Bay Terrace Rehabilitation And Health Center

Based on record review and interview, it was determined that for one (R60) out of two residents reviewed for hospitalization the facility failed to notify the Ombudsman of the residents transfer to the hospital. Findings include: The facility policy on Transfer and Discharge last updated September 2024, indicated Emergency Transfers/Discharges - The Social Services Director, or designee, will provide copies of the notices for emergency transfers to the Ombudsman, but the may be sent when practicable, such as in a list of residents on a monthly basis. Review of R60's clinical record revealed: 9/17/24 - R60 was transferred from the facility to the hospital emergently. 2/17/25 1:36 PM - E1 (NHA) provided the September 2024 Ombudsman Notification List of residents transferred out of the facility. A review of the list lacked evidence of notice of R60's transfer. 2/17/25 1:35 PM - E1 confirmed the findings. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1 and E2 (DON).

Based on interview and record review, it was determined that for two (R19 and R31) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for PASARR screening was completed. Findings include: 1. Review of R19's clinical record revealed: 3/7/18 - R19 was admitted to the facility with the diagnoses including non-Alzheimer's dementia. 4/16/18 - A PASARR level I was submitted to the state PASARR authority and had no evidence of any serious mental illness noted. 12/23/24 - A quarterly MDS assessment documented that R19 had the following diagnoses: non Alzheimer's dementia and psychotic disorder. 2/17/25 3:21 PM - A phone interview with E23 (SW) confirmed that a PASARR update had not been submitted since March of 2021. E23 also confirmed that the PASARR system had an issue with the system having previous employee information in system and resulting in the facility being unable to submit updates. 2. Review of R31's clinical record revealed: 2/13/19 - R31 was admitted to the facility with diagnoses including psychotic disorder with behavioral disturbances…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview it was determined that for one (R69) out of one reviewed for new admission, the facility failed to ensure that a baseline care plan was completed. Findings include: Record review for R69 revealed: 11/29/24 - R69 was admitted to the facility. 12/4/24 - A review of R69's clinical record revealed a lack of evidence of a baseline care plan. 2/17/25 12:57 PM - E1 (NHA) confirmed that there was no evidence that R69 had a base line care plan developed and that a summary of the plan was provided to the resident/ resident representative. 2/19/25 1:41 PM - Findings were reviewed during the exit conference with E1and E2 (DON).

Based on interview and record review, it was determined that for one (R63) out of eighteen residents in the investigative sample the facility failed to develop and implement a comprehensive resident centered care plan for an identified care area. Findings include: Cross refer F690 Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/23/24 - A care plan (last updated 1/6/25) was initiated for R63 and documented R63 had a self care defecit related to limited mobility with interventions including R63 was completely dependent on staff for toileting use and to encourage R63 to participate to the fullest extent possible with care. 9/27/24 - An admission MDS assessment documented R63 was dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and bladder and was not on a toileting program. 12/27/24 - A quaterly MDS assessment documented R63 was dependent on staff for toileting. The MDS also documented R63 was always incontinent of bowel and frequently incontinent bladder and was not on a toileting program. The…

