Breezy Hills Rehab And Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure complete and accurate documentation was in the resident's medical record for two (#93 and #68) out of 23 residents sampled. Findings Included: During an interview on 05/06/2025 at 11:47 a.m., Resident #93's Family Member and Power of Attorney (POA) stated he had received a call from the facility on Friday letting him know they were putting an order for Hospice for Resident #93. He stated he was told it was because Resident #93 had recently declined and there was a change in his appetite. The POA stated he tried calling back a few times to speak with someone in regard to the Hospice Order and had not received a call back. Review of Resident #93's admission Record revealed an initial admission date of 06/28/2024 and a readmission admission date of 11/26/2024 . Resident #93 was admitted to the facility with diagnosis to include Cerebral Infarction Due To Thrombosis Of Bilateral Cerebellar Arteries, Unspecified Cirrhosis Of Liver,…

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 provide medically related social services for one of three sampled residents (#2) related to assistance with a room change or assistance with a transfer to another facility as requested. Findings included: On 03/27/2025 at 9:30 AM, Resident #2 was observed lying in bed. Resident #2 said she spoke to the Social Service Director (SSD) in the past about a room change. Resident #2 stated she cannot sleep because her roommate talks all night and keeps the lights on. Resident #2 stated she also talked to the SSD about transferring to a rehab in Jacksonville that specialized in Guillain-Barre Syndrome because the rehab could maybe help her get better. A follow-up interview was conducted on 03/27/2025 at 11:30 AM with Resident #2. Resident #2 stated she talked to the SSD a couple of weeks ago about the room change and was told they did not have any room available. Review of Resident #2's admission Record showed she was admitted to the facility 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, interviews, and record review, the facility, 1. failed to ensure allegations of neglect were investigated for one (#8) of two residents reviewed for neglect and 2. failed to have evidence that alleged violations were thoroughly investigated for two (#2 and #7) of five residents sampled for alleged violations. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift…

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 prevent a fall with injury for one (#8) of two residents reviewed for falls. Findings included: On 07/02/24 at 12:30 p.m., an observation and interview was conducted with Resident #8. She was observed in her room laying on her bed. Her Right leg was observed in a cast and was elevated. She stated she was in pain. The resident stated she was involved in a [mechanical lift] accident. She stated she remembered the incident very well. She said two CNAs (Certified Nursing Assistants) were transferring her from the bed to her wheelchair. During the transfer, the [mechanical lift] tipped when she was in mid-air. She stated the staff put her to the ground, but the metal part of the side table caught her ankle. She said, One of the CNAs was standing away from the lift holding on to the wheelchair. One CNA was operating the lift. She stated the side table was very close to the lift and it caught the leg of the lift, causing the lift to tip. 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 review, the facility failed to assess, care plan and identify triggers related to trauma for one (#10) of two residents reviewed. Findings included: On 7/1/24 at 10:10 a.m., an observation of Resident #10 revealed she was lying in bed watching television. An interview with Resident #10 revealed she was upset by an experience she had on 6/21/24. She stated a nurse, who she could not recall her name, and [Staff A, Certified Nursing Assistant (CNA)] were providing catheter care. Resident #10 stated the door was closed. She stated a female resident entered her room and saw Resident #10 exposed from the waist down. Resident #10 stated, I was spread eagle and she saw me. An observation of Resident #10 revealed she was tearful and stated, I felt violated. She stated the nurse assisting Resident #10 escorted the female resident out of the room and closed the door. Resident #10 stated she reported the experience to another nurse, but she could not recall her name, and the Physician Assistant (PA) who followed her for catheter care at 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, interview, and photogenic evidence, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items and did not ensure the dishwasher temperature log was up to date. The failed practice had the potential to effect more than a limited number of Residents. Findings included: 1. An observation on 02/05/23 at 9:15 a.m., during the initial tour of the kitchen, showed the walk in refrigerator contained food items that were not labeled or dated. The following items were noted with photogenic evidence obtained: A bag of lettuce was not labeled or dated A container of white substance was not labeled or dated A container of chopped meat was not labeled or dated. During an interview 02/05/23 at 9:17 a.m., Staff J, [NAME] confirmed the bag of lettuce should have been labeled and dated. Staff J confirmed the container of white substance that was identified as cottage cheese was not labeled or dated and should have been. Staff J also confirmed the chopped meat identified as chopped chicken…

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 arbitration agreement explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it and the agreement did not explicitly state that neither the resident nor his or her representative was required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility for three (Resident #205, Resident #55, and Resident #293) of the sampled three residents. Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure…

