebral Infarction, and Major Depressive Disorder. Review of the resident's current medical record showed that while the facility's staff was providing care for Resident #81, he pulled down the left side rails of his bed and fell. Continued review of the medical revealed that the resident had no apparent injuries from the fall on 02/12/20. Review of Resident # 81's Annual Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to ensure a resident was free from a significant medication error for one (1) of 75 sampled residents (Resident #23). Findings included . During an interview on 02/10/20 at 11:00 AM, Resident #23 stated that the nursing staff failed to administer his antihypertensive medications for January 2020. Continued interview revealed that the nurses take his blood pressure daily, and he always requests his readings. Resident #23 said once his blood pressure reached 189/111, he asked to see the nurse practitioner, who informed him that his blood pressure medication had been left off the list. The resident also stated, The last time my blood pressure was that high (189/111). I had a stroke. Review of Resident #23's current medical record on 02/13/20 starting at 2:00 PM showed that the resident had an initial admission date of 07/30/19 with multiple diagnoses including Essential Hypertension, Cerebral Infarction, and Acute Kidney Failure. Continued review of…

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

Based on observation and interview, facility staff failed to provide a safe, sanitary environment to help prevent the expansion and transmission of communicable diseases and infections as evidenced by one (1) of one (1) heater blower in use, that was soiled with dust in the laundry room and the lack of a water management program with a risk assessment to identify where Legionella and other waterborne pathogens could grow in the facility's water system. Findings included . 1. During a walkthrough of the facility's laundry area on February 19, 2020, at approximately 11:07 AM, one (1) of one (1) heater blower, hanging down from the ceiling in the washing machine room, was soiled with dust. This deficient practice consistently exposes resident clean, personal clothing and linen to dust contamination. 2. A comprehensive water management plan to include a complete description of all potable and non-potable water systems in the building and a facility risk assessment to identify where Legionella and other water borne pathogens could grow and spread in the facility's water system 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, record review and staff interview, facility staff failed to: (I) maintain essential equipment in a safe condition as evidenced by a high internal temperature in one (1) of one (1) walk-in freezer, a broken temperature gauge in one (1) of five (5) reach-in refrigerators and one (1) of five (5) slats from one (1) of one (1) walk-in refrigerator that was completely torn off; and (II) ensure a New Life Intensity Oxygen Concentrator was operating in a safe condition for one (1) of 75 sampled residents (Resident #215). Findings included . (I). The facility's staff failed to maintain essential equipment in a safe condition as evidenced by a high internal temperature in one (1) of one (1) walk-in freezer, a broken temperature gauge in one (1) of five (5) reach-in refrigerators and one (1) of five (5) slats from one (1) of one (1) walk-in refrigerator that was completely torn off. a. Internal temperatures in one (1) of one (1) walk-in freezer fluctuated between 30 degrees Fahrenheit (F) and 38 degrees F between 7:22 AM and 9:30 AM and food items were not frozen solid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells in two (2) of 60 resident's rooms that failed to alarm when tested, torn protective call bells cord cover in five (5) of 60 observations and a broken reset button from one (1) of 60 resident call bell housing. Findings included . During an environmental walkthrough of the facility on February 10, 2020, between 10:35 AM and 3:30 PM: 1. Call bells in resident's rooms #332 and #355 did not alarm when tested, two (2) of 60 resident's rooms. This breakdown could prevent or delay care to residents in an emergency. 2. The top, protective plastic cover to call bell cords in resident's room's #124A, #205A, #214A, #235 and #332 was torn, five (5) of 60 resident's rooms. 3. The reset push-button to the call bell housing, attached to the wall in resident room [ROOM NUMBER] was broken, one (1) of 60 resident's rooms. These findings were acknowledged by Employee #14 on February…

