Ocean Grove Post Acute

Based on interview and record review it was determined that for two (R120 and R157) out of two residents reviewed for bowel and bladder, the facility failed to provide services to maintain or restore bladder continence. Findings include: 1. Review of R120's clinical record revealed: 8/11/23 - R120 was admitted to the facility. 8/22/23 - A care plan for R120 documented that R120 had urinary incontinence related to impaired mobility with the following interventions: clean peri-area with each incontinent episode, encourage fluids during the day to promote prompted voiding responses, and monitor intake and output per facility policy. 2/14/25 - A quarterly MDS documented that R120 had a BIMS score of 15 indicating R120 was cognitively intact. The MDS documented that R120 required maximum assistance for ADL's and frequently incontinent of urine. Additionally, the MDS documented R120 was not on a toileting program. February 2025 - The CNA documentation record revealed that R120 was continent of urine three times out of 84 opportunities. March 2025 - The CNA documentation record revealed…

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

2. R91's clinical record revealed: 12/1/23 - R91 was admitted to facility with diagnoses including, but not limited to, stroke, traumatic spinal cord dysfunction, and progressive neurological dysfunction. 6/23/25 - An order documented, One time a day continuous tube feeding .Product: Osmolite 1.5 at 55 ml/hour via PEG tube .up at 12 p.m., down when total volume of 1100 ml's has been infused. 6/23/25 2:18 PM - An Observation of tube feeding, Osmolite 1.5, hung and infusing at 55 ml/hr with no date, time, rate or initials labeled on tube feed bottle. 6/23/25 2:23 PM - During an interview, E18 (LPN) confirmed that the tube feed did not have the proper labeling of tube feeding bottles such as date, time, rate or initials. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference. Based on observation and interview it was determined that for two (R164 and R91) out of two residents reviewed for tube feeding, the facility failed to ensure that the standard of care for tube feeding was followed. Findings include: 1. Review of R164'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.

2. Review of R3's clinical record revealed: 7/12/25 - who admitted to the facility with diagnosis including, but not limited to, COPD, chronic anemia, and acute and chronic respiratory failue with hypoxia 7/20/24 8:26 PM - A physician's order documented change humidifier bottle weekly and prn. 7/21/25 - The facility treatment adminstration record documented that R3's humifier bottle was changed on 6/21/25. 6/23/25 10:51 AM - An observation of R3 's humidifier bottle dated 6/15/25. 6/24/25 9:30 AM - An observation of R3' s humidifier bottle dated 6/15/25. 6/25/25 11:30 AM - During an observation and subsequent interview, E27 (RN) confirmed the date on the humidifier bottle was 6/15/25. E27confirmed that the humidifier oxygen bottle should have been changed. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference. Based on observation, interview and record review, it was determined that for two (R3 and R16) out of two residents reviewed for respiratory care the facility failed to provide respiratory care consistent 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 interview, observation and record review it was determined that for three (R16, R101 and R120) out of three resident's reviewed for restraints, the facility failed to obtain consents from the resident/POA/resident representative before utilizing bed rails. Findings include: 1. Review of R16's clinical record revealed: 9/17/15 - R16 was admitted to the facility. 6/12/25 - A quarterly MDS documented that R16 is dependent for ADL's and positioning. 6/23/25 10:44 AM - During an observation, R16 was noted to have bilateral 1/4 bed rails present on each side of bed. 6/24/25 11:45 AM - During an observation, R16 was noted to have bilateral 1/4 bed rails present on each side of bed. 6/27/25 1:15 PM - During an interview, E19 (RN) stated that nursing was responsible to determine if a 1/4 bed rail was appropriate for a resident to use and the resident should have a firm grip to be able to use the bed rail. E19 stated that the bed rail was strictly used for mobility purposes. 6/27/25 1:41 PM - During an interview, E10 (RN UM) confirmed that all residents that have 1/4 bed rail 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.

