Kensington Gardens Rehab And Nursing Center

Based on observations, interviews, and record review, the facility failed to ensure updates of care plans for two out of four residents reviewed (Resident #1 and #231B). Findings included: A review of the facility policy titled Comprehensive MDS Assessment and Care Plan, Revised 2/2024, revealed - It will be standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS . The plan of care will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The plan of care will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally competent and trauma informed.On 1/15/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure ADLs (activities of daily living) related to nail care was provided for two residents (#1, #13) out of four residents sampled.Findings included: On 1/15/26 at 9:17 a.m., an observation of Resident #1 revealed orange and brown build up underneath the resident's nails.A review of Resident #1's admissions record revealed an admission date of 11/18/22 with diagnoses to include chronic obstructive pulmonary disease, Parkinson's disease, ataxia and tremors.A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 12/10/25, in section C - cognitive patterns revealed a Brief Interview Mental Score (BIMS) of 07, severe impairment. A review of Section E- Behavior for Resident #1's Rejection of Care- Presence and Frequency scored a 0-behavior not exhibited.A review of Resident #1's original Care Plan dated 12/25/25 revealed Resident #1 has a ADL, self-care deficit related to their Parkinson's diagnosis, and the resident should be encouraged and assisted with all ADL tasks including but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did not ensure equipment was safe, sanitary and operational, and failed provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas. Findings included: On 6/11/2025 at 10:45 a.m., an observation and interview were conducted with Resident #5 in his room. Resident #5 stated his overhead light does not work very well, and stated, it flickers on and off, and stated his roommate's [Resident #6] light, does not work at all. Staff P, Certified Nurse Assistant (CNA), entered the room and agreed the lights were not working properly. Staff P, CNA stated this was not her assignment. She stated she will notify their nurse. On 6/11/2025 at 10:52 a.m., an interview was conducted with Resident #7. Resident #7 stated she received a new bed this morning because the other bed was not working but stated, this bed's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#3) out of four residents sampled. Findings included: Review of Resident #3's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of displaced fracture of upper end of right humerus, with routine healing, asthma, dysphagia, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility, muscle weakness, major depressive disorder, post traumatic stress disorder (PTSD), and generalized anxiety disorder. An interview was conducted on 6/11/25 at 11:03AM with Resident #3. She said it was a Saturday around the last week of May 2025; she came out of the bathroom and was in a towel. She said Staff C, Occupational Therapist Assistant (OTA) knocked, came into her room, and she realized it was a male, so she said, I'm not dressed get 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate a resident-to-resident allegation of abuse involving two residents (#14 and #15) out of four reportable events sampled. Findings included: Review of the facility's state agency reportable log revealed on 5/22/25 a resident to resident report was made involving Resident #14 and Resident #15. An interview was conducted on 6/11/25 at 1:21 PM with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 6/11/25 at 1:21PM. The DON said she was the one who reported and investigated the event and the NHA said she was not working at the facility at the time the event occurred. The DON said the event occurred on 5/22/25 around 6:00 PM and she reported the event the state agencies on 5/22/25 at 6:00 PM. The DON said staff reported to Staff D, Eat Wing Unit Manager (UM) that Resident #14 made contact with Resident #15 to the back of his head. Staff were noted to be within close immediate proximity with both residents and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility did maintain an effective pest control program related to roaches for their residents. Findings include: On [DATE] at 10:11 a.m., an observation was made in front of Resident #4's room of a large moving roach on its back swept up in a pile of debris from Staff A, housekeeping. An interview was conducted with Resident #4 in his room. Resident #4 stated roaches are a problem and he sees them all the time in his room. Upon observation, live roaches were seen on the windowsill, walls and dressers. An observation was made behind Resident #4's dresser of a heavy growth of dark brown/black dusty-like debris on the floor by the baseboards behind his dresser. Staff