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, record review, and interviews for two (2) of 75 sampled residents, the facilty's staff failed to treat residents with respect and dignity, as evidenced by: allowing one (1) resident to lay on soiled linen until the change of shift, and by not providing incontinent care and not removing facial hair for one (1) resident. Residents # 169 and #197 Findings include . 1. The facilty staff failed to treat Resident #169 with dignity and respect by allowing her to lay in bed on soiled bed linen (a fitted sheet) until the change of shift. Resident #169 was admitted to the facility on [DATE] with diagnoses with included Hypertension, Diabetes Mellitus, Depression, and Anxiety Disorder. According to the Quarterly Minimum Data Set completed on 12/18/2019, Resident #169 had a Brief Interview for Mental Status (BIMS) score of 15 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status), the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview for two (2) of 75 sampled residents the facility's staff failed to ensure that one (1) resident was provided with a Bariatric bed to promote safety with bed mobility, and to ensure one (1) resident was clothed, cleaned and dry. (Residents' #23 and #197). Findings include . 1. The facility's staff failed to ensure that Resident#23 was provided a Bariatric bed to promote safety with bed mobility. Observation of Resident #23's room on 02/10/20 at 10:00 AM showed the resident lying in bed. When asked if he had any concerns, the resident pointed to his bed and stated, Yes, I weigh 337 pounds, and this bed is too small for me. I'm scared to move over in the bed. Continued observation revealed that Resident #23 attempted to pull himself to the left side of the bed. However, he was unsuccessful because the bed did not have room for him to change position in the bed safely. Review of the resident's current medical record on 02/10/20 starting at 2:00 PM showed that 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 observation, record review and staff interview for one (1) of 75 sampled residents, the facility staff failed to complete an Advance Directive for Resident #222. Findings Include . Review of the resident's clinical record showed that the resident was admitted to the facility on [DATE]. The record lacked documented evidence of a completed Advance Directive on the resident's record. Review of Section I (Active Diagnoses) of the annual Minimum Data Set (MDS) dated [DATE] showed diagnoses which include Hypertension, Renal Insufficiency, Diabetes Mellitus, Hyperlipidemia, Parkinson's Disease and Schizophrenia. Review of Section C (Cognitive Patterns) showed a Summary Score of 10 for C0500 Brief Interview of Mental Status (BIMS). A summary Score of 10 is an indication that the resident's cognition is moderately impaired and therefore he may be unable to make some decisions. A face-to-face interview was conducted with Employee #12 on February 11, 2020 at 12:30 PM. The employee was queried regarding 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 review of the facility's Abuse policy and staff interviews, the facility failed to instruct staff to report allegations of abuse immediately but not later than two hours in their abuse policy. The census on the first day of survey was 346. Findings include . Policy Title: OPS-346 Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property Revised 12/10/18 stipulates: VII. Reporting/Response A. All alleged incidents involving abuse, neglect, exploitation or mistreatment, including injures of unknown origin and misappropriation of resident's property will be reported immediately to the facility administrator .Appropriate state survey agencies and other officials in accordance with state law will be notified within 5 working days of the incident by the facility administrator or his/her designee . Facility staff failed to develop and implement an abuse policy that includes reporting immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if…

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

Based on review of the facility's incident report and staff interviews, one (1) of 75 sampled resident, the facility staff failed to thoroughly investigate an allegation of sexual abuse to one (1) female resident. Resident # 99. Findings include . An incident report dated May 14, 2019 at 19:15. Titled, Alleged Abuse .report to the charge nurse . incident description [Resident #99] sister reported to charge nurse that she thinks her sister had been sexually abuse. She said that Resident who is nonverbal had been demonstrating with her hands and head that she has been abused sexually by putting her fingers in her mouth pointing towards her vagina and the door . Immediate Action: police department is notified . [Officer] arrived . [Physician] notified . statements are being collected from staff that worked on that floor from Sunday night 5/12//19 to this evening (5/14/2019), investigation is ongoing. Review of the facility's investigation failed to show that the resident roommate was included in the investigative process to get her account or information related to the allegation.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 75 sampled residents, the facility's staff failed to develop patient-centered Care Plans for: (1) the use of oxygen for one (1) resident; (2) the resistant /refusal of ADL [activity of daily living] care for one (1) resident; and (3) the diagnosis of Adjustment Disorder with Anxiety and Depressed Mood for one (1) resident (Residents' #106, #220 and #235). Findings include . 1. The facility failed to develop a patient-centered Care Plan for Resident #106 use of Oxygen. Review of a physician's order for the resident dated September 18, 2019, showed that the resident has an order for O2 (Oxygen) at 2 liters continuously for SOB (Shortness of Breath). According to the Annual Minimum Data Set, dated [DATE], the resident was coded for receiving Oxygen Therapy. However, review of the comprehensive care plans failed to show a comprehensive person-centered care plan for the resident's continuous use of Oxygen. A face-to-face interview was conducted 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 observation, record review, and interviews, for three (3) of 75 sampled residents, the facility's staff failed to: (1) provide care per the person-centered Care Plan for one (1) resident; (2) provide medication per professional standards and as prescribed by the physician for one (1) resident; and (3) failed to obtain a physician's order to release the resident's body to the DC Medical Examiner for one (1) resident. (Residents' #23, #295, and #TF) Findings included . (1) The facility's staff failed to provide Resident #23 with care per his person-centered Care Plan. During an interview on [DATE] at 11:00 AM, Resident #23 stated that the nursing staff failed to administer his hypertension medications for [DATE]. Continued interview revealed that the nurses take his blood pressure daily, and he always requests his readings. Resident #23 said that once his blood pressure reached 189/111, he asked to see the nurse practitioner, who informed him that his blood pressure medication had been left off the list.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility's staff failed to provide incontinent care in a timely manner for one (1) of 75 sampled residents (Resident #23). Findings included . During an interview with Resident #23 on 02/14/20 at 10:00 AM, the resident stated that the dayshift staff did not provide incontinent care for him on 02/12/20 at 2:00 PM when he returned from his doctor's appointment. The resident then said, I was sitting in my wheelchair, wet all the way down to my feet. Continued interview revealed that staff answered his call light several times but did not provide the care until 4:00 PM when the next shift (evening shift) came to work. When queried, why staff didn't provide incontinent care? Resident #23 stated that he was told his assigned certified nursing assistant was providing one to one care for another resident. During an interview on 02/14/20 at 11:00 AM, Employee #22, the person who arranges residents' appointments, stated that Resident #23 returned from his appointment on 02/12/20…