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

Based on record review and interview, it was determined for two (R22 and R63) out of eighteen residents in the investigative sample the facility failed to review and revise the care plan. Findings include: 1. Review of R22's clinical record revealed: 12/14/18 - R22 was admitted to the facility. 12/14/18 - A care plan documented that R22 had a self care deficit related to impaired mobility and cognitive defect with the following interventions: provide total assist with personal hygiene and dressing, provide a bed bath per RP (responsible party) and risk for falls in shower chair due to severe chorea. 2/19/25 10:30 AM - An interview with E3 (ADON) confirmed that R22 was unsafe to use shower chair or stretcher related to falls and that care plan was not updated to accurately reflect R22's current plan of care. 2. Review of R63's clinical record revealed: 9/23/24 - R63 was admitted to the facility. 9/25/24 - A care plan for R63 was initiated for pain related to chronic pain with the following interventions: administer analgesia per orders, monitor and document side effects from pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, it was determined that for three (R19, R22 and R55) out of five residents reviewed for ADL's, the facility failed to ensure ADL care was provided to dependent residents. Findings include: 1. Review of R55's clinical record revealed: 1/2/25 - R55 was admitted to the facility with multiple diagnoses including legal blindness. 1/3/25 - A baseline care plan documented that R55 had visual impairment and needed substantial maximum assistance with hygiene. 1/9/25 - An admission MDS assessment documented that R55's vision was severely impaired, and that the resident required partial moderate assistance to complete hygiene related ADL's such as shaving. 2/11/25 9:08 AM - During an interview R55 stated, I have a brand new razor and they have used it once. I can't see and need help to shave. R55 was observed with significant unkempt facial hair that he confirmed was not his preference. 2/14/25 10:48 AM - R55 was observed with unkempt facial hair. 2/14/25 1:11 PM - The surveyor accompanied E11 (CNA) to R55's room where R55 remained with unkempt…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review it was determined that for two (R43 and R63) out of two residents reviewed for general care and services, the facility failed to ensure treatment and care in accordance with professional standards of practice and physician orders. Findings include: 1. Review of R43's clinical record revealed: 4/8/24 - R43 was admitted to the facility with diagnoses including but not limited to constipation. 12/30/24 - A quarterly MDS assessment documented that R43 has a diagnosis of constipation unspecified. 1/2/25 - A review of physician's orders revealed the following orders: -Milk of Magnesia (MOM) give 30 mL every seventy two hours as needed for constipation if no bowel movement (BM) after three days. -Bisacodyl suppository 10 mg insert one suppository rectally as needed for constipation daily if no results from MOM. -Fleet enema insert one dose rectally every twenty four hours as needed if no BM in three days. 1/21/25 to 2/10/25 - Review of the CNA documentation sheet revealed that the facility failed to ensure that physician's orders were implemented when…

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

Based on observation and interview, it was determined that for one (R31) out of two residents reviewed for positioning and mobility, the facility failed to apply an ordered splint device. Findings include: Review of R31's clinical record revealed: 2/13/19 - R31 was admitted to the facility with diagonoses to including hemipleglia and hemiparesis following a cerebral vascular accident. 2/13/19 - A care plan was initiated for R31 documented actual contractures related to decreased mobility with the following interventions: left and right hand/wrist orthotic on each shift, maintain joints and body in a neutral body position at all times, and passive range of motion as tolerated. 6/26/24 - A physician's order for R31 documented apply right hand/wrist orthortic on every shift and remove for range of motion (ROM), hygiene, and routine skin checks every two hours. 12/12/24 - A physician's order for R31 documented apply left hand soft resting hand splint to be on in morning and remove in evening. 1/7/25 - A quarterly MDS assessment documented that R31 had impairments bilaterally to upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review it was determined that for two (R53 and R63) out of two residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bowel and bladder continence. Findings include: 1. Review of R53's clinical record revealed: 4/5/24 - R53 was admitted to the facility. 4/5/24 - A care plan was initiated for bladder incontinence related to occasionally incontinent with the following interventions: apply barrier cream with each incontinent episode, change clothing with each incontinent episode, and check resident every two hours for incontinence and provide care. 10/9/24 - A quarterly MDS assessment documented that R53 required supervision of one for toileting. The MDS also documented that R53 had a BIMS score of 5 indicating cognitive decline and was occasionally incontinent of bladder, always continent of bowel, and was not indicated for a toileting program. 10/2024 - A review of the October CNA documentation record revealed that R53 was incontinent of urine 14 times out of 95 opportunities and incontinent of bowel 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, it was determined that for one (R375) out of one resident reviewed for respiratory care, the facility failed to provide professional standards of of practice by ensuring the oxygen tubing was changed weekly and nasal cannula was stored in a bag when not in use. Findings include: Review of R375's clinical record revealed: 12/12/24 - R375 was admitted to the facility. 12/12/24 - A physician order was written to administer oxygen at 2 liters/minute via nasal cannula, may titrate to maintain SpO2 90% or greater. 12/13/24 - A physician order was written to change oxygen tubing weekly and PRN (as needed) and to label tubing, date time and initial. Nasal cannula to be stored in a bag when not in use. 12/16/24 - An admission MDS indicated R375 had a BIMS score of 3 (severe impairment ) and diagnoses of COPD, asthma and respiratory failure. 2/11/25 10:29 AM - An observation of R375's oxygen tubing revealed a label dated 1/30/25, no time or initial. Oxygen tubing was on the floor beside R375's bed. 2/11/25 11;12 AM - During an interview, E15…

