Seaford Center

Based on interview and record review it was determined that for one (R1) out of three residents reviewed for abuse the facility failed to report an allegation of sexual abuse within the required time constraints. Based on the facility's evidence to correct the noncompliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 6/6/25. Findings include: Review of R1's clinical record revealed: 6/27/23 - R1 was admitted to the facility with diagnoses including but not limited to hypertension, low back pain and nervous system disorders. 5/27/25 2:38 PM - An incident summary documented On 5/24/25 [R4 (Spouse)] reported being in the bathroom and R1 and E4 (Activity Aide) were together in the activity room and E4 (Activity Aid) asked R1 to see his private parts R4 also reported R1 was very upset and asked R4 to report this 6/3/25 E1 (NHA) documented An employee passed me in the hallway and said R4 and R1 wants to see you 6/3/25 - A facility provided statement written by E1 (NHA) documented T.C. (sic) with E5 (Activities Director) I heard 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 (R2) out of two residents reviewed for respiratory therapy, the facility failed to have R2's BiPAP settings orders in R2's EMR at admission. Findings include: Facility's Bi-Level Positive Airway Pressure (BiPAP)/ Continuous Positive Airway Pressure (CPAP) procedure policy- . 1. Verify order . 9. Initial set-up: 9.1 Apply ordered settings to the unit per manufacturer's instructions . 11/30/24 - C1 (MD) documented in R2's [Hospital] discharge summary, .Plan: . OSA (Obstructive sleep apnea) BiPAP nightly . 11/30/24 - R2 was admitted to the facility with diagnoses, including but were not limited to, obstructive sleep apnea (OSA), emphysema and chronic respiratory failure with hypoxia (low oxygen concentration in the blood). 11/30/24 - E9 (Admissions) uploaded into R2's EMR a copy of R2's [hospital] BiPAP orders stating .Uses BiPAP HS at night. RT to titrate based home settings .IPAP (cmH2O) 21, PEEP/CPAP (cmH2O) 17, FiO2 40%. 11/30/24 9:44 PM - E8 (RN) documented in R2's EMR, . admission details: arrived by ambulance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that for three (R1, R5, R6) out of three residents reviewed for dialysis, the facility failed to establish a process to obtain complete lab reports from the dialysis provider. Findings include: Cross refer F711, F775 and F842. Facility NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation Policy- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments received at a certified dialysis facility. Purpose: To ensure ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis patient care and services . 1 .Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis (an invasive treatment for advanced…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that for three (R1, R5, R6) out of six residents reviewed for Physician Services, the facility failed to have the physician review the resident's total program of care. For R1, the physician failed to review R1's lab work (resident had labs obtained at hemodialysis) and regarding R1's supplemental oxygen usage. For R5 and R6, the physician failed to review lab work obtained at hemodialysis. R6 had a known hospitalization for hyperkalemia in November 2024. Findings include: Cross refer F698, F775 and F842 1. Review of R1's clinical record revealed: 11/15/24 - R1 was admitted to the facility with diagnoses including but not limited to, hyperlipidemia, end stage renal disease and stroke. 11/15/24 - E7 (MD) ordered in R1's EMR, .Dialysis days: Mondays, Wednesdays and Fridays . 11/18/24 - E7 (MD) ordered in R1's EMR, . Oxygen 2 L (liters) every shift . Review of R1's vital signs for pulse oximetry monitoring from 11/18/24 to 12/11/24 (the date of transfer to the hospital) revealed thirty-six documented occasions of pulse ox…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R5, R6) out of three residents reviewed for dialysis, the facility failed to have the clinical record laboratory report containing the name and address of the testing lab in the residents' EMR. Findings include: Cross refer F698, F711 and F842. 1. Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis. 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . 12/19/24 2:40 PM - During a telephone interview, C4 ([outside hemodialysis center 2] RN/ facility administrator) stated, [R5] gets lab work drawn every month. We use [laboratory] for our lab work. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed . We do not send the official lab reports to the facility. R5 had lab work obtained at the [hemodialysis center 2] in August, September,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R1, R5, R6) out of three residents reviewed for dialysis, the facility failed to maintain medical records that were complete and readily accessible with regards to lab results. Findings include: Cross refer F698, F711 and F775. 