Based on record review and interview it was determined that for one (R27) out of six residents reviewed for medication review the facility failed to provide medications and/or biologicals, as ordered by the prescribe, to meet the needs of the resident. Findings include: The facility policy on ordering medication updated June 2024, indicated, medications and related products are received from the pharmacy on a timely basis. Review of R27's clinical record revealed: 6/4/25 - R27 was admitted to the facility with multiple diagnoses including diabetes. 6/4/25 - A physicians order was written for R27 to receive Ozempic injections for diabetes every Tuesday. The same day the order was then changed to every Friday. 6/13/25 - A physicians order was written to discontinue R27's Ozempic injection. 6/13/25 - A physicians order was written for R27 to receive Bydureon (a once weekly injection similar to Ozempic) for diabetes every Friday. 6/20/25 12:48 PM - An orders administration note in R27's clinical record written by E20 (RN) unit manager documented Bydureon . medication not available. NP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and record review it was determined that for one (R164) out of three residents reviewed for nutrition the facility failed to ensure the resident received food that accommodated intolerance's. Findings include: Review of R164's clinical record revealed: 5/28/25 - R164 was admitted to the facility with multiple diagnoses including gastroesohageal reflux disease (GERD a severe and uncomfortable heart burn) and a feeding tube. 5/28/25 - A physicians order was written for R164 to receive a medication to treat GERD daily. 5/30/25 - A care plan for GERD was created for R164 that included an intervention to avoid foods or beverages that tend to irritate esophageal lining, i.e. alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods. Encourage resident to avoid alcohol, smoking, coffee (even decaffeinated), fatty foods, chocolate, citrus juices, [NAME], tomato products, garlic and onions. Encourage a bland diet. 6/3/25 - An admission MDS assessment documented that R164…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three (R127, R164 and R319) out of thirty-two (32) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include: A review of R127's clinical record revealed: 12/3/24 - R127 was admitted to the facility. 12/30/24 - A physician's order for R127 documented morphine sulfate ER (extended release) 15 mg tablet, give 1 tablet by mouth every 12 hours for pain. 1/3/25 9:00 PM - The medication administration record for R127 documented a blank, unsigned value for the morphine sulfate medication to be administered. 1/4/25 9:00 AM - The medication administration record for R127 documented a blank, unsigned value for the morphine sulfate medication to be administered. 7/2/25 - A review of the controlled drug administration record for R127 for the morphine sulfate medication documented that the medication was administered on 1/3/25 at 9:00 PM and on 1/4/25 at 9:00 AM. 7/2/25 11:02 AM - During an interview with E2 (DON), it was determined that E9 (RN) had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that essential kitchen equipment is maintained in safe operating condition. Findings include: 6/23/25 9:11 AM - An observation of the kitchen walk-in freezer revealed significant ice build-up on the floor in the doorway and numerous smaller chunks of ice on various other areas of the floor. 7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON) during the exit conference.

3. Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility. 4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment. 7/15/24 9:45 AM - A review of R146's care plans revealed the facility lacked evidence of a cognitive impairment care plan with interventions. 7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to R146's cognitive impairment. 4. Review of R109's clinical record revealed: 6/14/24 - R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs. 7/11/24 10:45 AM - A review of R109's care plan revealed no evidence of a care plan or interventions regarding R109's need for anti-coagulation therapy due to the diagnoses of Afib and DVT. 7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 six (R25, R37, R47, R66, R68, and R75) out of thirty-three sampled residents for care plan investigations, the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and for R66's care plan inaccurately includes dentures. Findings include: A facility policy entitled Comprehensive Care Plans (revised 4/24) states, The comprehensive care plan will be prepared by the interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. B. A registered nurse with responsible for the resident. c. A nurse aide with responsibility for the resident. d. a member of the food and nutrition staff . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 1. Review of R25's clinical record revealed: 9/21/23 - R25 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 record review and interview, it was determined that for six (R25, R37, R47, R66, R68, and R75) out of thirty-three residents in the investigative sample the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and additionally, R66's care plan inaccurately included dentures. Findings include: State of Delaware Board of Nursing- RN (registered nurse), LPN (licensed practical nurse) and NA (nurses aide)/UAP (unlicensed assistive personnel) Duties 2024 .admission Assessments - RN, admission History Review -RN .Plan of Care: Initial- RN . Updated 4/10/24 1. Review of R160's clinical record revealed: 3/30/24 - R160 was admitted to the facility. 3/30/24 - E8 (LPN) completed the Prestige Admit/Readmit Screener. 4/3/24 - R160's baseline care plan was e-signed by E9 (LPN). An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission assessment and baseline care plan for R160. 2. Review of R109's clinical record revealed: 6/14/24 - R109 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 7/9/24 11:05 AM - Observation of nourishment refrigerator located at the nurse's station number two (2) revealed a carton of Nutritional Shake that was undated. The instructions on the carton indicate that once opened, any remaining product should be discarded after four (4) days. 7/9/24 11:06 AM - The food storage shelves in the walk-in refrigerator were covered in numerous areas of rust, the floor of the walk-in was wet, and there was some small areas of ice build up in the walk-in freezer. 7/9/24 11:27 AM - During a tour of the kitchen, the surveyor observed E48 (Dining Services Director) and E49 (Assistant Dining Services Director) test the sanitizer level of the solution in two red sanitizing buckets. When E49 tested the sanitizing solution in the bucket from the prep area, the test strip from that bucket indicated that the level of chemical concentration was not at 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, interviews and record review, it was determined that for three (3) (R36, R47 and R461) out of thirty-three (33) reviewed in the investigative sample, the facility failed to ensure a urinary catheter bag was kept off the floor and to ensure staff utilized enhanced barrier precautions (EBP). Findings include: 2023 - A facility policy titled, Enhanced Barrier Precautions- It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refers to the use of gown and gloves for use (sic) during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) . Policy Explanation and Compliance Guidelines: 7. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes 1. Review of R47's clinical record revealed:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record review, it was determined that for one (R36) out of three residents reviewed for dignity, the facility failed to promote dignity by not using a privacy bag for a urinary collection bag. Findings include: A review of the facility's policy titled Catheter Care last revised 4/2024, documented . 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use . Review of R36's clinical record revealed: 1/26/24 - R36 was admitted to the facility. 2/22/24 - A care plan documented that R36 has an indwelling catheter for neurogenic bladder. 4/3/24 - A physician's order for foley catheter to straight bag drainage for urinary retention. 7/9/24 - Observations of R36 lying in bed with the catheter collection bag was visible from the hallway and not in a privacy bag at 10:23 AM, 11:14 AM and 1:56 PM. 7/10/24 11:31 AM - An observation of R36's being pushed back to the room in a wheelchair where the catheter collection bag was not in a privacy bag and hooked onto the wheelchair. An interview with E15 stated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one (R143) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure care preferences were being honored. Findings include: Review of R143's clinical record revealed: 4/4/24 - R143 was admitted to the facility. 4/6/24 - An admission MDS revealed that R143 was not assessed for shower or bathing preferences. 4/10/24 - An admission recreation assessment revealed that for R143 it was very important to choose between a tub bath, shower, bed bath or sponge bath. 7/9/24 - R143 was readmitted from hospital. 7/9/24 12:31 PM - A physician's order revealed shower days were Wednesday and Saturday on the 3 -11 shift with skin check on Saturday and to document refusals every Wednesday and Saturday. 7/10/24 12:58 PM - An interview with R143 revealed that the facility did not give R143 a choice of shower day or time. R143 stated that she prefers showers in the morning. 7/17/24 11:00 AM - An interview with E12 (Activities Assistant Director) revealed that the initial recreation assessment is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R146) out of three residents reviewed for abuse, the facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments that do not have a legal decision maker. Findings include: Cross refer F602 and F745. Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status. 4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit . 4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment. 5/29/24 - E46 (Psychologist) documented in R146's EMR, Her judgment and insight are impaired. At this time, patient is not capable of making her own healthcare decisions. 5/31/24 - The facility made a referral for capacity determination. 6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that R146…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R146) out of three residents reviewed for beneficiary notice, the facility failed to provide notification of service changes to R146's authorized representative. Findings include: Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility. 4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment. 4/12/24 - R146 given a Notice of Medicare Non-Coverage (NOMNC) that advised that R146's effective date of last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Work) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice . 7/9/24 1:54 PM - During a telephone interview, F2 (R146's sister) stated that she was not informed about R146's last day of Medicare coverage and was not offered the opportunity to appeal. 7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 out of five resident units, the facility failed to provide a clean and homelike environment. Findings include: 7/9/24 10:13 AM - An observation in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled on wall with a stain. Subsequently the same observation occurred on 7/10/24 and 7/11/24. 7/12/23 1:00 PM - An interview with E13 (Maintenance Director) revealed that the facility has a plan to replace all handrails with new design. E13 stated he will cover the broken handrail for safety concerns for the current time until new rails are installed. E13 also stated that maintenance will clean the base boards and wall of the 400 hallway. 7/15/24 9:51 AM - An observation of a handrail in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled 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.

Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to protect R146 from misappropriation of resident property/funds. Findings include: Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility. 4/5/24 - R146's admission Minimum Data Set (MDS) assessment documented R146's BIMS score of three, which reflected severe cognitive impairment. 4/12/24 - A Notice of Medicare Non-Coverage (NOMNC) documented that R146's last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice . 5/16/24 - According to a signed and dated statement, F2 (R146's sister) provided the facility with R146's identification, bank statement, other documents and R146's checkbook. F2 had E1 (NHA) and E5 (SW Director) sign the document listing all the documents and belongings that F2 handed over to…

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

Based on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify R130's family representative and the Ombudsman of R130's transfers to the hospital on 3/15/24 and 3/24/24. Findings include: 10/26/23 - R130 was admitted to the facility's locked dementia unit with diagnoses, including: dementia with agitation. 1/31/24 - R130's quarterly MDS documented a BIMS score as five, which reflected severe cognitive impairment. 3/15/24 - R130 was transferred to the hospital for three episodes of coffee-ground emesis and was diagnosed with a gastrointestinal bleed. R130 returned to the facility on 3/17/24. 3/25/24 - R130 was transferred to the hospital for a syncopal episode. R130 returned to the facility on 3/27/24. 7/17/24- Review of R130's EMR revealed F1 (R130's son) was listed as Emergency contact # 1 and R130 was listed as responsible party. 7/17/24 - Review of R130's Transfer Notices, dated 3/15/24 and 3/25/24, both revealed R130 listed as the responsible party to whom the notice was presented. In…