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

Based on clinical record review and interview, it was determined that for two (R31 and R53) out of five residents reviewed for unnecessary medications, the physician failed to ensure that an appropriate diagnosis was reflected in the resident's chart while antipsychotic medications were being administered. Additionally, the facility failed to ensure that a fourteen day stop date was implemented for an as needed antipsychotic medication. Findings include: 1. Review of R31's clinical record included: 2/13/19 - R31 was admitted to the facility with the following diagnosis, but not limited to, psychotic disorder with delusions. 1/24/25 - A physician's order for R31 documented risperidone (antipsychotic) tablet 0.5 mg: give one tablet by mouth at bedtime for delusional disorder. 1/2025 - A review of the monthly medication review (MRR) documented a recommendation to evaluate use of risperidone for delusional disorder. 2/1/25 - A physician's order for R31 documented risperidone tablet 0.5 mg: give one tablet by mouth at bedtime for delusional disorder. 2/14/25 9:55 AM - An interview 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.

Based on observation, interview and record review, it was determined that for two (R59 and R63) out of two sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include: 1. Review of R59's clinical record: 1/8/24 - R59 was admitted to facility. 4/4/24 - A review of R59's care plan documented R59 has a risk for an alteration in nutrition/hydration secondary to dementia, type II diabetes, and hypertension. The interventions included the following but not limited to explain and reinforce the importance of maintaining diet ordered and educate on refusals and risks. The care plan lacked evidence of a care plan relating to dental concerns. 12/17/24 - An annual MDS documented R59 had no natural teeth, no broken or loosely fitting dentures/partials, and no mouth or tooth pain. 2/11/25 9:37 AM - An interview with R59 revealed that R59 did not have dentures and complained of difficulty chewing due to not having dentures. R59 stated she wanted to see a dentist and had not been offered to see one. 2/18/25 2:53 PM - 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 record review and interview, it was determined that for one (R1) out of three reviewed for quality of care , the facility failed to provide services for hygiene that met with R1's stated preference of a shower for personal hygiene. Findings include: Cross refer F677 and F684. Review of R1's clinical record revealed: 8/14/15 - R1 admitted to the facility with diagnoses, including but not limited to, diabetes, stroke with left-sided weakness, constipation, dementia and PEG feeding tube in-situ. 10/14/24 - R1's annual Minimum Data Set (MDS) assessment documented in Section F- Preferences for Customary Routine and Activities that it was very important for R1 to choose between a tub bath, shower, bed bath or sponge bath. Due to R1 being nonverbal, F1 (R1's wife) was documented as the primary respondent who answered the MDS questions. Review of R1's care [NAME] revealed, Bathing: Showers preferred Sundays and Thursdays 3-11 (evening shift) (bed bath all other days unless otherwise specified). 11/3/24 10:43 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that for one (R2) out of three residents reviewed for Advanced Directives, the facility failed to have a process for documenting and communicating R2's code status decision to the staff. Findings include: The facility's Residents' Rights Regarding Treatment and Advanced Directives Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . revised 5/2024 [DATE] - R2 formulated an Advanced Health Care Directive in the presence of a lawyer that named her daughter, [F2], with her other children, as her attorneys-in-fact to make health and/or personal care decisions . Declarant's Health Care Instructions to Physicians - 2.01 If I…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and 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, it was determined that for one (R1) out of three residents reviewed for quality of care, the facility failed to provide the necessary services to R1 to maintain good grooming and oral hygiene. Findings include: Cross refer F561 and F684. Review of R1's clinical record revealed: 8/14/15 - R1 admitted to the facility with diagnoses, including but not limited to, diabetes, stroke with left-sided weakness, dementia, PEG feeding tube and supra- pubic catheter in-situ. 10/14/24 - R1's annual Minimum Data Set (MDS) assessment documented in Section GG- Functional Abilities documented R1 as dependent for oral hygiene, shower/bathe self, and personal hygiene. The MDS defined dependent as helper does all of the effort. Resident does none of the effort to complete the activity. Oral hygiene was defined in the MDS as the ability to use suitable items to clean teeth. The task of shower/bathe self was defined in the MDS as the ability to maintain perineal hygiene, adjust clothes before and…