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, record review and staff interview for one (1) of 75 sampled residents, facility staff failed to administer Resident #148's enteral feeding as directed by the physician. Findings included . Review of physician's order showed resident with newly inserted Gastrostomy tube (Inserted 2/7) and enteral feeding with Jevity 1.5 at 40ml/hr. x 18 hours. Feeding to be hung at 12:00 PM and to run until 6:00 AM; plus water flushes of 200ml every 6 hours. During an observation of Resident #148's room at 1:20 PM on February 11, 2020 the resident was observed lying in bed on his right side. A pole was on the right side of the bed but no enteral feeding was noted hanging on the pole or in the room. Employee #5 was taken to the room and asked to verify the time that the feeding should be hung. The employee checked the order and acknowledged that the feeding was scheduled to be hung at 12:00 PM one hour and twenty minutes earlier. Employee #5 acknowledged the finding; that the facility staff failed to administer Resident #148's enteral feeding as directed by the physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview for one (1) of 75 sampled residents, the facility's staff failed to provide appropriate care to the Percutaneous Endoscopic Gastrostomy tube (PEG-tube) site for one (1) resident. (Resident #233). Findings included . According to the Nursing Times Journal, It is vital that nurses are aware of the complications that may arise when caring for a patient with a PEG [percutaneous endoscopic gastronomy] tube (g-tube) .The most common complication is an infection at and around the insertion site . Infection can present as inflammation around the site, coupled with discharge and pain or discomfort . Nurses should follow their local dressing policy for cleaning wounds . The number of times per day that sites need to be cleaned will depend on the amount of leakage; a dressing may be required to absorb any moisture from the wound. https://www.nursingtimes.net/clinical-archive/nutrition/peg-tubes-dealing-with-complications-31-10-2014/ Review of the facility's policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility staff failed to ensure that they followed a physician order for oxygen therapy for one (1) of 75 sampled residents (Resident #215). Finding included . Observation on 02/09/20 at 8:00 AM of Resident #215's room showed the resident sitting in bed receiving oxygen at a flow rate of 7 liters per nasal cannula by way of an oxygen concentrator. Review of the resident's current medical record on 02/09/20 at 8:15 AM showed that Resident #215 was admitted on [DATE] with several diagnoses including Restrictive Lung Disease, Chronic Obstructive Pulmonary Disease, Sarcoidosis of Lungs, Acute Respiratory Failure, and Dyspnea. Further review of the record revealed a physician order dated 12/26/19 that ordered: Continuous Oxygen @ (at) 6L (liter) via nasal cannula r/t (related to) history of restrictive lung disease. During a face to face interview at the resident's bedside on 02/09/20 at 8:20 AM, Employee #17 (RN) observed Resident #215's oxygen concentrator and acknowledged…

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, record review and staff interview for one (1) of 75 sampled residents, facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility and dialysis staff was included in the medical record for Resident #322. Findings included . Facility staff failed to ensure the dialysis communication form used to reflect ongoing collaboration between the facility staff and dialysis staff was included in Resident #322's medical record. Resident #322 was admitted to the facility on [DATE], with diagnoses to include Hypotension, Hyperlipidemia, End-stage renal disease, Dementia, Diabetes Mellitus, Major Depression, and Cataract. Review of Resident #322's medical records from 1/25/20 to 2/3/20, showed that the resident goes to Dialysis on Tuesdays, Thursdays, and Saturdays. The resident's dialysis record for communication between the dialysis center and the facility was not included as part of the resident's medical record. Observation made on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a nursing assistant had the skill to safely provide 1:1 care for one (1) of 75 residents in the sample (Resident #235). Findings included . Review of Resident # 235's current medical record on 02/19/20, starting at 1:00 PM, showed that the resident was admitted on [DATE] with multiple diagnoses, including Alteration in Neurological Status related to Closed head Injury, Seizures, Muscle Weakness, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. Continued review of the record revealed a physician order dated 01/21/20, which ordered 1:1 monitoring for safety. Further review of Resident # 235's medical record revealed a nursing note dated 01/27/20 that documented, At about 6:05 PM, Resident was noted standing up in the lounge .bleeding from .left eyebrow measuring 0.5cm (centimeter) X 0.5 cm. Resident stated .I was making a move forward when I fell and hit my left eye. The nursing note also documented that the resident was…