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

Based on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify the family representative of the bed-hold policy. Findings include: Review of R130's clinical record revealed: 10/26/23 - R130 was admitted to the facility's locked dementia unit with diagnoses including: dementia with agitation. 1/31/24 - R130's quarterly MDS documented a BIMS score of five, which reflected severe cognitive impairment. 3/15/24 - R130 was transferred to the hospital for three episodes of coffee-ground emesis (vomit) and was diagnosed with a gastrointestinal bleed. R130 returned to the facility on 3/17/24. 3/25/24 - R130 was transferred to the hospital for a syncopal (fainting) episode. R130 returned to the facility on 3/27/24. 7/17/24 - Review of R130's EMR revealed F1 (R130's son) was listed as Emergency contact # 1 and R130 was listed as responsible party. 7/17/24 - Review of R130's Bed-hold Policy Notices, dated 3/15/24 and 3/25/24, both revealed R130 listed as the responsible party to whom the notice 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 record review and interview, it was determined that for three (R66 and R146) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure an accurate assessment. Findings include: 1 Review of R66's clinical record revealed: 5/10/18 - R66 was admitted to the facility. 2/17/24 - Section I of the annual MDS revealed the following: No natural teeth or tooth fragment(s) (edentulous): Yes. Obvious or likely cavity or broken natural teeth was not checked. 7/11/24 11:45 AM - In an interview, E20 (CNA) and E21 (CNA) revealed R66 does not complain of pain with eating and does not wear dentures. 7/11/24 11:50 AM - In an interview, it was revealed that R66 does not have dentures. The surveyor noted that R66 has teeth, but they are in disrepair. R66 stated that although dental exams are offered, R66 declines to attend. 7/12/24 3:35 PM - In an interview, E19 (MDS Coordinator) confirmed that the MDS reflected that resident is edentulous (lack of teeth). Surveyor advised that R66 has broken teeth and R66 confirmed she does not have dentures. 2. Review…

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

2. Review of R37's clinical record revealed: 11/4/18 - R37 was admitted to the facility. 11/5/18 - A level l PASARR was completed and revealed . this patient appears to have: Indicators of mental illness, mental retardation/related conditions, but meets physician's exemption criterion . 12/20/18 - A level 1.5 PASARR was completed and revealed The individual does have a documented serious mental illness (SMI) or a mental illness other than SMI but further review of level of impairment, recent treatment history, or other circumstances demonstrates a full level II is not required . 5/12/23 - Unspecified mood (affective) disorder and unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety were added to R37's list of diagnoses. 7/11/24 2:28 PM - In an interview, E1 (NHA) confirmed that given the transition with social workers, there were issues with PASARR's not being completed. E1 stated this situation is being audited and this has been ongoing since May. 7/11/24 - A request for a Level II PASARR was completed by E5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R128) out of seven residents reviewed for ADLs, the facility failed to provide mobility from bed to chair. Findings include: Cross refer F842. Review of R128's clinical record revealed: 8/11/23 - R128 was admitted to the facility with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side. 4/23/24 - A physician order documented that R128 was to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift. 5/16/24 - A quarterly MDS revealed that R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. R128 required substantial or maximal assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed and was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition. 7/9/24 - An interview with R128 stated, I stay in bed and they don't get me up. Observations 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 record review and interview, it was determined that for one (R146) out of ten resident reviewed for hospitalization, the facility failed to ensure that R146's warfarin dosing was managed in accordance with the professional standards of practice. Findings include: The acceptable time frame to achieve anticoagulation with warfarin typically ranges from 5 to 7 days. However, it's important to note that the full therapeutic effect may take up to a week due to the long half-life of prothrombin (factor II), which is essential for converting fibrinogen to fibrin12. Warfarin inhibits the production of vitamin K-related factors, and its antithrombotic effect gradually becomes evident as prothrombin levels decrease. During this period, concurrent use of more rapidly acting anticoagulants, such as low-molecular-weight heparin (LMWH) or unfractionated heparin, is recommended. National Library of Medicine, Turkish Journal of Hematology 2016 Warfarin Dosing Guideline- .V. Warfarin dosing nonogram (in medicine, 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, interview and record review it was determined that for two (R123 and R143) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to restore bladder continence. Findings include: 1. Review of R123's clinical record revealed: 2/15/24 - R123 was admitted to the facility. 2/20/24 - A bowel and bladder initial assessment revealed that R123 was continent of bowel and bladder. 2/21/24 - An admission MDS assessments revealed that R123 was always continent of bowel and bladder and not indicated for a toileting program. April 2024 - A review of the April CNA task flow sheet revealed that R123 was incontinent of bladder sixty-five times out of ninety opportunities. 5/21/24 - A quarterly MDS assessment revealed that R123 was frequently incontinent of bladder and always incontinent of bowel and not indicated for a toileting program. May 2024 - A review of the May CNA task flow sheet revealed that R123 was incontinent of bladder seventy-two times out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that for two (R47 and R121) out of two residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice. Findings include: 1. Review of R47's clinical record revealed: 5/27/16 - R47 was admitted to the facility with diagnoses including traumatic brain injury and tracheostomy status. 7/7/22 - A physician's order was written for R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *. 5/22/24 - An annual MDS revealed that R47 required tracheostomy care. 7/15/24 9:15 AM - A review of the R47's physician's orders lacked evidence of current tracheostomy size and brand of use. 7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that 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.