1. Review of R5's clinical record revealed: 6/26/24 - R5 was admitted to the facility with diagnoses including but not limited to, diabetes, anemia, seizure disorder and end stage renal disease with dependence on hemodialysis. 6/26/24 - E7 (MD) ordered in R5's electronic medical record (EMR), .Dialysis days: T-Th- Sat Time for pick up: 0600 . Review of R5's lab results tab in the EMR reveal no laboratory blood work since 7/26/24. R5 did have COVID screening lab results as recent as 11/6/24 in the lab results profile. 12/19/24 2:40 PM - During a telephone interview, C4 ([outside hemodialysis center 2]RN/ facility administrator) stated, [R5] gets lab work drawn every month. We have standing orders for hemodialysis patients that require monthly lab work with redraws as needed . We do not…

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

Based on record review and interview, it was determined that for four (R7, R22, R43 and R66) out of twenty (20) sampled residents, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings and that meetings occurred every three months. In addition, R66's care plan had not been reviewed and revised to reflect a behavior of frequently removing his nebulizer equipment from the protective plastic bag. Findings include: 1. Review of R7's clinical record revealed: 4/10/24 - R7 was admitted to the facility. 9/19/24 - A review of the notes for the initial care plan meeting on 4/25/24 lacked evidence of input from the Physician. Additionally, there was no evidence that a quarterly care plan meeting occurred in July, 2024. 2. Review of R22's clinical record revealed: 4/10/14 - R22 was admitted to the facility. 9/19/24 - A review of the notes for the care plan meeting on 10/11/23 lacked evidence of input from R22's nurse. A review of the notes for the care plan meeting on 8/14/24 lacked evidence of input from the Physician.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 three (R20, R38 and R45) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to maintain or restore bladder continence. Findings include: A policy revised on 6/15/22 titled Continence Management documented continence status will be reviewed quarterly as part of the care planning process to provide appropriate treatment and services for patients with urinary incontinence to restore continence to the extent possible. 1. Review of R20's clinical record revealed: 5/12/22 - R20 was admitted to the facility. 5/5/24 - The Annual MDS assessment documented that R20 was dependent for toileting hygiene and not on a toileting program. The MDS also documented that R20 was frequently incontinent of bowel and bladder. 5/2024 - The CNA task sheet documented that R20 was incontinent of urine seventy-three out of eighty-five opportunities. 6/2024 - The CNA task sheet documented that R20 was incontinent of urine seventy-eight out of eighty-four opportunities. 6/12/24 - A skilled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 five (E7, E8, E9, E10 and E11) out of five certified nursing assistants reviewed, the facility failed to complete an annual evaluation. Findings include: 9/23/24 approximately 8:50 AM - E1 (NHA) provided documentation regarding CNA evaluations for the following employees: E7 (CNA) with a date of hire of 12/6/22; E8 (CNA) with a date of hire of 5/24/22; E9 (CNA) with a date of hire of 11/20/17; E10 (CNA) with a date of hire of 10/14/19; E11 (CNA) with a date of hire of 3/7/23; 9/23/24 11:59 AM - In an interview, E1 stated that there had been a system failure due to turnover with facility staff. The facility was in the process of completing the overdue performance evaluations at the time of the survey. 9/24/24 2:00 PM - Findings were reviewed with E1, E2 (DON) and E3 (Corporate 1) at the exit conference.

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: 9/16/24 - 9:15 AM - During the initial tour of the kitchen, an open plactic bag containing lettuce and celery with browned edges and negative changes in quality and texture was observed in the walk-in refrigerator. 9/17/24 - 8:50 AM - During a tour of the kitchen, a puddle of standing water was observed under the ice machine and the water line that supplies the ice machine. 9/17/24 - 9:25 AM - During a tour of the kitchen, the surveyor observed E13 (Dietary Services Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E13 tested the sanitizing solution, the test strips from each of the buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization. 9/24/24 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate 1) at the exit conference.