A, housekeeping, returned to the room and was witnessed moving the dresser to sweep the debris on the floor. Staff A, housekeeping through an interpreter's phone, stated she sees roaches all the time. Photographic evidence obtained. On [DATE] at 10:52 a.m., an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of the Plan of Correction (PoC) the facility failed to ensure it had a functioning Quality Assurance Performance Improvement (QAPI) plan. The facility was actively involved in the creation, implementation, and monitoring of their PoC for deficient practice identified during a complaint survey on 05/13/2025. The plan was ineffective resulting in citation F908 being recited related to ensuring timely repairs of essential equipment, for one roof-top Air-Conditioning (A/C) unit (#11) of 19 roof- top A/C units and F908 being recited related to failure to ensure equipment was safe, sanitary and operational, and failure to provide a safe, functioning, sanitary and comfortable environment in resident's rooms for six residents (#5, #6, #7, #11, #12 and #13) out of 15 residents sampled, and in common areas to include food storage areas. Findings included: A review of an undated facility policy titled, Quality Assurance and Performance Improvement (QAPI), showed 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, record review, and interviews, the facility failed to ensure timely repair of essential equipment, two (#5 and #19) roof top air-conditioning units of 19 roof top air-conditioning units. Findings included: An interview was conducted on 5/13/2025 at 10:30 a.m. with the facility's Maintenance Director. He stated the facility had 19 rooftop air conditioning (A/C) units and the units were assigned numbers 1 through 19. He expressed concerns for A/C unit #19, located over the facility's North Wing near the nurse's station; A/C unit# 5, located over the facility's dining room; and A/C unit #1, located over the facility therapy gym. The Maintenance Director stated A/C unit #5, over the dining room, had been out of working order since 1/19/2025. He said if the dining room gets too warm, 81 degrees or anything above that, they move the residents to their room. The Maintenance Director stated A/C unit #19, over the North Wing nurses station, was an older unit and it started having issues at the end of 7/2024. At the end of 7/2024 or the beginning of 8/2024, A/C unit #19…

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

Based on observations and interviews, the facility failed to ensure one pantry (South Wing) of three pantries and one of five eye wash stations, was maintained in a safe and sanitary manner. Findings included: On 5/13/2025 at 1:10 p.m. during the tour of the facility's South Wing, an odor of strong musty smell was identified at the rear corner of the nurses station. The odor was located near the pantry door at the rear of the nurses station. When the door was opened, a strong smell was present in the room. The room was observed to have multiple areas of water damage. (Photographic Evidence Obtained) During the observation, interviews with staff were conducted: Staff A, Licensed Practical Nurse (LPN) stated she could smell the odor from the pantry. She said some of the nurses will not work on the South Wing due to the odor. Staff A, LPN stated, We cannot use the pantry. The refrigerator was moved to the small activity room across from the nurses' station. We have to go to the East Wing for ice. Snacks are stored in the activity room. We do not let the residents in the activity room…

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

Based on observations and interviews, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during three of four days of survey. Findings included: An observation on 01/29/24 at 9:00 a.m., revealed no nurse staffing data was posted in the facility. An observation on 01/30/24 at 6:00 p.m., revealed no nurse staffing data was posted in the facility. An observation on 01/31/24 at 3:00 p.m., revealed no nurse staffing data was posted in the facility. During an interview on 01/31/24 at 3:00 p.m., the Administrator stated normally the staffing coordinator would be responsible for posting the staffing numbers, however, the daily staff posting had not been getting posted with the absence of the staffing coordinator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) Level I for six (#61, #43, #5, #342, #48, and #45) of fifty-seven residents reviewed; and failed to ensure a PASARR Level II was completed for one (#100) of fifty-seven residents reviewed. Findings included: Review of the clinical record for Resident #61 revealed admission to the facility on [DATE], with admission diagnosis that included, but not limited to, major depressive disorder, anxiety, and adjustment disorder with anxiety as per the face sheet. Review of the PASARR dated 12/05/2023 for Resident #61 revealed no diagnosis checked in Section I A (mental illness or suspected mental