Gainesville Health and Rehabilitation

Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for 1 (Resident #151) of 4 residents reviewed for oxygen therapy. Findings include: Review of the admission record for Resident #151 documented an admission date to the facility of 3/14/25 with a pertinent diagnosis that included of heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris [buildup of plague in artery walls without chest pain], and anemia. During an observation on 3/31/25 at 12:29 PM, Resident #151 has oxygen tubing hanging from the over bed table (OBT). During an observation on 4/1/25 at 9:36 AM, Resident #151 has oxygen tubing hanging from the OBT with the oxygen concentrator up against the bed. During an interview on 4/1/25 at 9:36 AM, Resident #151 stated, I only use it when I am short of breath, I only use it when I need to, and I've used it several times. During an observation on 4/2/25 at 7:42 AM, Resident #151 has oxygen tubing hanging from the…

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

Based on observations, interviews, and record reviews, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards for 1 of 5 medication carts and failed to ensure that drugs and biologicals were stored in a secured manner for 2 of 3 units. Findings include: 1.) During an observation on 3/31/25 at 9:32 AM of Resident #23's room, 5 unidentifiable pills were sitting in a clear medicine cup on the residents over the bed table, and an unlabeled creamlike substance in a small plastic medicine cup was sitting on the residents bedside table. During an observation on 3/31/25 at 10:00 AM of Resident # 23's room, 2 unidentifiable pills in a clear medicine cup were still sitting on the residents bedside table. During an interview on 4/1/25 at 10:00 AM, Resident #23 stated that the staff always leave his pills on his bedside table and he takes them later. During interview on 4/3/25 at 8:37 AM, Staff E, Licensed Practical Nurse (LPN) Unit 300, confirmed the medication on Resident #23's bedside table,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure resident medical records were accurate and complete for 1 (Resident #22) of 2 residents reviewed for advanced directives. Findings include: 1) Review of the admission record for Resident #22 documented an admission date of 10/18/24 with diagnosis that included chronic obstructive pulmonary disease unspecified, major depressive disorder, generalized anxiety disorder, iron deficiency anemia unspecified, and hypertension. Review of the electronic medical record resident profile for Resident #22 read, Code Status: (Advance Directives) Full Code. Review of Resident #22's physician's order dated 2/5/25 reads, FULL CODE. Review of the Social Services Assessment for Resident #22 dated 1/16/25 documented Do Not Resuscitate on page 1 and the summary note on page 3 read, Resident will remain DO NOT RESUSCITATE (DNR) and plans to remain a short term resident at [the facility's name]. Review of Resident #22's comprehensive resident centered care plan, last revised on 1/21/25, reads, Resident has an established DNR (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure standards of professional practice were followed for administering tube feedings with the use of a tube feeding pump for 1 of 5 residents, Resident #7. Findings include: Review of the medical record for Resident #7 documented the resident was admitted on [DATE] with diagnoses including cerebral infarction [a stroke], dysphagia [inability or difficulty swallowing], aphasia [inability to speak], and major depressive disorder. Review of the physician's order dated 3/11/2024 for Resident #7 read, Enteral Feeding: Jevity [a calorie dense, fiber-fortified therapeutic nutrition for long or short-term tube feeding] 1.5 65ml [milliliters]/hr [per hour] continuously x [times] 24 hrs [hours] with auto flush of 55ml/hr water x 24 hours. During an observation on 11/18/2024 at 6:32 AM Resident #7 no Enhanced Barrier Precaution (EBP) supplies (gowns) near Resident #7's room in the hallway or inside of Resident #7's room. Resident #7 was lying in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when failing to perform hand hygiene or use appropriate personal protective equipment (PPE) when performing care for 2 of 11 residents, Residents #7 and #9 on Enhanced Barrier Precautions. Findings include: 1) Review of the medical record for Resident #7 documented the resident was admitted on [DATE] with diagnoses including cerebral infarction [a stroke], dysphagia [inability or difficulty swallowing], aphasia [inability to speak], and major depressive disorder. Review of the physician's order dated 3/11/2024 for Resident #7 read, Enteral Feeding: Jevity [a calorie dense, fiber-fortified therapeutic nutrition for long or short-term tube feeding] 1.5 65ml [milliliters]/hr [per hour] continuously x [times] 24 hrs [hours] with auto flush of 55ml/hr water x 24 hours. Review of the physician's order dated 4/22/2024 for Resident #7 read, Enhanced Barrier Precautions [EBH] due to G-tube [Gastrostomy tube…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure residents were informed of the bed hold policy upon transfer to hospital for 3 of 3 residents reviewed for discharge to hospital, Residents #1, #2 and #3. Findings include: 1. Review of Resident #1's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including Huntington's disease, mood affective disorder, major depressive disorder and dysphagia. Further review of the records showed the resident was informed of bed hold policy of the facility. Review of Resident #1's progress note dated 9/5/2024 showed it read, Resident noted physically and verbally to staff this pm [afternoon]. Remain on 1:1 supervision. Resident and his roommate were fighting over the TV remote unable to redirect. Resident got upset and started hitting staff. Call made to on call spoke with Dr. [Physician's name] verbal orders given to transfer resident to [Local Emergency Room's name] for psych evaluation. Review of Resident #1's SNF/NF…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure policies and procedures were implemented for the prevention of abuse, neglect, exploitation of residents and misappropriation of resident property related to training for 1 of 10 employees (the Chef) and reporting allegations immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency and other officials as required for 1 (Resident #23) of 3 residents sampled. Findings include: 1. Review of the Chef's personnel records documented a hire date of 8/28/2023. The personnel records did not contain any documentation since date of hire of education on abuse, neglect, exploitation, and misappropriation of resident property. During an interview on 12/21/2023 at 8:30 AM, the Executive Director (ED) stated that there was no training documented for the Chef for abuse in his personnel file. The ED stated that the Chef had not attended any in-services given for abuse. 2. Review of the progress note for Resident #23 dated 12/15/2023 at 18:47 (6:47 PM) read, [Resident #23's Name] is upset about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the resident assessment accurately reflected the resident's status for 1 resident (Resident #68) of 2 reviewed for dialysis services and 1 resident (Resident #81) of 1 reviewed for restraints. Findings include: Review of Resident #68's physician's order dated 10/19/2021 read, Dialysis is Tues, Thus, Sat, .Seat time 10:25 AM. Review of Resident #68's Minimum Data Set (MDS) Quarterly assessment dated [DATE] reads, Section O-Special Treatments, Procedures, and Programs: Check all of the following treatments, procedures and programs that were performed. Dialysis services were not checked off as special treatments received. During an interview on 12/20/2023 at 2:28 PM the MDS Coordinator stated, [Resident #68's Name] is on my dialysis list and he has not been sent out to the hospital. He should be marked as yes [on the assessment] for dialysis. It was an error. 2. Review of Resident #81's physician's order documented no orders for restraints. Review…