Based on observation, interview and record review, it was determined that for one (R18) out of six residents reviewed for activities of daily living (ADLs), the facility failed to get R18 out of bed in accordance with his preference. Findings include: Review of R18's clinical record revealed: 1/31/24 - R18 was admitted to the facility. 8/8/24 - A quartlerly MDS documented that R18 was dependent for transfer and requires a sit to stand lift for transfer. R18 has a BIMS score of 13 and was cognitively intact. 9/16/24 10:58 AM - An observation of R18 laying in bed watching television. 9/17/24 10:45 AM - An observation of R18 laying in bed watching television. 9/18/24 1:06 PM - An observation of R18 laying in bed watching television. 9/19/24 12:41 PM - An observation of R18 laying in bed watching television. 9/20/24 9:25 AM - An observation of R18 laying in bed watching television. 9/23/24 12:00 PM - An interview with R18 revealed that his preference is to get out of bed daily. R18 stated that staff tells him they are too busy to get him out of bed. 9/23/24 12:14 PM - 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 review of facility documentation and interview it was determined that for two (R10 and R48) out of three Medicare Part A discharges reviewed the facility failed to have evidence of a completed Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). Findings include: Review of surveyor requested Skilled Nursing Facility Beneficiary Protection form for three discharged Medicare A residents the following was revealed: 1. R10 started Medicare Part A skilled services on 2/15/24. The last day of covered services was 4/2/24. The resident stayed at the facility as a long-term care resident. There was no evidence the facility provided the SNFABN when Medicare Part A services ended and the resident converted to another payer source. 2. R48 started Medicare Part A skilled services on 4/29/24. The last day of covered services was 7/2/24. The resident stayed at the facility as a long-term care resident. There was no evidence the facility provided the SNFABN when Medicare Part A services ended and the resident converted to another payer source. 9/23/24 2:00 PM - During 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 has been determined that for one (R64) out of three sampled for PASARR, the facility failed to ensure a referral for a PASARR screening was done for a new mental health diagnosis. Findings include: Review of R64's clinical record revealed: 1/8/23 - R64 was admitted to the facility with the following diagnoses of atrial fibrillation (irregular rapid heart rate), hypertension and major depressive disorder. 1/6/23 - Review of R64's PASARR Level I screen outcome documented . No Level II required 2. No SMI (serious mental illness), ID (intellectual disability or RC (related condition). 12/30/23 - R64's annual MDS (Minimum Data Set) documented a new diagnosis of schizophrenia. 9/23/24 11:50 AM - E6 (SW) was interviewed and stated, I am not sure if a new PASARR application was done for [R64], I wasn't here then, but I can check. I'm not finding her; I'm searching for her and it's not here. It looks like there was not a new one, but it looks like she is due for a PASARR on 9/22/24, and honestly I am working on it now. 9/24/24 11:40 AM - Findings were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that for two (R39 and R89) out of six residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include: A facility policy and procedure titled, Activities of Daily Living (ADLs) revised 5/1/23 documented . Activities of daily living include, hygiene, bathing, dressing, grooming, and oral care. 1. Review of R39's clinical record revealed: 4/12/21 - R39 was admitted to the facility. 8/24/24 - The CNA task list documented R39's shower schedule was on Tuesday and Friday on the 7 AM to 3 PM shift and prefers a bed bath. 9/8/24 - The quarterly MDS documented that R39 was dependent for bathing and personal hygiene. 9/16/24 10:58 AM - An observation of R39 with overgrown finger nails with debris noted underneath. 9/17/24 11:05 AM - An observation of R39 with overgrown finger nails with debris noted underneath. 9/17/24 - A review of the CNA task flow sheet revealed that R39 had a complete bed bath. 9/18/24 2:06 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.

Based on observation, interview, and record review, it has been determined that for one (R66) out of two residents sampled for respiratory care the facility failed to provide professional standards of practice by ensuring R66's nebulizer equipment was stored in a protective plastic bag. Findings include: Cross refer F657 Review of R66's clinical record revealed: 5/24/23 - R66 was admitted to the facility with diagnoses including, but not limited to, chronic obstructive pulmonary disease (lung disease that blocks air flow and makes it difficult to breathe) and stroke. 12/5/23 2:00 PM - A physician's order written for R66 documented . Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 ml inhale as needed for Shortness of Breath Pre-treatment evaluation in supplemental documentation. In progress note document response to instructions and education and any adverse reactions. Notify the provider of any adverse reactions. 8/30/24 - A quarterly MDS (Minimum Data Set) assessment revealed R66 was severely cognitively impaired. 9/16/24 10:09 AM - R66's nebulizer tubing and mask…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R22 and R57) out of five residents reviewed for unnecessary medications, it was determined that psychoactive medications lacked monitoring. For R22, the facility failed to ensure adequate monitoring with an AIMS assessment. Additonally, the facility failed to monitor R57, a resident taking antipsychotic medication, for symptoms of psychosis. Findings include: A policy and procedure titled Behaviors: Management of Symptoms revised 7/1/24 documented . Patients exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the patient's behavior. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. 4/10/14 - R22 was admitted to the facility. 