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

Based on observation and staff interview, facility staff failed to post daily nurse staffing information in a readily accessible location. The resident census on the first day of the survey was 346. Findings included . On February 9, 2020 at approximately 7:10 AM there was no posting of the staff information on Units One (1) North, One (1) South, Two (2) North, Two (2) South, Three (3) North and Three (3) South. Upon arrival on the units between 7:00 AM and 7:10 AM Surveyors observed staff erasing information from all of the grease boards directly across from the nurses' stations. It was later determined that they were erasing the staffing information from the prior shift (11 PM on 11/8 through 7 AM on 11/9/2020.) In addition, facility staffing information was not observed in readily accessible locations within the facility. During a face-to-face interview on February 14, 2020, at approximately 10:00 AM Employee #2 stated, the daily staffing is posted on the door in the supervisors' office. The writer stated, that this is not a location where residents and visitors can view the form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, for two (2) of 75 sampled residents, the facility's pharmacist failed to identify a medication error (Omission of Antihypertensive medications ) during the January 2020's Drug Regimen Review for one (1 resident; and to ensure the pharmacist completed The Pharmacist's Chronological Record of Medication Regimen Review for 2 months (August 2019 and Jaqnuary 2020) for one (1) resident. (Residents #23 and #220). Findings include . 1. During an interview on 02/10/20 at 11:00 AM, Resident #23 stated that the nursing staff failed to administer his hypertension medications for January 2020. Review of Resident #23's current medical record on 02/13/20 starting at 2:00 PM showed that the resident had an initial admission date of 07/30/19 with multiple diagnoses including Essential Hypertension, Cerebral Infarction, and Acute Kidney Failure. Further review of the resident's record revealed a January 2020 Medication Administration Record (MAR) that showed the following: Amlodipine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 75 sampled residents, the facility's staff failed to respond to the pharmacist's recommendation for dosage reduction for one resident who receives Remeron. (Antidepressant). Resident #56 Findings included . Resident #56 was admitted to the facility on [DATE], with diagnoses that included Hypertension, Peripheral Vascular Disease, Seizure, Hypercholesterolemia, Anxiety and Major Depressive Disorder. A review of the Pharmacist's Medication Regimen Review showed that on 08/15/19 the Pharmacist documented, RMP [Recommendation made to Physician] decrease Remeron. Continue review of Resident #56's medical record lacked documented evidence the physician responded in writing to the Pharmacist reccommendations. A face-to-face interview was conducted on 02/14/20 at 2:00 PM with Employee#4 concerning the physician response to the Pharmacist Recommendation dated 08/15/19. She stated,I will look for it. A face-to-face interview was conducted on 02/18/20, at…

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

Based on observation resident and staff interview for one (1) of 75 sampled residents, the facility's staff failed to ensure the food prepared for the resident was attractive refers to the appearance of the food when served to residents. (Resident #246). Findings included . During a face-to-face interview with Resident #246 on 02/12/20 at 10:38 AM, she stated, I don't like the food here . I get food from the grocery store .I need food to take my meds (medication). During dining on 02/12/20 at approximately 1:30 PM (the lunch meal), the resident came to the writer upset about the salad that was served for her to eat. Resident #246 stated, I can't eat this food, look at it [pointing to the plate of food]. The writer observed the resident with a plate of salad that appeared to have withered lettuce. The resident stated, She asked for an alternate meal a half smoke, and was told she could only have chicken or a cold cut sandwich. The resident siad, I'm tired of eating chicken and cold cuts. I asked for a half smoke The resident became tearful and said she could not eat the food. 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 observations, record review, resident and staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems; as evidenced by failing to ensure that they developed plans of action to identify quality deficiencies. The resident census during the survey was 346. Findings included . A review of the facility's previous survey dated December 18, 2018 showed that the facility was cited for the following deficiencies: F558 Reasonable Accommodations Needs/Preferences F584 Safe/Clean/Comfortable/Homelike Environment F656 Develop/Implement Comprehensive Care Plan F600 Free from Abuse and Neglect F607 Develop/Implement Abuse/Neglect Policies F610 Investigate/Prevent/Correct Alleged Violation F656 Develop/Implement Comprehensive Care Plan F657 Care Plan Timing and Revision F684 Quality of Care F689 Free of Accident Hazards/Supervisions/Devices F812 Food Procurement, Store/Prepare/Serve-Sanitary F865 QAPI/QAA Improvement Activities F880 Infection Control Program F908 Essential…

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.