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

Based on record review and interview the facility failed to ensure residents that were reviewed for Preadmission Screening and Resident Review (PASARR) with newly evident or possible serious mental disorders were referred to the appropriate state designated authority for review for 3 (#4, #69, #40) of 6 resident reviewed. Findings include: 1.) Record review of Resident #4's most recent PASARR Level II, dated 1/18/2017, revealed Resident #4 was assessed as having mental health diagnoses as follows: Axis I: Depressive Disorder; and Bipolar Disorder. Record review of Resident #4's admission record revealed Resident #4 was subsequently diagnosed with psychotic disorder with hallucinations due to known physiological condition, on set date 8/2/23. Record review of Resident #4's clinical records failed to reveal documentation Resident #4 was identified with a newly evident or possible serious mental disorder and was referred to the appropriate state designated authority for an updated Level II evaluation and determination. 2.) Record review of Resident #69's most recent PASARR Level l,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure residents received a PASARR (Pre-admission Screening and Resident Review) for possible serious mental disorders, intellectual disabilities, and related conditions prior to admission for 1 (#25) of 6 residents reviewed. Findings Include: Review of Resident #25's admission record documented a diagnosis of paranoid schizophrenia, onset date 4/25/23. Review of the psychiatry note dated 4/25/23 read, chief complaint depression, insomnia, and schizophrenia. Plan of Action: continue medication Abilify for schizophrenia, Divalproex for mood and Trazodone for depression. Review of the hospital note dated 9/04/23 read, discharge summary. discharge diagnosis: bi-polar disorder. Review of the clinical record revealed no documented PASARR screening. During an interview on 12/19/23 at 11:17 AM, the Director of Nursing (DON) stated that with the diagnosis of schizophrenia, bi-polar, and depression, a PASARR should have been completed.