8/2023 - R22's MAR reflected that he was ordered Zyprexa (olanzapine) tablet 10 MG Give 0.5 tablet by mouth one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R11) out of three residents reviewed for change in condition, the facility failed to immediately consult the Physician when R11 experienced a change in condition. Findings include: Cross refer F684 Review of R11's clinical record revealed: 11/8/11 - R11 was admitted to the facility. 9/10/23 - R11 was diagnosed with panlobular emphysema, chronic obstructive pulmonary disorder (COPD), and chronic respiratory failure with hypoxia. 10/24/23 - A physician's order was written for oxygen at 6 liters per min continuously via nasal cannula. 1/6/24 7:40 AM - A progress note revealed that R11 was experiencing dyspnea (difficulty breathing) with labored breathing. R11's pulse oximetry was 85% on 6 liters of oxygen and R11 was requesting to be sent to the hospital. 4/26/24 2:40 PM - An interview with E6 (RN) confirmed that the aforementioned progress note on 1/6/24 was the care she performed for R11. There is no evidence that E6 contacted the provider regarding the change in condition for R11. The facility records lacked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, it was determined that for one (R14) out of three residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include: Review of R14's clinical record revealed: 3/21/24 - R14 was admitted to the facility. 3/22/24 - A care plan revealed that R14 was dependent for ADL care including bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to limited mobility. 3/27/24 - An admission MDS revealed that R14 was cognitively intact and was dependent for eating, bathing, toileting, dressing, personal hygiene and transfers. 4/26/24 - A review of the CNA task sheet lacked evidence of care provided to R14 on the following dates on the 7AM - 3PM shift: March 25, 2024; March 26, 2024; April 2, 2024; April 9, 2024; April 16, 2024; April 17, 2024; April 19, 2024; April 22, 2024; April 24, 2024; April 25, 2024. 4/29/24 1:45 PM - An interview with E7 (CNA) confirmed that the CNA task flow sheet lacked evidence that care was provided to R14 for the following…

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

Based on interviews and record review it was determined that for one (R11) out of three residents reviewed for quality of care, the facility failed to ensure treatment and care in accordance with professional standards of practice. R11 had a change in respiratory status that was unrecognized and hospital transfer was delayed. Findings include: Cross refer F580 Review of R11's clinical record revealed: 11/8/11 - R11 was admitted to the facility. 9/10/23 - R11 had diagnoses including but not limited to panlobular emphysema, chronic obstructive pulmonary disorder (COPD), and chronic respiratory failure with hypoxia. 10/24/23 - A physician's order for R11 was written for oxygen at 6 liters per min continuously via nasal cannula. January 2024 - R11's MAR revealed a baseline oxygen levels between 92 and 98 percent on 6 liters of oxygen. 1/5/24 1:45 PM - A progress note from a respiratory therapist revealed that R11 was ambulating to the bathroom and the pulse oximeter reading was 86% on 6 liters of oxygen. E5 assisted R11 back to bed, applied her Bipap mask and rechecked R11's pulse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 establish a Grievance Policy that informed the residents of their right to obtain written decision regarding their grievance. The posted grievance policy did not have the correct name of the current Grievance Official and contact information. Also, the grievance policy was not prominently displayed at wheelchair level in large print to accommodate wheelchair bound and /or poor visual acuity residents. The grievance box for completed grievance forms outside the main office is not marked as the grievance box nor is it at wheelchair level. Additionally for R70, the facility failed to inform R70 of the outcome of his grievance investigation or offer R70 a resolution to his grievance. Findings include: 1- Review of the facility revealed: 8/15/23 9:13 AM - The Surveyor observed three pin up boards on three different hallways that were covered with glass that displayed the typewritten Grievance/ Concerns Policy & Procedure as depicted in the 2023 Welcome packet. The posting stated E45 (former NHA) was 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 observation and interview it was determined that the facility failed to ensure safe sanitary storage of food, provide the sanitizing solution required for disinfecting food preparation surfaces, and maintain sanitary food preparation areas. Findings include: 8/14/23 10:10 AM - During a kitchen tour, several food items including a container of sliced beets, a large container of a red liquid, a large container of a yellow liquid, and a container of unidentified leftovers were observed with partially open coverings exposing the contents to dust and other debris in the walk-in refrigerator. The reach-in refrigerator contained cartons of thickened juices, sandwiches, and salads, which were missing the date stamp required for safe food storage. 8/14/23 10:20 AM - During a tour of the kitchen, no red sanitizer buckets containing sanitizing solution were available in the kitchen for disinfecting food preparation surfaces. 8/14/23 10:25 AM - Crumbs and other food debris were observed on the floor in the kitchen and food prep surfaces in areas where food prep was not occurring during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to ensure attendance of required members at the quarterly quality assurance and performance improvement (QAPI) meetings. Findings include: Review of the facility's QAPI plan, last updated 1/6/21, indicated, .Meets at least 10 times annually . is composed of . The Infection Preventionist, or designee 8/21/23 - A review of the QAPI Meeting Sign-in Sheets revealed that the Infection Preventionist or designee was not present during the 10/20/22, 11/22/22, 12/22/22, 1/19/23, 2/23/23, 3/23/23, 4/27/23, 5/15/23, or the 7/27/23 meetings. 8/21/23 10:45 AM - During an interview with E1 (NHA) and E2 (DON), it was confirmed that E20 (Infection Preventionist) had been in that role with the facility for more than one year and was not in attendance during the quarterly QAPI meetings. 8/21/23 2:50 PM - Findings were reviewed with E1, E2 and E3 (ADON).