Based on interview and record review, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to ensure that the Physician's orders included trach size, type, and accurate emergency orders. Findings include: Review of R47's clincal record revealed: 5/27/16 - R43 was admitted to the facility. 7/7/22 - A physician's order was written for R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *. 7/15/24 9:15 AM - A review of the R47's physician's orders lacked evidence of current tracheostomy size and brand of use. 7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that all tracheostomy orders would be located in EMR under orders. E27 confirmed R47's size and type of trach was not indiciated in EMR. 7/15/24 10:40 AM - 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 interview and review of the clinical record, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to have nursing staff with the appropriate competencies and skill sets to provide nursing and related services to a resident with a tracheostomy. Findings include: Review of R47's clinical record revealed: 5/27/16 - R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status. 5/22/24 - An annual MDS revealed that R47 required tracheostomy care. 7/15/24 02:58 PM - An interview with E32 (RN) stated she was unsure of R47's trach size prior to today. 7/17/24 10:30 AM - An interview with E36 (Agency LPN) revealed in an emergency you would insert the smaller size trach if it comes out. 7/17/24 10:45 AM - An interview with E37 (Agency LPN) revealed that E37 was unable to articulate what to do in an emergency with a tracheostomy resident. E37 stated I would call the supervisor for help. 7/17/24 12:30 PM - A review of tracheostomy care competency checklists…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R146) out of three residents reviewed for abuse, it was determined that the facility failed to provide medically related social services to R146, who was cognitively impaired and did not have a legal decision maker. Findings include: Cross refer F582 and F602. Review of R146's clinical record revealed: 3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status. 4/1/24 3:09 PM - R146 signed the facility's admission Agreement, which included an authorization form to release financial data. The clauses that identified R146's legal representative and responsible party were left blank in this signed document. The facility's admission Agreement included information regarding resident's rights, payment obligations, grievance process, advanced directive and other services provided by the facility. 4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.Her sister [F2] was invited to the meeting (care plan meeting) .SW (social work) was unable to get in…

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

Based on record review and interview, it was determined that for one (R128) out of thirty-three (33) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include: Cross refer F676. Review of R128's clinical record revealed: 8/11/23 - R128 was admitted to the facility. 4/23/24 - R128's physicians orders documented R128 to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift. 5/16/24 - A quarterly MDS revealed that R128 was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition. 7/10/24 at 10:32 AM - 7/11/24 at 2:56 PM - Multiple observations of R128 laying in bed. 7/12/24 9:33 AM - During an interview R128 stated he did not get out of bed at any time on 7/11/24. A review of the treatment administration record (TAR) revealed a checkmark with E8 (LPN)'s initials for the treatment order that states, Resident to be out of bed for a minimum of 2 hours every day - Nursing to…