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, the facility failed to ensure the arbitration agreement provided for the selection of a venue that was convenient to both parties for three (Resident #205, Resident #55, and Resident #293) of three sampled residents. Findings included: Section G of the admission Agreement included the arbitration agreement and it read the following: G. Disputes. Any controversy, dispute or disagreement arising out of or in connection with this Agreement, the breach thereof, or the subject matter thereof, including Facility's obligation thereof, shall be settled by binding arbitration, which shall be conducted in Jersey City, New Jersey in accordance with the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for Arbitration, and which to the extent of the subject matter of the arbitration, shall be binding not only on all the parties to this Agreement, but on any other entity controlled by, in control of or under common control with the party to the extent that such affiliates joins in the arbitration, and judgement 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for two (Residents #3 and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #65 and #143) admitted with mental health diagnoses of four residents sampled for PASARR. Findings included: 1. Review of the Face Sheet for Resident #3 revealed admission to the facility on [DATE], with diagnoses that included cirrhosis, benign prostate hypertrophy and hepatitis. Further review revealed additional diagnoses identified after admission to the facility; they included: -schizophrenia, diagnosed 06/09/2015 -major depressive disorder (MDD), diagnosed 07/01/2020 -dementia, diagnosed 10/01/2022 Review of a Psychiatric Note dated 01/06/2023 revealed psychiatric diagnoses and history that included dementia, schizophrenia, MDD and dysphagia. Review of the Annual Minimum Data Set (MDS)…

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 implement an effective infection control program as evidence by not ensuring the appropriate hand hygiene was completed after delivering a meal tray to one (Resident #143) of one resident infected with Clostridioides Difficile (C Diff) on one of four units, failed to designate Contact precautions for one (Resident #55) of 35 sampled residents, and failed to ensure that non-dedicated equipment was cleaned in between two (Residents #7 and #145) of five residents observed during medication administration. Findings included: 1. A review of the admission Record revealed Resident #143 was admitted on [DATE] with a primary diagnosis of Enterocolitis due to Clostridium Difficile not specified as recurrent. The Order Summary Report for the resident included a physician order, dated 2/3/23, for Isolation C Diff every shift for isolation and Isolation maintained for shift, activities, and services brought to room C Diff every shift for Isolation.…

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 reviews and interviews, the facility failed to provide timely and specific notifications to include the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS 10055 to two (Residents #341 and #48) of three sampled residents who were discharged from Medicare Part A services but remained in the facility. Findings included: A review of the SNF Beneficiary Protection Notification Review form completed by the Social Services Director (SSD) for Resident #341 indicated Medicare Part A Skilled Services Episode Start Date 11/03 and a last covered date of 12/02. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility but was not provided the SNF ABN, Form CMS-10055. The SSD completed the SNF Beneficiary Protection Notification Review form for Resident #48 verbally. The last covered day was 01/12. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The resident remained in the facility but was not provided…

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 review, and interviews, the facility failed to follow the baseline care plan related to the use of oxygen for one (Resident #242) of thirty-five sampled residents. Findings included: On 02/05/23 at 10:00 a.m., Resident #242 was observed sitting on the side of the bed. An oxygen concentrator was next to the bed with oxygen tubing sitting on the top of the concentrator. The machine was not on. The resident was not using the oxygen at this time. On 02/06/23 at 10:14 a.m., the resident was sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. The resident was not using the oxygen at this time. On 02/07/23 at 10:19 a.m., Resident #242 was observed in her room sitting next to the bed. The oxygen concentrator was next to the bed, but the machine was not on. She was not using the oxygen at this time. She reported she did not know the last time she used the oxygen. She stated, I can't keep up with it. A review of the admission Record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two (#55 and #36) of two residents sampled for pressure ulcers received wound care per the physician orders. Findings included: 1. An observation and interview was conducted, on 2/5/23 at 2:02 p.m., with Resident #55. The resident confirmed the presence of an infection to the right thigh. The resident reported that wound care was supposed to be every day but a couple of them forgot. The observation of the resident identified a double lumen peripherally inserted central catheter (PICC) located in the right upper extremity. The review of Resident #55's admission Record indicated the resident was admitted on [DATE] with diagnoses that included right femur acute hematogenous osteomyelitis. The admission Minimum Data Set (MDS), 1/24/23, identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. The MDS revealed the resident had one stage IV pressure ulcer and required pressure…