Based on random observation and interview, it was determined that for one (Unit 2) of two units reviewed, the facility failed to promote care for residents in a manner and environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her own individuality. Findings include: 8/17/23 12:36 PM - The Surveyor observed that R15's lunch tray had plastic utensils. R15 was unable to pick up his grilled chicken caesar salad as the plastic fork kept bending as R15 tried to spear it with the plastic utensil. 8/17/23 12:40 PM - A random observation of Unit 2's lunch trays by the Surveyor revealed that seven rooms (229 B, 236 A, 236 B, 238 A, 238 B, 240 A and 240 B) out of thirty-six (36) rooms with lunch trays had plastic utensils on their tray. 8/17/23 12:49 PM - During an interview, E2 (DON) stated that she was not aware of any issues with the kitchen's dishwasher but that is not my area. 8/17/23 12:49 PM - During an interview, when notified of the plastic utensils on lunch trays and asked if there was a problem with the dishwasher in the kitchen,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that for two out of two resident units, the facility failed to provide a clean and homelike environment. Findings include: 1. 8/14/23 2:50 PM - During an observation of Unit 1, room [ROOM NUMBER] bathroom had scuffs noted on wall, the toilet was stained and appeared uncleaned and tiles behind the toilet were loose and elevated in the air. A repeat observation for room [ROOM NUMBER] on 8/18/23 9:22 AM revealed scuffs remained on wall and the toilet not cleaned. 8/14/23 9:52 AM - room [ROOM NUMBER] revealed that the door handle to room did not engage with lock when the handle was turned. The bathroom had black stains noted on floor in multiple areas, stains noted around base of toilet and stains inside toilet. The hot water faucet knob was missing the end piece resulting in a flat edge exposed. A repeat observation on 8/18/23 at 9:24 AM revealed that the door handle was not functioning, the sink knob was still not replaced or repaired, and stains remain on 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 four (E13, E14, E15, and E16) out of five certified nursing assistants reviewed, the facility failed to complete an annual evaluation. Findings include: 8/18/23 approximately 9:00 AM - E1 (NHA) brought documentation regarding the following CNA's evaluations, which occurred on the following dates: E13 (CNA), column undated (date of hire 7/12/22) E14 (CNA), 10/4/21 (date of hire 4/13/21) E15 (CNA), 5/10/22 (date of hire 4/5/88) E16 (CNA), 5/30/20 (hire date 5/29/01) 8/21/23 12:56 PM - When questioned about yearly performance reviews, E2 (DON) stated it is not the company's policy to do a yearly review for CNA's. 8/21/23 2:50 PM - Findings were reviewed with E1, E2 and E3 (ADON).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to ensure that medications were stored and labeled properly in two out of six medication carts and in one out of two medication rooms reviewed. In addition, the facility failed to monitor refrigerator temperatures in one medication fridge on Unit 1. Findings include: [DATE] 1:07 PM - During a medication storage review of the Unit 1 Medication Room the following was observed inside the medication room: 1. Expired on [DATE] Flu vaccine: two bottles and one box of pre-filled syringes. 2. Expired on [DATE] Epi-pen (medication to treat allergic reactions). 3. Expired on 8/22 bottle of Pedialyte. 4. Expired on 12/22 package of Cepacol throat lozenges. 5. Expired on 11/22 bottle of Magnesium. 6. Albuterol inhalation solution: opened and no date. [DATE] 1:23 PM - A review of temperature log for the medication fridge revealed that facility failed to monitor temperatures. [DATE] 1:27 PM - An interview with E11 (RN) confirmed medications were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four (R7, R16, R20 and R60) out of six sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include: A facility policy and procedure titled, OPS160 Dental Services, with last revision of 9/1/22, documented, Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. 1. Review of R7's clinical record revealed: 4/17/23 - R7 was admitted to the facility. 4/17/23 - R7's care plan documented that R7 .exhibits or is at risk for oral health or dental care problems as evidenced by absence of natural teeth 4/23/23 - The admission MDS assessment documented that R7 had no natural teeth or [having] tooth fragments. 8/14/23 9:57 AM - During 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 observation and interview, it was determined, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections. Findings include: The manufacture's instructions for cleaning and disinfecting, with a revision of March 2015, indicated cleaning and disinfecting of the glucometer needs to be completed after each resident use. 8/16/23 9:44 AM - During medication administration observation, E12 (LPN) used an alcohol pad before and after performing fingerstick blood sugar testing. 