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

Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff. Findings include: 7/9/24 12:17 PM - Several pipes in the ceiling area of the clean laundry room were dripping onto the floor and into a trash can that had been placed under a portion of the leaking area. All of the leaking pipes had numerous areas of black staining, which appeared fuzzy in some sections. Three wet and stained towels were on the floor under the areas of the leaks. 7/9/24 1:46 PM - During an interview, E50 (Laundry Staff) confirmed the dripping and standing water and stated that the water had been dripping from the pipes and pooling on the floor for several months. 7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, it was determined that for one (R15) out of four residents reviewed for accident hazards, the facility failed to ensure the resident's environment was free of accident hazards. On 6/3/24, while being transported in the facility van, R15 fell from the wheelchair due to improper restraining. R15 was taken to the hospital for treatment of a cut to the forehead. The unsafe facility transport caused R15 harm. Findings include: An undated facility instruction guide titled Driver/Operator Instruction Guide QRT MAX included: Step 2. Attach lap and shoulder belt. Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger's hip. Adjust the bets as firmly as possible consistent with user comfort. A review of R15's clinical record revealed: 11/30/18 - R15 admitted to facility with diagnoses including but not limited to, hemiplegia and hemiparesis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and review of other facility documentation, it was determined that in accordance with accepted professional standards and practices, the facility failed to maintain the Controlled Drug Count Record report accurately and completely for the month of May 2024. The facility did not accurately reconcile the transfer of controlled drugs from one shift to another. Findings include: Review of the Controlled Drug Count Record report for the month of May 2024 revealed the following: 5/2/24 - 3:00 PM - 11:00 PM shift lacked evidence that the narcotic count was completed for Nurse Reporting On and there was no entry for Received From Pharmacy (+). 5/3/24 - 11:00 PM - 7:00 AM shift lacked evidence that the narcotic count was completed for Nurse Reporting On. 5/7/24 - Under the 3:00 PM - 7:00 AM shift, the Received from Pharmacy (+) number was scribbled out and it appears that it was initially marked as 0 and then changed to 1. 5/8/24 - Under the 11:00 PM - 7:00 AM shift the following categories were not completed: Completed/Disposed (-), Received from Pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and review of other facility documents, it was determined that for one (R4) out of the nine sampled residents, the facility failed to identify and immediately report allegations of physical and/or emotional abuse. Findings include: The facility's undated Abuse Policy and Procedure documented: Investigation and Reporting - Once an allegation of abuse has been made, the supervisor who initially recieves the report must inform the Administrator/Director of Nursing immediately and intimate gathering requested information. - The Administrator, Director of Nursing or designee shall notify the Department of Health via the Event Reporting System electronically, or by phone in the event of the electronic system being unavailable. - Reporting requirements in response to allegations of abuse, neglect, exploitation or mistreatment will be made immediately to the Administrator, DON or designee and the State Survey Agency. - The facility will report these allegations immediately but no later than 2 hours of any allegation which includes injuries of unknown source…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to ensure that R1's transfer and discharge requirement was met when he was discharged on 10/31/23 despite requesting a discharge appeal. Findings include: Cross refer to F623 example 1 and F660 Review of R1's clinical record revealed the following: 4/26/22 - Resident was admitted to the facility. The facility's document titled, Resident admission Agreement & Reference Guide, revised 3/1/22, documented: VIII. TRANSFER, DISCHARGE AND LATE PAYMENT .A .B .C .D. NON-PAYMENT .The Resident may be discharged after thirty (30) days' notice where: .An appeal of a denial of benefits is not pending . 9/21/23 - A State document titled, Basic Payment Class Assignment revealed that R1 was assessed by P2 (Medicaid Assessment Nurse) and it was determined that R1 did not meet the requirements for nursing home care. 9/26/23 - A State document titled, Notice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, record review and review of other facility documents, it was determined that for two (R1 and R2) out of four residents reviewed for discharge, the facility failed to ensure that the notice requirements before discharge were met. For R1, the facility failed to notify the resident and update the notice as soon as practicable when information became available that the 30 day discharge notice dated 10/2/23 was rescinded by the facility on 10/27/23. In addition, the facility failed to communicate to the receiving community case manager necessary information to ensure a safe and effective transition of care. For R2, the facility failed to ensure that a written discharge notice was provided at least 30 days before his discharge on [DATE]. Findings include: Cross refer to F622 and F660 1. Review of R1's clinical record revealed the following: 4/26/22 - Resident was admitted to the facility. a. 10/2/23 - R1 was issued a 30 day discharge notice by the facility. 10/27/23 1:18 AM - An email…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to develop and implement a discharge plan to include identified specific needs and goals for a safe discharge to the community when R1 was issued a 30 day discharge notice on 10/2/23. In addition, the facility lacked communication with the community transition case manager. Findings include: Cross Refer to F622 and F623 example #1 R1's clinical record revealed: 4/26/22 - Resident was admitted to the facility. 9/21/23 - A social worker progress note by E14 (SW) revealed that a meeting was held with P2 (Medicaid Assessment Nurse), E3 (ADON/UM), E23 (Therapy Manager), E24 (Restorative Nurse) and P4 (Case Manager) regarding R1 not meeting the required criteria to receive further NFLOC (Nursing Facility Level of Care) Medicaid benefits in the nursing home and that the last day of covered payment was set for 10/31/23. 10/2/23 - R1 was issued 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 observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include: 7/13/23 10:15 AM - During an observation and interview on the 400 unit, E28 (Corporate) confirmed the extensive amount of dust and dirt on the baseboards, under the air conditioners in the halls, disrepair of the paint on the walls and that there was no molding or flooring next to the air conditioner in front of the 400 unit nurses' station. 7/13/23 10:40 - During the interview with E26 (ESD), stated that the condition of the facility was unacceptable. 7/14/23 - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference, beginning at 9:45 AM.