Based on observation, interview, and record review the facility failed to provide nutritional services with adequate nutritional interventions to maintain acceptable parameters of nutritional status for 1 (Resident #19) of 7 residents reviewed nutrition. Findings include: Review of Resident #19's admission record documented diagnoses that included other forms of systemic lupus erythematosus, dysphagia, folate deficiency anemia, and vitamin D deficiency. Review of Resident #19's care plan, revised 4/19/2023, documented a nutritional problem or potential nutritional problem related to diagnoses of congestive heart failure, hypertension, anxiety, and chronic pain with interventions that include provide and server diet as ordered and RD (registered dietitian) to evaluate and make diet change recommendations. Review of Resident #19's complete blood count with differential lab results, collection date 11/25/2023, documented results that included hemoglobin at 9.6, reference range 12.0 - 16.0, and albumin at 2.7, reference range 3.5 - 5.7. Review of Resident #19's quarterly dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to ensure that residents received respiratory care services consistent with professional standards of practice for 1 (Resident #13) of 2 residents receiving respiratory services. Findings include: During an observation on 12/18/2023 at 10:30 AM, Oxygen Concentrator at bedside. Resident was not currently using oxygen. Oxygen tubing was dated 11/30/2023. The nasal canula was on the floor. A nebulizer mask was observed not bagged. (photo evidence obtained). During an observation on 12/19/2023 at 8:43 AM, the nebulizer mask was under a telephone receiver with no bag. (photo evidence obtained) During an interview on 12/18/2023 at 10:30 AM, Resident #13 said, I am not currently using the oxygen concentrator. During an interview on 12/21/2023 at 8:26 AM the Director of Nursing, stated oxygen tubing is changed every 7 days, and the oxygen tubing was overdue for being changed. She also stated, when a nebulizer is not in use it should be bagged. Review of the admission record for Resident #13 documented the most recent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principle for 3 of 4 medication carts. Findings include: During an observation on [DATE] at 9:09 AM of station #1 medication cart #1 with Staff D, Registered Nurse, (RN), there was one expired insulin vial with an expiration date of [DATE], one expired Novolog insulin pen with expiration date of [DATE], one unopened Novolog pen with a blue label which read refrigerate until opened, one open Novolin pen with no open or expired date, two open Lantus Solostar insulin pen with no open or expired date, and one open Novolog flexpen with no open or expired date, two medication cups with pre-poured medications, and one opened Advair Diskus with no open or expired date. During an interview on [DATE] at 9:15 AM, Staff D, RN, stated, The insulin pen is not opened, the insulin will be used tonight, it should have been kept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure resident records were complete and accurately documented for 2 of 4 residents reviewed for intravenous catheters (Residents #81, #40). Findings include: 1. During an observation on 12/18/2023 at 11:00 AM, Resident #81 was lying in bed with no intravenous (IV) catheter noted on the resident's arms. During an interview on 12/19/2023 at 1:10 PM, Resident #81 stated, I do not have an IV at this moment. They had to take it out about three days ago. Review of Resident #81's physician order dated 12/11/2023 reads, Discontinue peripheral IV per MD [Medical Doctor]. Review of Resident #81's physician order dated 12/8/2023 reads, Give 2 liters of normal saline @ [at] 75 cc/hr x 2 liters [75 milliliters per hour times 2 liters] one time a day for labs until complete. Review of Resident #81's Medication Administration Record for December 2023 showed that 2 liters of normal saline was administered from 12/11/2023 to 12/20/2023. Review of Resident #81's…