8/16/23 11:04 AM - During medication administration observation, E12 (LPN) used an alcohol pad before and after performing fingerstick blood sugar testing. 8/17/23 10:48 AM - During medication administration observation, E24 (RN) used an alcohol pad before and after performing fingerstick blood sugar testing. 8/21/23 10:23 AM - During an interview E22 (RN) stated she uses an alcohol pad to clean the glucometer, they don't have any more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and interview, it was determined that for one (R264) out of five residents reviewed for activities of daily living (ADLs), the facility failed to get R77 out of bed in accordance with her preference. Findings include: Review of R264's clinical record revealed: 6/4/22 - admission to the facility. A care plan initiated on 6/23/22 revealed, Resident/Patient is at risk for or is experiencing adjustment issues related to: Change in customary lifestyle and routines and/or difficulty accepting placement in center. A care plan initiated on 6/23/22 revealed, Review ADL status for impact on social involvement and provide ADL assistance, as needed, to increase social involvement. A care plan initiated on 7/23/22 revealed, It is important for me to go outside when the weather is good and enjoys sitting/relaxing and smoking-on occasion. 10/11/22 - A physician's order documented the resident is a total lift with all transfers into wheelchair. An annual MDS dated [DATE] confirmed R77 is 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 (R393) of fourteen (14) residents reviewed for abuse, the facility failed to ensure that an allegation of abuse was reported to the State Agency within the two hour time frame. Findings include: 8/2/23 - R393 admitted to the facility with diagnoses that included traumatic brain injury and epilepsy. 8/8/23 - R393's Minimum Data Set (MDS) Assessment documented moderate cognitive impairment, extensive two-person assist to transfer and use the toilet, frequently incontinent of bladder and always incontinent of bowel. 8/9/23 - During an interview, E44 (CNA) alleged witnessing R393 as the recipient of a verbally abusive statement from E2 (DON) in which R393 was told to just shit on himself . when R393 was asking to go to the bathroom. E44 then verbally reported this allegation to E8 (Social worker), who asked E44 to write a statement. 8/21/23 9:37 AM - The Surveyor was given a witness statement written by E44 (CNA) documenting R393 making an allegation of verbal abuse against another staff member. E44 stated, I'm not…

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

Based on record review and interview it was determined that for two (R91 and R192) out of two new admissions reviewed the facility failed to ensure a written summary of their baseline care plan was provided. Findings include: 1. Review of R91's clinical record revealed: 6/16/23 - R91 was admitted to the facility. Review of R91's clinical record lacked evidence that the facility provided the resident and their representative with a summary of the baseline care plan. During an interview on 8/15/23 at 8:50 AM with CG1, it was reported that R91 and CG1 did not receive a copy of the baseline care plan summary. During an interview on 8/17/23 at 10:10 AM E4 (RNC) stated, Families/residents are sat down with staff at the 72 hour care plan meeting and they receive the summary then. 2. Review of R192's clinical records revealed: 8/5/23 - admission to facility. 8/11/23 - admission MDS revealed R192 was cognitively intact. 8/17/23 10:10 AM - E4 (Corporate) stated to two members of the Survey team that the facility sat families down at a 72-hour care plan meeting. 8/17/23 12:35 PM - R192…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R13 and R82) out of twenty-six (26) of the investigative sampled residents the facility failed to develop and implement a comprehensive person centered care plan for identified needs. Findings include: 1. Review of R13's clinical record revealed: 9/11/09 - R13 was admitted to the facility. 4/25/23 - A physician order was written for a hospice consult per family request. 5/7/23 - A quarterly MDS documented severe cognitive impairment. 6/30/23 - Review of the hospice binder included a signed admission to hospice contract. 8/7/23 - Review of R13's care plan revealed a lack of evidence that a person centered care plan with interventions was developed for hospice services. 8/18/23 3:40 PM - During an interview E3 (UM) comfirmed R13's care plan lacked evidence that a person centered care plan with interventions was developed to identify that R13 was receiving hospice services. 