Based on observation and interview, it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of Kitchen operation. Findings include: 7/5/23 11:05 AM - During an observation and interview, E32 (Regional Dining Consultant) and E33 (Assistant Dining Services Manager), disclosed that no members in the facility's food service department possessed valid Food Protection Manager certificates from an Accredited Food Safety Program. 7/5/23 3:22 PM - Findings were confirmed with E32 and E33. 7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on observation and interview, it was determined that the facility failed to prevent the occurrence of mold in high moisture areas, ensure safe storage of food and provide the sanitizing solution required for disinfecting food preparation surfaces. Findings include: 7/5/23 9:25 AM - During a tour of the kitchen, no red sanitizer buckets containing sanitizing solution were available in the kitchen for disinfecting food preparation surfaces. 7/5/23 9:32 AM - During a kitchen tour, an improperly covered tray of sliced ham and turkey, a partially covered container of leftovers and a tray of sliced cheese and bread with the plastic film cover peeled up at the corner exposing the contents to moisture and other debris were observed in the walk-in refrigerator. 7/5/23 1:08 PM - During a tour of the kitchen, numerous areas of black spotted staining, which appeared to be mold, were observed on the kitchen ceiling directly above the water pipes that hang several inches below the ceiling. 7/5/23 3:22 PM - Findings were confirmed with E32 (Regional Dining Consultant) and E33 (Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in one out of five units, the facility failed to ensure that a handrail in a resident corridor was firmly affixed to the wall. Findings include: 7/5/23 10:43 AM - During an observation and interview, E27 (LPN) revealed to the Surveyor that a handrail approximately four feet long, on the 400 unit, next to the linen room, was loose and about to fall off. The end closest to the unit could easily be pulled away from the wall. 7/5/23 10:50 AM - During an observation and interview, E26 (ESD) confirmed that the handrail was broken and could easily be pulled away from the wall. 7/5/23 11:24 AM - During an observation and interview, E29 (Maintenance) confirmed that the handrail could just pop right off when residents attempted to utilize it. 7/5/23 11:25 AM - During an interview, R36 (RN) stated that she observed other residents use the handrail and one end would fall off the wall. The interview occurred with E29 present. 7/10/23 2:26 PM - During an observation and interview, E1 (NHA) confirmed that the handrail was firmly secure to…

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

Based on interview and record review, it was determined that for one (R32) out of eight residents reviewed for abuse, facility staff failed to immediately report an allegation of abuse to the Administrator and the State Agency within two hours. Findings include: Cross refer F610 The facility policy titled Abuse Policy and Procedure, revised 1/2023, stated, once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information. An investigation must be directed by the Administrator or designee immediately. Review of R32's clinical record revealed: 8/20/21 - R32 was admitted to the facility. 7/5/23 9:25 AM - An interview with R32 revealed an allegation of abuse by a staff member (CNA - [E10]). R32 alleged that E10 punched him in the stomach during care. 7/5/23 3:15 PM - An allegation of abuse was reported to E1 (NHA) and E2 (DON) by the Surveyor. 7/5/23 4:51 PM - An incident report was submitted to the State Agency for an allegation of abuse for R32. 7/10/23…

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

Based on interview, record review, and review of other facility documentation as indicated, it was determined that for one (R32) out of eight residents reviewed for abuse, the facility failed to have evidence of a thorough investigation of an allegation of abuse. Findings include: Cross refer F609 Review of R32's clinical record revealed: 8/20/21 - R32 was admitted to the facility. 7/5/23 9:25 AM - An interview with R32 revealed an allegation of abuse by a staff member (CNA - [E10]). R32 alleged that he was punched in the stomach during care. 7/5/23 3:15 PM - An allegation of abuse was reported to E1 (NHA) and E2 (DON) by the Surveyor. 7/5/23 4:51 PM - An incident report was submitted to the State Agency for an allegation of abuse for R32. 7/10/23 12:48 PM - An interview with E1 revealed that the allegation of abuse from (R32) occurred on or around March/ April (2023) timeframe. The facility failed to report or investigate the allegation of abuse. E1 stated the current investigation did not reveal any evidence of abuse and that E10 was able to return to work. 7/12/23 1:20 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.

Based on interview and record review, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed following new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: The facility policy on PASARR, last updated October 1, 2022, indicated that the Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or related condition will be referred promptly to the State authority for a review. Review of R16's clinical record revealed; 8/9/21 - A level I PASARR screening was completed for R16 that determined no level II PASARR was required and that R16 did not have a diagnosis of dementia or any mental health diagnoses. 8/11/21- R16 was admitted to the facility with multiple diagnoses listed including delusional disorder, unspecified mood disorder and anxiety.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R118) of two sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) Level I, the facility failed to have a currently dated PASRR Screening. Findings include: Review of R118's clinical record revealed: 3/26/23 - R118 was admitted to the facility. 3/24/23 - A review of the Initial PASARR revealed it was completed on 3/24/23 and was approved for a 60 day short term convalescence admission. The PASARR also revealed if the short term stay surpassed the expiration date, a new screening would have to be initiated by the Provider for completion. 7/7/23 - A review of R118's electronic medical record revealed a PASARR was completed on 3/24/23 to determine placement in a medical facility for a short term convalescence admission. 7/7/23 1:10 PM - An interview with E5 (Social Worker) confirmed that a PASARR was not completed for R118 after the 60 day expiration. The facility failed to maintain a current PASARR screening for R118. 7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 two (R7 and R32) out of twenty six residentssampled, the facility failed to develop and implement a comprehensive person-centered care plan. Findings include: 1. 8/2/21 - R7 was admitted to the facility. 7/5/23 1:25 PM - During an interview, R7 stated she feels chained to the bed. 7/7/23 approximately 8:50 AM - An interview with E17 (Rehabilitation Director) revealed that R7 was receiving PT, but she often refused to get out of bed, although R7 will usually do bed exercises. 7/7/23 approximately 11:06 AM - An interview with E16 (Unit Manager) confirmed that the resident prefers to stay in bed and typically refuses to get out of bed. 7/7/23 untimed - A review of the care plan revealed there was no specific care plan for refusal of care or getting out of bed. 7/10/23 approximately 1:30 PM - An interview with E18 (Activities Director) and E19 (Assistant Activities Director) both said that R7 has not been out of bed in years. 7/11/23 approximately 1:40 PM - An interview with E5 (SW) stated it was R7's preference to not get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R32) out of twenty six sampled residents for care plans, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings. Findings include: Review of R32's clinical record revealed: 8/20/21 - R32 was admitted to the facility. 5/31/22 10:00 AM - A review of R32's comprehensive resident centered care plan conference notes revealed the following attendees were present: Unit Manager, Social Worker and R32. 3/30/23 - A review of Care Plan meeting notes revealed the following attendees were present: R32, Unit Manager, R32's decisionmaker and the Admissions Director. The facility lacked evidence that the post-admission care plan conference attendees included: Physician input, Food and Nutrition Services staff input and CNA (Certified Nursing Aide) input with responsibility for the resident. 7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