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 staff interview, the facility failed to provide pain management services per the physician orders. The facility provided pain medication outside the physician ordered parameters for two (Residents #46 and #30) of two residents reviewed for pain management. Findings included: 1. During an interview on 02/05/23 at 10:25 a.m., Resident #46 stated the facility gave her medications for pain however the pain was always there even after medications were given. A review of Resident #46's medical record showed she had a diagnosis of Paraplegia, unspecified, pain in left leg and other muscle spasms. The care plan showed a focus of Chronic pain due to paraplegia, spinal cord injury and history of meningitis with an intervention to include an intervention to administer analgesia as per orders. A physician order dated 01/18/23 stated, Hydrocodone-Acetaminophen Tablet 5-325- Give tablet by mouth every 8 hours as needed for pain severe (7-10) not to exceed 3 grams. The Medication Administration…

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, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and three errors were identified for two (Residents #71 and #53) of five residents observed. These errors constituted a 11.11% medication error rate. Findings included: 1. Staff D, Licensed Practical Nurse (LPN) obtained, at 8:45 a.m. on 2/7/23, a blood pressure of 147/83 and a pulse of 70 from Resident #71. On 2/7/23 at 8:50 a.m., Staff D dispensed the following medications for Resident #71: -- Carbamazepine Extended Release 100 milligram (mg) - 6 tablets -- Amlodipine 5 mg tablet -- Aspirin 81 mg Enteric Coated tablet -- Calcium Carbonate 500 mg chewable tablet - Vitamin D3 5000 unit tablet -- Citalopram 10 mg tablet -- Lisinopril 10 mg tablet -- Memantine 10 mg tablet -- Daily Vitamin with multimineral tablet -- Pregabalin 50 mg capsule The staff member confirmed 15 tablets/capsules prior to entering Resident #71's room. An interview, on 2/7/23 at 9:14 a.m., after the administration…

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 insulins were removed after expiration date, medications were stored per route and not in same compartment with non-medications in one ([NAME]) of two sampled medication carts, failed to ensure one (Canterbury) of two sampled medication carts were locked while unsupervised, and failed to ensure one ([NAME]/[NAME]) of two medication rooms did not contain expired medications. Findings included: On 2/6/23 at 12:00 p.m., an observation of the [NAME] medication cart was conducted with Staff G, Licensed Practical Nurse (LPN). The observation identified a clear bag containing an Insulin Lispro injection KwikPen. The bag indicated the pen was opened on 1/3/23 and expired on 2/1/23. A pharmacy bag contained 2 vials of Insulin Lispro. The bag identified that the vials were opened on 1/2/23, one of vials was labeled with 1/5. The website, https://www.humalog.com/u100, identified that Opened Humalog vials, prefilled pens, and cartridges…

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 maintain drugs and biologicals used in the facility in a safe, secure and orderly manner in three medication carts (Canterbury Hall, [NAME] Hall, and [NAME] Hall) of four medication carts. Findings included: On 5/27/21 at 2:26 p.m. an observation of the medication cart for the Canterbury Hall was conducted. Staff J, Licensed Practical Nurse (LPN) was present during the observation. In the third drawer of the cart a loose round yellow pill, one yellow oblong pill, four loose round white pills, and three oblong loose white pills were observed. In the second drawer three half white pills, and one oval white pill were observed loose. In the top drawer, an unopened multidose vial of Humalog was observed stored in a container with no date indicating when it was removed from the refrigerator. A Lantus Pen was observed stored in a bag, with no open or expiration date documented. An Insulin Aspart Prot-Asp pen was observed with no open or…

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 reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on [DATE]. Findings of deficient practice were identified during the revisit survey for three (F695, F700, and F761) of the seven citations reviewed for correction. Findings included: 1. A review of the facility plan of correction for the recertification survey ending [DATE] revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F695: The Director of Nursing or designee will perform weekly observational audits for 3 months to verify the facility staff are providing care for tracheostomy patients, following proper procedures and use of personal protective equipment during care and the care of equipment related to respiratory care. Immediate education if required. Audit results will be reviewed by…