2. Review of R82's clinical record revealed: 5/23/23 - A physician order was written to administer oxygen at 2-3 L/min (liters per minute) using…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, it was determined that for one (R15) out of twenty-six (26) residents reviewed for comprehensive care plans, the facility failed to provide R15 the opportunity to participate in his care plan meetings. Findings include: R15's clinical record revealed: 5/3/21 - R15 was admitted to the facility with a diagnosis of end-stage renal Disease, which required offsite dialysis three days a week. According to the clinical record, R15 was scheduled and transported for offsite dialysis every Monday, Wednesday and Friday (M/W/F). Review of E40's (Social Worker) care plan meeting notes revealed that R15 was Invited but not in attendance for the following dates: - 2/8/23 at 2:15 PM; - 5/3/23 at 10:30 AM; - 7/26/23 at 10:40 AM. Despite R15's scheduled dialysis days for M/W/F, the facility repetitively scheduled R15's care plan meetings on Wednesdays (2/8/23, 5/3/23 and 7/26/23). The facility failed to provide the resident with multiple opportunities to participate in his own care plan meetings. 8/15/23 at 9:02 AM - During an interview, R15 stated that he has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 (R60) out of five residents reviewed for ADL care provided for dependent residents, the facility failed to provide the necessary assistance to get OOB (out of bed). Findings include: 7/25/19 - R60 admitted to facility with diagnoses including stroke and persistent vegetative state. 10/11/22 - E33 (MD) ordered Resident (R60) is a total lift for all transfers. 10/12/22 - E33 (MD) ordered Heel protectors to bilateral feet at all times . 4/7/23 - E33 (MD) wrote OOB seating and positioning Clarification Order: patient to be positioned OOB in geri-chair, 3X/wk (three times per week) for 2-3 hours as tolerated. 8/14/23 1:14 PM - During a telephone interview, CG2 (R60's daughter) stated, I want her to sit in the chair. They don't get her OOB like they use to. CG2 stated that she believes the staff use a lift to get her OOB. 8/16/23 8:48 AM - R60 was lying in bed towards the left side (with pillow prop) with heel protectors on bilateral feet with pillow between her legs. 8/16/23 11:34 AM - R60 was lying in bed propped 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 two (R11 and R23) out of three residents reviewed for quality of care, the facility failed to ensure that each resident received treatment and care in accordance with the plan of care. Findings include: 1. Review of R11's clinical record revealed: 4/4/23 - R11 was readmitted to the facility. 9/28/23 - A physician note from P2 (MD) at a specialized eye hospital documented that R11 had viral conjunctivitis in the left eye and to follow up with the regular eye doctor or the cataract and primary eye care service in 3 to 6 weeks. The note also confirmed that R11's test results were consistent with glaucoma. The note further documents to follow up for glaucoma in 2 to 3 days for consideration of cataract extraction with insertion of intraocular lens. 9/30/23 2:01 PM - A nursing note documented a call was made to the eye clinic to follow-up with an appointment but there was no answer and the clinic was closed on the weekends. The facility lacked evidence of a follow-up appointment for R11. 11/28/23 2:35 PM - 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 (R82 and R243) out of two residents reviewed for respiratory care, the facility failed to provide professional standards of practice by ensuring the oxygen tubing and humidifier bottle was labeled and changed weekly. Findings include: 1. Review of R82's clinical record revealed: 1/8/23 - R82 was admitted to the facility. 1/14/23 - An admission MDS indicated R82 was cognitively intact and diagnoses of acute respiratory failure with hypoxia and COPD. 5/23/23 - A physician order was written to administer oxygen at 2-3 L/min (liters per minute) using a nasal cannula for drop in O2 (oxygen) saturations, keep above 92% PRN (as needed). 8/14/23 - An observation of R82's oxygen tubing revealed a label dated 7/22/23. 8/16/23 - A review of R82's physician orders revealed no order to change oxygen tubing. 8/16/23 10:18 AM - During an interview E3 (UM) stated that they haven't been changing the tubing because R82 hasn't been using it and she is PRN and the tubing was outdated. E3 reviewed the physician orders 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 it was determined that the facility failed to develop and maintain policies and procedures for the Medication Regimen Review (MRR) that included time frames for the various steps in the process. Findings include: A review of the facility policy 6.1 Pharmacist Consultant Services dated 8/1/16, stated, POLICY- Residential Care Facilities with more than 10 beds shall retain the services of a pharmacist consultant no less than quarterly .PROCESS- 1. On a quarterly basis, the pharmacist consultant shall review: 1.1 Written policies and procedures for pharmaceutical services .1.4 Medication records, and initial and date the records when reviewed; 1.5 Adherence to stop orders; and 1.6 Staff performance in carrying out pharmaceutical policies and procedures. 