illness). Review of the clinical record for Resident #43 revealed admission to the facility on [DATE], with admission diagnosis that included, but not limited to, depression as per the face sheet. Review of the PASARR dated 12/15/2023 for Resident #43 revealed no diagnosis checked in Section I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to ensure all grievances were tracked through to their conclusions for two residents (#56 and #16) of seven sampled residents for choices. Findings included: On 1/29/2024 at 12:48 PM an observation of Resident # 56's room revealed an un-opened box containing an electric wheelchair sitting at the foot of the resident bed against the wall. An interview was conducted on 1/29/2024 with Resident #56 regarding the electric wheelchair. Resident #56 stated,They haven't hooked it up for me. It's just sitting in the box. Look at it. I can't get around if I wanted to. I would like to go to activities. It's been sitting here since September. A review of Resident #56's medical record revealed the following progress note: 12/14/2023 at 11:30 AM: Social Service Note Resident has an electric scooter /chair in her room and was given the okay to use it by the Administrator. She is unable to use a regular wheelchair due to immobility reasons. Rehab Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one resident (#120) out of four residents reviewed for falls had the comprehensive care plan revised with additional interventions after a fall. Findings included: An observation on 01/29/24 at 10:13 a.m. showed Resident #120 had a bruised left eye. During an interview on 01/29/24 at 10:13 a.m., Resident # 120's Family Representative (FR) stated Resident #120 obtained her black eye from a fall roughly a week and half ago. Resident #120's FR stated the fall occurred in the bathroom. Resident #120's FR stated he asked staff about maybe bed rails or other interventions to be put in place so Resident #120 didn't fall again but the facility said Resident #120 could not have bed rails because that would be considered a restraint. Review of the facility's Incident Log for January 2024 showed Resident #120 had a fall on 01/19/24. Review of the admission Record showed Resident #120 was admitted to the facility on [DATE] with diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide care and services related to accessible emergent tracheostomy supplies at the bedside and providing oxygen as ordered for one resident (#109) out of one resident reviewed for tracheostomy care. Findings included: Review of Resident #109's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses included Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side, encounter for attention to tracheostomy, acute respiratory failure with hypoxia, dysphagia, and need for assistance with personal care. An observation was conducted on 01/29/24 at 11:05 AM. Resident #109 was observed to be in bed, looking around the room, with her head of bed elevated, breathing comfortably. Resident #109 was observed to have a tracheostomy tube in place. She was receiving 28% humidified oxygen with the oxygen concentrator set on two liters via trach…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a clean, comfortable, home-like environment in three of four community shower rooms, one of one dining rooms, and resident rooms in two of three units, on four of four days observed (1/29/2024, 1/30/2024, 1/31/2024 and 2/1/2024) during the survey. Findings included: 1) On 1/29/2024 at 9:30 a.m. and 2:00 p.m.; On 1/30/2024 at 7:45 a.m.; On 1/31/2024 at 10:00 a.m.; and on 2/1/2024 at 9:00 a.m., tours were conducted in the South Unit Community Shower Room which revealed the following: --Two of three white plastic (PVC) and plastic webbed backed shower chairs were observed with black and pink biogrowth on the under seat railing, the joints of all four legs, and heavy black biogrowth on all four legs at and near the wheel castors. --The plastic webbed backing of the chairs were observed with a white biogrowth coating. --The walls in the room at and near the shower stalls, especially at the baseboards, revealed many holes and gouges…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and record review, the facility failed to ensure one resident (#106) out of three residents reviewed received scheduled dialysis treatments as ordered in accordance with professional standards. Findings included: A review of the medical record for Resident #106 revealed the resident was re-admitted to the facility after hospitalization on 12/17/2023 with a diagnoses to include: End Stage Renal Disease (ESRD), alcoholic cirrhosis of liver with ascites, Type 2 Diabetes Mellitus, and dependence on renal dialysis. A review of Physician orders for Resident #106 revealed the following: -Hemodialysis (HD)-Resident receives HD every (Monday and Friday at [name of facility], chair time is 10:45 a.m. -Hemodialysis- right chest - [Type of catheter] dialysis access port/line. Monitor