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

Based on record review and interview, it was determined that for eight (R3, R7, R9, R10, R14, R27, R32 and R53) out of of sixteen (16) sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. In addition, R53's nutrition risk care plan was not revised. Findings included: 1. Review of R3's clinical record revealed: 5/25/05 - R3 was admitted to the facility. 2/21/24 - A review of quarterly care plan meetings for the following dates 1/12/23, 4/6/23, 6/29/23, 9/21/23 and 12/14/23 lacked evidence of input from the Physician and the CNA. 2. Review of R7's clinical record revealed: 8/25/22 - R7 was admitted to the facility. 2/22/24 - A review of quarterly care plan meetings for the following dates 3/6/23, 6/8/23, 8/31/23 and 1/4/24 lacked evidence of input from the Physician and CNA. A review of a quarterly care plan meeting on 11/22/23 lacked evidence of input from the Physician, dietary and the CNA. 3. Review of R9's clinical record revealed: 8/14/08 - R9 was admitted to the facility. 2/21/24 - 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 document review and interview, it was determined that the facility failed to provide a sufficient number of staff qualified to safely and effectively provide food and nutrition services. Findings include: 2/19/24 9:48 AM - Interview with E1 (NHA) revealed that only two members of the Kitchen staff were in possession of a current Food Protection Manager's certification from an accredited Food Safety program, and that neither of them were present in the kitchen during this day's morning and mid-day meal preparation. A staff person with a current Food Protection Manager's certification from an accredited Food Safety program must be on duty during every meal service. 2/19/24 12:25 PM - Document review revealed that one (1) of the two (2) Food Protection Manager certificates had an expiration date of 2/19/24. 2/19/24 2:43 PM - Findings were confirmed with E1 (NHA).

Based on observation and interview, it was determined that the facility failed to ensure food was stored, prepared and served in a manner that prevents foodborne illness to the residents. Findings include: 2/19/24 8:57 AM - During the initial tour of the kitchen, the walk-in refrigerator contained the following undated items: turkey lunchmeat, individual serving size pies, which had no protective covering, green peas, and baked potatoes. Containers of thickened juice, regular juice, and gravy were noted with expired use by dates. 2/19/24 10:39 AM - During a tour of the kitchen, there was some sugar and coffee grounds spilled on the floor below one of the prep tables. 2/19/24 11:48 AM - A block of butter was left uncovered on a prep-table for more than three (3) hours allowing possible contamination from dust, debris, and other contaminants. 2/19/24 1:23 PM - During a review of the food temperature logs, the facility kitchen records had no food temperatures recorded for twenty-four (24) meals out of two-hundred seventy-six (276) meals sampled. Temperatures of cooked foods and cold…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, it was determined that the facility failed to ensure garbage and refuse were disposed of properly to prevent pest invasion. Findings include: 2/19/24 9:34 AM - During the initial tour of the kitchen, two large garbage cans were not in use, but were uncovered. 2/19/24 11:57 AM - Subsequent tours of the kitchen revealed the two garbage cans remained uncovered throughout the day. 2/19/24 2:43 PM - Findings were confirmed with E1 (NHA).

Based on record review and interview, it was determined that for one (R1) out of sixteen residents reviewed for care plans, the facility failed to develop and implement a comprehensive resident centered care plan for an identified care area. Findings include: Review of R1's clinical record revealed: 1/24/23 - R1 was admitted to the facility. 1/24/23 - A physician's order was written for R1 to use the hoyer lift with assist of two for transfers. A review of the January 2023 and February 2023 CNA task flow sheet revealed that CNA's were marking not applicable for transfers. 2/22/24 9:33 AM - An interview with E4 (RN) confirmed that R1 refuses to get out of bed. 2/22/24 10:35 AM - An interview with E12 (CNA) revealed that R1 refused to get out of bed regularly despite staff offering to get R1 out of bed. The facility lacked evidence of developing and implementing a person centered care plan related to R1's repeated refusals to get out of bed. 2/23/24 2:50 PM - Finding was reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on observation, interview and record review, it was determined that for one (R53) out of one resident reviewed for assistance with ADL's, the facility failed to provide cueing, prompting or assistance to R53 while she was eating her lunch. Findings include: Cross refer to F692 and F810 Review of R53's clinical record revealed the following: 4/3/23 - R53 was admitted to the facility with various diagnoses, including dementia. 4/10/23 (revised 11/27/23) - A care plan was developed for R53's nutritional problem related to general condition with interventions, including but not limited to .assist resident as needed .encourage resident to eat .encourage resident to feed self 75% of meal .staff to finish feeding meal PRN (when necessary) if resident will allow . 11/24/23 - R53's quarterly MDS assessment revealed that R53's cognition was severely impaired. In addition, R53 required setup and/or clean up assistance for eating and was noted with behavioral symptoms including throwing or smearing of food. 2/19/24 12:19 PM through 12:30 PM - During multiple dining observations 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.