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

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the development and transmission of communicable diseases and infections. Findings include: During an observation on 12/20/2023 at 8:28 AM, Staff G, License Practical Nurse (LPN), started preparing medications for Resident #56 after using hand sanitizer. The medication blister pack fell on the floor and Staff G picked it up from the floor. Without performing hand hygiene, Staff G continued to pour medication in individualized medication cups. Staff G began to crush the medication and placed them back into the individualized medication cups. Staff G donned gloves and opened a capsule and poured the medication in the medication cup and then removed gloves. Staff G entered Resident #56's room and donned gloves and administered medications via the gastric tube. Staff G did not perform hand hygiene. During an interview on 12/20/2023 at 8:59 AM, Staff G, LPN, stated, I should have done hand hygiene after picking up the blister pack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the training program on abuse and neglect was completed for 1 of 10 employees, the Chef. Findings include: Review of personnel records for the Chef, hired on 8/26/2023, revealed no training on abuse, neglect, and exploitation during the orientation training. Review of the in-service on abuse, neglect, and exploitation on 12/18/2023 showed the Chef did not attend the in-service. During an interview on 12/21/2023 at 11:50 AM, the Executive Director (ED) confirmed that the Chef had an orientation training and the training did not include abuse, neglect, and exploitation. The ED also confirmed that the Chef had not attended any in-services on abuse, neglect, and exploitation since her hire date of 8/26/2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for enteral nutrition was provided for 1 of 3 residents (Resident #3). Findings include: During an observation on 9/06/2023 at 8:10 AM Resident #3 was lying in bed receiving enteral nutrition via a feeding pump running Jevity 1.5 at 60ml (milliliters) per hour and 40ml per hour auto water flushes. During an observation on 9/06/2023 at 10:48 AM Resident #3 was lying in bed receiving enteral nutrition via a feeding pump running Jevity 1.5 at 60ml per hour and 40ml per hour auto water flushes. During an interview on 9/6/2023 at 10:51 AM Staff A, License Practical Nurse (LPN) stated, [Resident #3's name] should be at 20ml per hour flushes but I will check. Staff A looked up physician order in electronic medical record. Staff A stated The order was changed yesterday. It should be at 80 ml per hour. I see they have it on 40ml per hour not on 80ml I will change it. During an interview on 9/6/2023 at 10:58…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the nurse staffing data was posted on a daily basis in a prominent place readily accessible to residents and visitors. Findings include: An observation on 7/11/2022 at 9:00 AM failed to show any nurse staffing data posted in the front lobby or anywhere in the facility. An observation on 7/11/2022 at 10:28 AM failed to show any nurse staffing data posted in the front lobby or anywhere in the facility. During an interview on 7/11/2022 at 10:35 AM, the Administrator stated, I do not know where the staffing is posted. Let me ask if [Staff I, Staff Coordinator's name] in staffing knows where it is posted. I do not know where the form is to fill out for staffing, but the facility is working on getting the form. During an interview on 7/11/2022 at 10:53 AM, Staff I, Staff Coordinator, stated, I was told over two months ago to stop doing the federal staffing sheet. I was told that personnel would be completing the staffing sheet. I have not posted the federal staffing for the last two months. I no longer have the sheet to…