site for s/s (signs and symptoms) of infection, pain, drainage, increased temp, edema . Notify physician of abnormal findings -Hemodialysis -right/ chest - [Type of Catheter] dialysis access port/line. HD center to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the medication error rate was less than 5.00%. Forty-three medication administration opportunities were observed, and twenty errors were identified for three residents (#30, #65, and #101) out of five residents observed. These errors constituted a 46.51% medication error rate. Findings included: On 1/30/2024 at 8:20 a.m. an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted for Resident #30 The staff member dispensed the following medication: 1. Amoxicillin-Pot Clavulanate Tablet 875-125 milligram (MG) Tablet (Tab). 2. Prednisone 20 mg Tab 3. Budesonide Inhalation Suspension 0.5 MG/2 milliliters (ML) Inhalation 4. Isosorbide Mononitrate Extended Release (ER) Tab 30 MG (2 Tabs) 5. Colace Oral Capsule (Cap)100 MG Over the counter (OTC) 6. Guaifenesin ER Tab 600 mg OTC 7. Eliquis Tab 5 MG (medication was not available in the medication cart) 8. Diltiazem ER Coated Beads 180 MG Cap 9. Lasix 20 MG Tab 10. Gabapentin 400 MG Cap 11. Ipratropium-Albuterol…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and facility failed to ensure allegations of neglect involving one resident (#106) out of one sampled resident for dialysis was reported immediately to the governing agency in accordance with State law and thoroughly investigated. Findings included: On 1/30/24 at 5:12 p.m., an interview was conducted with Staff K, Registered Nurse (RN). Staff K stated he worked with Resident #106 quite often. Staff K stated the resident was alert and oriented, and used to go to dialysis on Monday, Wednesday, and Friday, but now goes on Thursday and Friday. The nurse stated Resident #106 received peritoneal drainage on 11pm to 7am shift. Staff K, RN stated sometime in December 2023, on a Tuesday, the police had come to speak with the resident because someone had called to report Resident #106 had missed too many dialysis appointments. Staff K, RN said, I was here, he was missing dialysis appointments. The police interviewed him. The problem was lack of transportation. The police resolved it. I believe it turned out to be miscommunication issues. Staff K stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to evaluate and analyze hazards and risks, implement interventions to reduce hazards and risk, monitor for the effectiveness of the interventions, and ensure neurological monitoring was completed after a head injury for one resident (#48) out of two residents sampled. Findings included: A family interview was conducted on 01/29/24 at 10:23 AM. He said a couple weeks ago the resident fell from his bed and hit his head on the dresser and that is why there is a hole in his dresser. The family member said Resident #48 had a bruise on the right side of his forehead because of the fall. An observation was conducted on 1/29/24 at 10:23 AM, during the family interview, and Resident #48 was observed to be in bed looking around the room, wearing a hospital gown. The bed was in the lowest position, there was a fall mat only on the right side of the bed. There was no fall mat on the left side of the bed. The dresser was observed to be pushed against…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to convey and provide a final accounting of personal funds within 30 days of discharge for three (#5, #7, and #8) of three residents reviewed. Resident #5 was discharged from the facility on 10/29/2023, as of 12/13/2023, Resident #5's patient trust account had $4,442.73 in it and his room and board bill documented he was due a refund of $736.80. Resident #7 was discharged from the facility on 01/20/2023, as of 12/13/2023, Resident #7's patient trust account had $1249.69 in it. Resident #8 was discharged from the facility on 04/26/2023, as of 12/13/2023, Resident #8's patient trust account had $45.00 in it. Findings included: A review of Resident #5's clinical chart, the face sheet, documented an admission of 12/16/2022 and a discharge date of 10/29/2023. A review of Resident #5's profile, listed a Power of Attorney (POA) for care and financial, with home and cell phone number. A review of Resident #5's Discharge summary, dated [DATE], documented Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure personal funds were accurately billed or adjusted for Room and Board (Care Cost) for one (#2) of six sampled residents. Findings included: On 12/13/2023 at approximately 2:00 p.m., Staff A, Registered Nurse (RN) was interviewed. She confirmed Resident #2 was on her assignment. She stated the resident was able to be interviewed at times. She was unable to say if he was able to make medical decisions, but, if there was a change in condition, she would notify the resident's [family member]. An attempt to interview Resident #2 was conducted with Staff A present. Resident #2 was observed in his bed. He stated he was hard of hearing. The attempt at an interview with Resident #2 was unsuccessful. Staff A stated he can hear better some days than others. A review of Resident #2's clinical record documented he had resided in the facility from 05/2021 and had been transferred to the hospital on [DATE]. The admission record documented he was…