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, staff interviews and record review, the facility failed to ensure resident rights for a comfortable and homelike environment by not maintaining comfortable sound levels for residents and maintaining the dignity of one resident (#57) related to 1. one resident (#57) of thirty-one sampled residents yelling and calling out loudly and repetitively during four days (5/24/2021, 5/25/2021, 5/26/2021, and 5/27/2021) of four days observed and, 2. the use of mechanical floor cleaning machines by housekeeping staff in three halls ([NAME], Canterbury, and [NAME]) of four halls while residents were still sleeping for two days (5/24/2021 and 5/25/2021) of four days observed, and 3. a loud floor buffing machine by housekeeping staff in one resident's room (#57) of thirty-one sampled residents room, when the resident has agitation and behaviors related to loud noises during two (5/25/2021 and 5/26/2021) of four days observed. Findings included: 1. On 5/24/2021 at 6:45 a.m., 10:00 a.m., 11:00 a.m., 12:00…

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 medical record review, the facility did not ensure a comprehensive person-centered care plan was developed for bed rail/bed enablers and failed to implement interventions for bed positioning and reducing loud noises to prevent agitation for one resident (#57) of thirty-one sampled residents for three days (5/24/2021, 5/25/2021, and 5/26/2021) of four days observed. Findings included: A review the Plans of Care policy and procedure, with a last revision date of 9/25/2017, revealed: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure section revealed: Develop and implement an individualized person-centered comprehensive plan of care by interdisciplinary team that includes but not limited to - the attending physician, a registered nurse with responsibility of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to provide wound care in a sanitary manner that would promote healing for two residents (#61 and #26) out of two residents as evidenced by cleaning and dressing three separate wounds at the same time; not completing hand hygiene between the cleaning and dressing of wounds; leaving wounds uncovered; and not wearing personal protective equipment during wound care. Findings included: 1. The policy titled, Dressing Change, effective 11/30/2014 and revised 12/6/2017, identified that a clean dressing would be applied by a nurse to a wound as ordered to promote healing. A review of the admission Record for Resident #61 was admitted on [DATE], 3/22/19, and 4/23/21. The admission Record identified diagnoses not limited to Type 2 Diabetes Mellitus without complications, acquired absence of right leg above knee, and unspecified peripheral vascular disease. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident scored a 15 out of…

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

Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to oxygen and humidification therapy, consistent with professional standards of practice for one resident (#15) of one resident investigated for respiratory care. Findings included: On 5/26/21 at 11:30 a.m. an observation was conducted during tracheostomy care for Resident #15 with Staff O, Licensed Practical Nurse (LPN) who was assisted by Staff L, Registered Nurse (RN) unit manager. Resident #15 was observed seated upright in his bed. The tracheostomy site was open to air and had a dressing around the base of the tracheostomy between the device and the neck. There was an oxygen concentrator and humidifier set up in the room. The equipment was not connected to the resident and was not in operation. There was a nebulizer machine noted on a bedside table with the tubing and mask noted to be inside of a plastic wash bin mixed in with personal items for the resident. The tubing and mask were not properly stored in a clean separate bag. Resident #15…

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 medical record review, the facility failed to did not ensure an assessment for bed rails/enablers, a consent was received for use of bed rails/enablers or a physician order was received for bed rails/enablers for one resident (#57) of thirty-one sampled residents. Findings included: On 5/24/2021 at 6:45 a.m., and 8:30 a.m.; 5/25/2021 at 7:38 a.m., 10:45 a.m., and 11:40 a.m.; and 5/26/2021 at 7:20 a.m., 8:30 a.m.; and 10:00 a.m., Resident #57 was observed in his room, lying either flat on his back with his head on a pillow at twenty to thirty degrees, or seated flat in bed and upright at forty-five degrees. Resident #57 had been observed with calling out and repetitive yelling behaviors throughout the day, each day observed. During each observation, the resident was observed in his bed and both bed rails were observed up and locked into position. Resident #57 was observed and interviews were attempted several times with Resident #57 but he was not able to respond 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 observations, record reviews, and interviews the facility failed to ensure a repeated pharmacy recommendation was responded to within a timely manner for one resident (#56) of five residents reviewed for unnecessary medications. Findings included: The Policy and Procedure titled, Monthly Drug Regimen Review, effective 4/21/2017 and revised 10/10/2018, indicated that the procedure to ensure the requirement was met for monthly drug regimen review the Executive Director (ED)/Director of Nursing (DON) should implement the following processes which included: - Provide the consultant with responses (Consultant Report - Continuous Print) for consultant comments and recommendations from previous visits. - Discuss the recommendations not responded to and develop to plan for completing. - Download of Pharmacist Consultant Reports: -- Consultant Reports - 1 recommendation per page. ---- Non-Urgent: Report provided to the attending physician for timely response: ------ Day 1-14 provide recommendation(s) 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.