2. The Pharmacist Consultant shall provide the Center Executive Director with a timely, written report of findings, with specific recommendations in each of the areas reviewed. This policy did not address the federally mandated time frames for the various steps in the MRR process. It did not address the steps 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 (R5) out of six residents reviewed for medication review, the facility failed to ensure that R5's erythromycin eye ointment was not continued for an excessive duration after confirming no active infection in June 2023. Findings include: 8/19/20 - R5 was admitted to the facility. 4/5/23 - E22 (NP) ordered erythromycin ophthalmic ointment 5 mg (milligrams) /gm (gram) instill 1 drop in both eyes four times a day for conjunctivitis for 7 days for R5. The stop date listed for this order was 4/12/23. 4/20/23 - E27 (MD) restarted R5 on erythromycin ophthalmic ointment 5 mg/gm instill 1 drop in both eyes three times a day for chronic conjunctivitis. 5/7/23 4:24 PM - E27 documented in R5's Progress Note, .Vision issues have improved in general about both eyes Review of Systems: Sight has gradually gotten better by degree There is no mention of conjunctivitis/pink eye or it's treatment in E27's note. 6/2/23 - R5's Medication Regimen Review (MRR) recommended evaluation of erythromyocin eye drops (sic)as the order was missing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of six residents reviewed for medication review, the facility failed to ensure that R91 was free from significant medication error. Findings include: Cross refer F711 and F773 Synjardy, which is the trade name for a fixed-dose combination anti-diabetic medication used to treat type 2 diabetes. It contains both empagliflozin and metformin and is taken by mouth. It is used to control high blood sugars in people with type 2 diabetes. Controlling high blood sugar helps prevent kidney damage, blindness, nerve problems, loss of limbs and sexual function problems. Proper control of diabetes reduces the patient's risk of stroke and heart attack. 6/5/23 - R91 admitted to an acute care rehabilitation center. 6/16/23 - R91 admitted to the facility with diagnoses including diabetes and aftercare following joint replacement therapy (recent full revision right total knee replacement on 5/31/23). 6/16/23 - R91 transferred from the acute care rehabilitation center to the nursing home (the facility). R91's Discharge Reconciliation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 four (R91, R102, R103 and R104) out of four residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results that fell outside of clinical reference ranges. In addition, the facility failed to have a policy and procedures, for notification of the practitioner, when laboratory results fall outside of the clinical reference range. Findings include: Cross refer F711 and F760 1. Review of R91's clinical record revealed: 6/16/23- R91 admitted to the facility with diagnoses including diabetes and aftercare following joint replacement therapy (recent full revision right total knee replacement on 5/31/23). Of note, 6/16/23 was a Friday. 6/16/23 - E33 (MD) gave a verbal order for a complete metabolic panel (CMP) and complete blood count (CBC) to be drawn. 6/17/23 7:50 AM - R91 had CMP and CBC labs drawn. 6/17/23 11:17 AM - R91's CMP and CBC lab results are reported to the facility with nine lab values marked as abnormal or not within the normal clinical range.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received the selected food from the menu for one (R78) out of ten sampled residents for food investigation. Findings include: 8/16/23 11:40 AM - During a random dining observation of R78's lunch tray, the meal ticket did not match and R78 did not receive a dinner roll or fruit sherbet. 8/16/23 11:44 AM - An interview with E21 (CNA) confirmed that items are often missing from tray and she will walk down and get them. E21 confirmed the dinner roll and sherbet were missing from tray. 8/16/23 11:49 AM - The Surveyor observed E21 providing R78 a dinner roll and a container of fruit sherbet. 8/21/23 2:50 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON).

Based on interview, record review and review of other facility documentation it was determined that the facility failed to ensure, in accordance with professional standards and practices, that medical records for one (R82) out of twenty six (26) of the investigative sampled residents were accurate. Findings include: Review of R82's clinical record revealed: 1/8/23 - R82 was admitted to facility. 6/22/23 3:47 PM - A physician's order was written for Tramadol 50mg give 25 mg by mouth every 6 hours as needed for moderate to severe pain for R82. 8/18/23 - A review of R82's Individual Patient Controlled Record form for Tramadol lacked evidence of staff receiving the drug including date and time. 8/18/23 11:11 AM - An interview with E17 (LPN) and E3 (ADON/UM) confirmed that the facility lacked evidence of completing the Individual Patient Controlled Record for R82's Tramadol. 8/21/23 2:50 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3.