Based on record review and interview, it was determined that for one (R53) out of two residents reviewed for nutrition, the facility failed to identify and assess a significant weight loss. Additionally the facility failed to increase a nutritional supplement as requested by the RD. Findings include: Cross Refer to F676 and F810 Review of R53's clinical record revealed: 4/3/23 - R53 was admitted to the facility. 4/7/23 - A physician's order was written for regular diet, pureed texture, thin consistency, with extra calories. 4/10/23 - A care plan was created for nutrition risk potential related to general condition with the following interventions: allow enough time to finish meals; assist resident as needed; encourage resident to feed self 75% of meal; evaluate ability to swallow, etc. 6/22/23 - A physician's order was written for two cal one time a day for supplement give four ounces. 11/30/23 - A quarterly MDS assessment revealed that R53 was a set up and/or clean up assistance with eating and the resident completes the task. 12/4/23 - A review of the weight and vitals in the EMR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, it was determined that for one (R34) out of one resident reviewed for enteral (tube used to feed resident directly into the stomach) feeding, the facility failed to ensure that R34, received the appropriate treatment to prevent potential complications of enteral feeding. Findings include: Review of R34's clinical record revealed: 8/6/23 - R34 was admitted to the facility with difficulty of swallowing. 11/17/23 - R34's comprehensive MDS assessment revealed that R34's cognition was severely impaired and was dependent on one staff member for assistance. R34 was receiving enteral feeding. 2/5/24 - R34 had a physician's order for Jevity 1.5 to run at 45 ml/hr (milliliters/hour) up at 10:30 AM and down at 6:30 PM. 2/19/24 9:46 AM - In an observation in R34's room, E14 (LPN) was observed setting R34's feeding pump flow rate at 45 ml/hr. 2/19/24 9:47 AM - E14 was observed infusing an unlabeled enteral bottle of approximately 400 ml of enteral feeding formula into R34's enteral tube. An unlabeled bottle with approximately 200 ml of enteral feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review, it was determined that for two (R1 and R17) out of two sampled residents for respiratory care, the facility failed to maintain oxygen as ordered. Findings include: 1. Review of R1's clinical record revealed: 1/24/23 - R1 was admitted to the facility with a diagnosis of chronic obstructive pulmonary disease (COPD). 1/24/23 - A physician's order was written for continuous oxygen at 1.5 L/min (Liters per minute) via nasal cannula. 2/20/24 10:33 AM - An observation of R1's oxygen tubing revealed R1 was receiving oxygen via nasal cannula and the tubing had no date or label. 2/21/24 11:49 AM - An observation of R1's oxygen tubing revealed R1 was receiving oxygen via nasal cannula and the tubing had no date or label. 2/22/24 9:39 AM - An observation of R1's oxygen tubing revealed R1 was receiving oxygen via nasal cannula and the tubing had no date or label. 2/22/24 10:31 AM - During an interview, E4 (RN) revealed that R1 did not have an order for tubing change weekly and confirmed no date on current oxygen tubing. 2. Review of R17'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.

Based on observation, interview and record review, it was determined that for two (R3 and R57) out of three sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include: 1. 5/25/05 - R3 was admitted to the facility. 1/16/24 - A progress note revealed that Resident's molar fell out this shift. No bleeding noted. No c/o (complaint of) or s/s (signs or symptoms) of pain or discomfort. 1/17/24 - A progress note revealed Communication with Family Note test: RP (responsible party) . of molar that fell out on its own on 1/16/24. Still no pain or bleeding noted. 2/19/24 9:59 AM - During an interview, R3 said that his teeth are decaying. R3 said that several have fallen out. 2/20/24 - A progress note revealed Resident's RP called with the date and time for resident's dental appointment. This Thursday on 2/22/24 at 8:00 AM with (name and address of dental office). This information was related (sic) to the Unit RN for transportation scheduling. 2/20/24 3:27 PM - A progress note revealed SW called resident's RP back…

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