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

Based on observation, record review and interview, the facility failed to implement the grievance policy and procedure for one (Resident #2) of ten sampled residents. Findings included: A review of the facility's Standards and Guidelines: Grievances-Resident Rights, last revised 06/2023, documented the Standard: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state Ombudsman). Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. The procedure included, Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and /or complaint on behalf of the resident, will be informed (verbally and/or in writing as per request) of the findings of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable and homelike environment by not ensuring 1. resident closet room doors in three rooms (228, 231 and 328) were functioning, 2. HVAC (Heating, Ventilation, and Air Conditioning) system filters in 12 resident rooms (303, 304, 306, 307, 309, 311, 319, 320, 323, 324, 325, and 326) were free of dust and debris, 3. walls, floors, closet ceiling (resident room [ROOM NUMBER]), handrail, an electrical outlet, resident room furniture and trim molding were maintained in two units (300 and 200) of three units to include nine resident rooms (317, 309A and 217P, 326, 328, 330, 332, 333, and 334), and 4. An overhead wall light and cover worked and had a light pull cord for use for one resident (#56) for a total of four days (4/11/2022 to 04/14/2022) four days observed. Findings included: 1. An observation was conducted of resident room [ROOM NUMBER] on 4/11/2022 at 12:37 p.m. The observation revealed sliding doors to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident smoking supplies were secured and residents adhered to designated smoking times for seven residents (#40, #9, #57, #4, #68, #78, and #81), on four (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed Findings included: During an observation of Resident #40's room on 4/12/2022 at 11:20 AM. a full pack of cigarettes was noted on the resident's bedside tray table. (Photographic evidence obtained.) According to admission records, Resident #40 was admitted on [DATE] with diagnoses including alcohol abuse, anxiety, adult failure to thrive, emphysema, and personal history of adult neglect. Review of Resident #40's Minimum Data Set (MDS) Section C (Cognitive Patterns) indicated her Brief Interview for Mental Status (BIMS) score is 15, indicating resident is cognitively intact. Review of Resident #40's care plans indicated a care plan in place for smoking, potential for injury. Interventions included monitor for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility 1. failed to store medications securely and appropriately in five medication carts (East Hall Medication Cart #1, North Hall Medication Cart #2, East Hall Medication Cart #3, South Hall Medication Cart #1, and South Hall Medication Cart #2 ) of seven medication carts and one of one treatment cart on the South Hall, and 2. failed to ensure controlled substances were stored in a permanently attached container in two refrigerators (East Hall and North Hall) of three refrigerators used for storage of medications; and 3. failed to appropriately secure medications for four residents (#98, #85, #46 and #40) of 61 sampled residents. Findings included: 1. A facility policy titled, Medication Storage In The Facility, with a revision date of January 2018, was reviewed and revealed the policy for Storage of Medications as: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to maintain an effective pest control program for two units (300 and 200) of three units related to small flying insects, ants, and wasp like insects for four days (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022) of four days observed. Findings included: 1. On 4/11/2022 at 11:30 a.m. and 1:40 p.m. the restorative dining/activity room on the 300 Unit was observed. There were four tables with chairs, which have been used at times by residents for various activities. The windowsill at the back of the room and in between the two large sliding glass doors was observed with over ten small ants crawling on the windowsill, the window and wall. In addition, ants were observed to crawl on the table that was placed under the windowsill. (Photographic Evidence Obtained) On 4/12/2022 at 7:55 a.m. the restorative dining/activity room on the 300 Unit was again observed with many small ants at and near the windowsill in between both sliding glass doors. Ants…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and interviews, the