2. Review of R195's clinical record revealed: 5/30/18 - R195 was admitted to the facility with diagnoses including: a stroke affecting the left dominant side, difficulty swallowing and need for assistance with personal care. 5/31/18 - R195's Baseline Care Plan under Assistance with ADL's stated, Nursing staff to provide care as needed related to deficits to ensure ADL care is being met. 12/14/20 - R195's quarterly MDS (Minimum Data Set) assessment documented R195 as an extensive, two plus person assist for transfers and toilet use, limited one person assistance (assist) for eating and extensive, one person assist for bed mobility, dressing, and personal hygiene. 12/16/20 2:12 PM - A Grievance email from F2 (R195's stepdaughter) to E15 (NHA) stated, Good afternoon E15 (former NHA), My mother (F3) just had a facetime with her husband (R195) who is my stepfather . She called me very upset. R195 was lying in bed eating lunch with only an undershirt on. He is suppose (sic) to be up in his wheelchair for all meals due to aspiration risk and dressed in an undershirt, shirt and flannel 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.

Based on observations, interview and record review, it was determined that for one (R67) out of one sampled resident reviewed for respiratory care, the facility lacked evidence that R67's nebulizer reservoir and tubing were labled with a date of use and were stored in a sanitary manner. Findings include: Review of R67's clinical record revealed: 6/10/21 - R67 was admitted to the facility with COPD (Chronic Obstructive Pulmonary Disease). 5/12/2023 - A Physician's order for R67 included to administer a nebulizer treatment every four hours for shortness of breath or wheezing related to COPD. 5/13/23 - A Physician's order for R67 included to administer a nebulizer treatment once a day related to chronic sinusitis (inflammation of the nasal passage cavities). 7/5/23 12:10 PM - During a random observation during screening, R67's nebulizer reservoir and tubing were noted to be on his bedside table covered with clothing and a pair of shoes next to it. The nebulizer equipment was not contained to keep it sanitary. In addition, the equipment was not labeled with a date to discern when it had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R16) out of two residents reviewed for PASARR, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days. Findings include: The facility policy on psychotropic medications last updated October 2022, indicated, A psychotropic drug is any drug that affects brain activities . include but not limited to antianxiety [medications]. If the attending physician or prescribing practitioner believe it is important for the PRN to be extended beyond 14 days, they shall document their rationale in the residents medical record and indicate the duration for the PRN order. Review of R16's clinical record revealed: 6/1/23 - A hospice nursing note documented Recommendations: per hospice when patient unable to swallow, antianxiety medication every morning and evening as needed for anxiety. 6/2/23 - A Physicians order was written by R16's Attending Physician for R16 to receive an antianxiety medication every 12 hours as needed with no stop date. During an interview on 7/10/23 at 11:44 AM, E23 (RN)…

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

Based on interview and record review, it was determined that for two (R32 and R118) out of four sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include: Cross refer F656 The facilities policy titled, Dental Services, revised 10/2022, indicated The dental needs of each resident are identified through the physical assessment and MDS assessment process and addressed in each resident's plan of care. 1. Review of R32's clinical record revealed: 8/20/21 - R32 was admitted to the facility. 8/21/21 - Review of the care plan initiated 8/21/21 revealed no evidence of R32 having a care plan related to dentures or dental needs. 5/28/22 - Review of the MDS (Minimum Data Set) assessment documented that R32 had broken teeth or loosely fitting full or partial dentures. 5/28/23 - Review of the MDS assessment documented that R32 does not have broken teeth or loosely fitting full or partial dentures. 7/5/23 9:33 AM - An interview with R32 revealed that R32 has dentures that do not fit, resulting in R32 not wearing…

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