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

Based on observation, interview and record review the facility failed to maintain infection control practice standards for performing hand hygiene during medication administration in 6 out of 8 observations of medication administration and failed to conduct monthly water supply monitoring. Findings include: During an observation of medication administration on 7/12/2022 at 7:38 AM Staff A, Licensed Practical Nurse (LPN), assembled medication, without performing hand hygiene. Entered Resident #249's room without performing hand hygiene room, donned gloves, and administered normal saline flush to left upper arm PICC (peripherally inserted central catheter) after cleaning the needless connector for 3 seconds. During an observation of medication administration on 7/12/2022 at 9:05 AM Staff C, LPN, poured medications for Resident #15 without performing hand hygiene, entered the resident's room without performing hand hygiene and administered medications. Staff C returned to the medication cart and began pouring medications for another resident. During an observation of medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and facility policy review, the facility failed to ensure the residents were informed and provided written information concerning their right to choose and to formulate an advance directive for 19 of 33 residents reviewed, with missing advanced directives (Residents #10, #15, #30, #82, #71 #77, #74, #75, #64, #249, #7, #24, #28, #37, #42, #49, #81, #248 and #56). Findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses including psychoactive substance abuse with other psychoactive substance induced disorder, opioid abuse, hypertension, toxic encephalopathy, major depressive disorder, muscle weakness, history of transient ischemic attack and cerebral infarction without residual deficits, chronic pain syndrome, disorder of brain, major depressive disorder, and abscess of bursa, left shoulder. Review of records failed to reveal Resident #10 had an advanced directive or was informed of his/her right to choose. 2. Resident #15 was admitted to 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 5. During an observation on 7/11/2022 at 10:27 AM, Resident #50 was resting in bed with a catheter drainage bag hanging on the right side of the bed. There was no privacy bag covering the clear plastic collection bag. The resident's door was open, and the catheter collection bag was visible from the hall. Review of the admission records for Resident #50 revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, neuromuscular bladder dysfunction, generalized anxiety disorder, essential primary hypertension, recurrent depressive disorder, renal and perinephric abscess, and coronary artery disease. During an observation on 7/11/2022 at 11:27 AM, Resident #50 was in bed with a catheter drainage bag hanging on the right side of the bed. There was no privacy bag covering the clear plastic collection bag. The resident's door was open, and the catheter collection bag was visible from the hallway.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy and procedure review, the facility failed to maintain a clean environment for 2 of 4 residents requiring tube feeding equipment, Residents #29 and #64. Findings include: 1. During an observation on 7/11/2022 at 10:56 AM, Resident #29 was receiving tube feedings via a feeding pump. There was a buildup of a dried tan substance covering the tube feeding pole base. There were dried tan substances on the feeding pump covering both the back and front of the pump. There were large spots of a dried amber colored substance that covered the floor next to the resident's bed. During an observation on 7/11/2022 at 3:44 PM, Resident #29 had a feeding pump and pole at bedside with dried tan stains on the feeding pump on both the front and the back of the pump, multiple spots of a dried tan colored substance on the feeding pole base and large dried amber to brown colored spots on the floor next to the resident's bed. During an observation on 7/13/2022 at 8:01 AM with the Director of Nursing (DON), Resident #29 was receiving tube feedings via a feeding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for peripherally inserted central catheters for 2 of 3 reviewed residents, Residents #249 and #100, in a total sample of 51 residents. Findings include: During an observation on 7/11/2022 at 7:20 AM, Resident #249 was observed in bed with a left upper arm double lumen PICC line with a dressing date of 7/7/2022. Three edges of the transparent dressing were pulling up and exposing the insertion site. During an observation on 7/11/2022 at 10:00 AM, Resident #249 was in bed with a left double lumen PICC line in the left upper arm. The date on the dressing was 7/7/2022. Three edges of the transparent dressing were pulling up and exposed the insertion site. During an interview on 7/12/2022 at 7:30 AM, Staff A, Licensed Practical Nurse (LPN), stated, Oh, the nurse last night was supposed to change that. It is needing to be