facility failed to implement care plan interventions with relation to bed rail use and bed rail monitoring for seven of sixty-one sampled residents (#64, #43, #40, #62, #38 and #56, and #55), during four of four days observed (4/11/2022, 4/12/2022, 4/13/2022, and 4/14/2022). Findings included: 1. On 4/11/2022 at 10:15 a.m. Resident #64 was observed in his room and in bed. He was observed lying in low bed, flat and under the covers with his feet hanging off the right side of the bed. There were ½ bed rails/enablers up and in position. Both side rails appeared not secured and loose fitting. Once the bed rails/enablers were handled, it was found they swayed approximately two to three inches from side to side. It was determined that they were not tightened enough next to the bed frame to ensure resident positioning safety. On 4/12/2022 at 10:00 a.m., 1:10 p.m. and 4/12/2022 at 7:40 a.m. and 11:10 a.m. Resident #64's room was observed, and he was noted in low…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 3. According to the clinical record, Resident #22 was admitted on [DATE] and included diagnoses of hypertension and pneumonia. An observation was conducted at 9:25 a.m. on 4/11/22 of Resident #22's nebulizer equipment. The observation indicated a nebulizer mask with an attached medication cup was lying on top of electronic equipment on the resident's bedside dresser, uncovered. The medication cup had droplets of residual liquid in it. On 4/12/22 at 9:17 a.m., an observation of Resident #22 identified nebulizer equipment lying on top of the resident's bedside dresser. The nebulizer mask was not in a protective bag and had liquid residual in the attached medication cup. Resident #22 was observed, on 4/13/22 at 9:35 a.m., lying in bed. A nebulizer mask was lying on the bedside dresser with liquid residue in the medication cup. During an interview with Staff Member W, Unit Manager/Registered Nurse on 4/13/22 at 10:40 a.m. she viewed Resident #22's nebulizer equipment lying on the bedside dresser and said it should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review the facility failed to ensure Nursing Staffing Information was posted for three days (04/08/22, 04/09/22 and 04/10/22). Findings included: Upon entrance to the facility on [DATE] at 9:00 a.m. the required Nursing Staff Posting was observed on the wall in front of the Nursing Home Administrator's (NHA) office titled, Daily Staffing Levels, with a date of 04/07/22 (Photographic Evidence Obtained). On 04/14/22 at 11:30 a.m. an interview was conducted with Staff Y, Staffing Coordinator. He confirmed he was responsible for posting the Nursing Staff, daily. He stated he worked on 04/08/22 but forgot to post the required daily staffing sheet. He confirmed the weekend supervisor was responsible to post the daily staffing sheet on 04/09/22 and 04/10/22. Review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, with a revision date of 07/2016, revealed the following policy statement: Our facility will post daily for each shift, the number of nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and two medication errors were identified for two (Residents #98, and #275) of seven residents observed. These errors constituted an 8.00% medication error rate. Findings included: Facility-provided policy titled Specific Medication Administration Procedures, revised January 2018, Page 125, under Metered Dose and Dry-Powder Inhalers revealed: Q. For Steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. On 04/12/2022 at 09:48 a.m., an observation of medication administration with Staff G, Licensed Practical Nurse (LPN), was conducted with Resident #98. Staff G, LPN was observed administering Advair Diskus 100-80 microgram (MCG)/Dose Aerosol Powder 1 puff by mouth. Once the medication was completely administered by Staff G, LPN, she did not ensure the resident rinsed her mouth, and spit out the contents afterwards. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure the wound care for one (#44) of twelve residents with wounds was completed in a sanitary manner to promoted healing. Findings included: Resident #44 was admitted on [DATE]. The admission Record included diagnoses not limited to Parkinson's Disease, Type 2 Diabetes Mellitus without complications, and End Stage Renal Disease. A Weekly Wound Evaluation, dated 4/7/22, identified a Diabetic Right Heel ulcer that measured 1.5 x 2.5 x 0 centimeter (cm). The evaluation indicated a small/minimal serous exudate with a wound bed of 26-50% granulation and 26-50% necrotic tissue. The physician's order, dated 4/4/22, for treatment identified the following regarding the dressing of the right heel: Silver alginate packed Right (R) heel, Abdominal (ABD) roll gauze three (3x) times a week (wk). Cleanser of choice, Return to Clinic (RTC) 2 weeks, and offload Right heel. The Treatment Administration Record (TAR) instructed staff to Cleanse Right…

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