changed. I saw that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to ensure the drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable in 2 of 4 medication carts reviewed. Findings include: During an observation of Medication Cart #1 with Staff A, Licensed Practical Nurse (LPN), on 7/11/2022 at 9:02 AM, there were one Enoxaparin Sodium syringe with no resident identifier and not in the original pharmacy packaging, two opened Lispro insulin pens with no opened or expiration dates, one unopened Glargine insulin pen with pharmacy instructions to refrigerate until opened, and one small medication cup with 10 white capsules with no identification of the medication or resident identifier. During an interview on 7/11/2022 at 9:10 AM, Staff A, LPN, stated, All insulin should be labeled or kept in the refrigerator until it is ready to be used. I should not have any medication that isn't in the containers that come from pharmacy. I don't know what the pills are. 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 record review and interview, the facility failed to report the results of all investigations to the officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. Findings include: Review of the facility records related to reporting the incident occurred on 6/5/2022 between Resident #38 and Resident #10 revealed no five-day report filed as of 7/12/2022. During an interview on 7/12/2022 at 2:30 PM, the Administrator stated, No one had access to the reporting system and therefore we were unable to provide a five-day report for the incident. Review of the facility policy and procedure titled Compliance with Reporting Allegations of Abuse/ Neglect/ Exploitation implemented on 9/3/2020 and reviewed on 5/20/2022, reads, Policy: It is the policy of this facility to report all allegations of abuse/ neglect/ exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance 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, interview, and record review, the facility failed to ensure that the medication error rate was not 5% or greater for 2 of 4 residents observed during medication pass, Residents #1 and #5. Medication error rate was 20.8%. Findings include: 1. During a medication administration observation on 9/7/2022 beginning at 8:58 AM, Staff D, Registered Nurse (RN), unlocked the medication cart and logged in to the computer. Staff D started pulling medications from the bubble packs and dropping the pills to a medication cup. Staff D entered Resident #5's room with the medication cup on hand and administered Protonix 2 tabs 20 mg 1 by mouth, Metoprolol Succinate ER 25 mg 1 by mouth, Tamsulosin 0.4 mg 1 cap by mouth, and Reglan 10 mg 1 by mouth. Review of Resident #5's physician order dated 8/28/2022 revealed Pyridoxine HCL 25 mg, give 1 tablet by mouth one time a day for supplement; Vitamin B-1 250 mg, orally one time a day for supplement; Vitamin A, give 3 mg orally one time a day for supplement;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to store food items in accordance with professional standards for food service safety in the facility's nourishment room. Findings include: During a tour of the facility's nourishment room conducted with the facility's Certified Dietary Manager (CDM) on 7/11/2022 beginning at 10:00 AM, there were one wrapped hoagie style sandwich in a plastic bag on a shelf in the refrigerator, two plastic containers of yogurt parfait in a shelf on the door of the refrigerator, and two frozen individually wrapped tacos and an opened box of frozen popsicles in the freezer. All items listed were not labeled with a resident name or date. During an interview on 7/11/2022 at 10:05 AM, the CDM verified the food items listed were not labeled with resident names or dates to show when they needed to be thrown away. Review of the facility policy and procedure titled Food: Safe Handling for Foods from Visitors revised in October 2019 and reviewed on 5/20/20 22 reads, Action Steps: . 4. When food items are intended for later consumption,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide therapy services for 1 of 3 residents reviewed for therapy services, Resident #17. Findings include: During an interview on 7/13/2022 at 12:00 PM, Resident #17 stated, I still have not started receiving any therapy [Physical Therapy, PT] yet. During an interview on 7/13/2022 at 12:10 PM, the Therapy Director stated, I have not been here long. I will try to find out from the previous therapy director why [Resident #17's name] has not received therapy [PT] services. During an interview on 7/13/2022 at 2:10 PM, the Therapy Director stated, I did some digging and this resident's PT order was not sent to therapy. I do not know how therapy receives the physician's orders. The resident was not evaluated by therapy and is not receiving physical therapy. During an interview on 7/14/2022 at 10:30 AM, Resident 17 stated, I cannot walk as well now as before I went out to the hospital last month [June 2022]. Review of Resident #17's admission records…

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