Gardens Nursing And Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations records reviewed and interviews the facility failed to ensure a safe bathing environment for one resident (Resident #100) out of two sampled. Resident #100 sustained a cut on the bottom of his right foot in the shower from a protruding metal screw, which secured the metal grate drain cover. This deficient practice increased Resident #100's risk for serious chronic wound complications such as an infection. The findings included: During the Residents' Council meeting held on 03/25/2026 at 1:45 PM Resident #100 reported he sustained a cut on his foot in the shower.On 03/25/26 at 3:25 PM Resident #100 was observed in his room sitting in a chair the resident showed the surveyor an undated bandage on the bottom of his right foot and reported the cut was treated by a Staff I Registered Nurse (RN) on 03/24/2026. The resident removed the bandage and a cut measuring approximately 1.5 inches long with scant yellow drainage was noted.On 03/25/26 at 3:27 PM inspection of Resident #100's shared bathroom…

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 under sanitary condition in two out of two snack/nourishment refrigerator on the resident's unit. as evidenced by residents' foods brought to the facility by visitors and family were observed unlabeled and not appropriately dated. This deficient practice has the potential to affect residents receiving food brought in from outside sources. The findings include.Observation on 06/25/2025 at 3:15 PM of the facility's Nourishment Pantries refrigerators that stores resident's food that is brought into the facility by visitors, family and other outside sources revealed the refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names. The third-floor refrigerator also had several unlabeled undated plastic bags with food items. Interview on 06/25/2025 at 3: 25 PM Interview with Staff J, Registered Nurse revealed (RN) stated: all these foods belong to the residents. items in the refrigerator…

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 reviews and interviews facility failed to notify one (Resident #1) out of three sampled residents' representative of a change in condition. As evidenced by Resident #1 with a clinical diagnosis of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) left the facility Against Medical Advise (AMA) and the responsible party was not notified.The findings included:Record review of a demographic sheet revealed Resident #1 was admitted on [DATE] with diagnosis that included: Schizophrenia and Psychosis, responsible party listed: [] Advocacy Group and discharged on 5/5/2025.Record review of an admission/discharge/transfer list revealed Resident#1 was listed as discharged Against Medical Advice on 5/5/25.Record review of an admission Minimum Data Set (MDS) reference dated 3/24/2025 revealed Resident#1 had a Brief Interview of Mental Status score of 14 out of 15; indicated no cognitive impairment,…

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 interviews the facility failed to ensure one (Resident #1 out of three (Resident #1) safely and appropriately discharged to a safe location where ongoing clinical care could be provided, as evidence by on 05/05/2025 Resident #1 a vulnerable resident with clinical diagnoses of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) insisted on leaving the facility was presented with an Against Medical Advise (AMA) form which he refused to sign. The facility did not obtain a valid address for Resident #1's next place of residence and did not inform the resident's advocate/representative about the AMA discharge. At the time of this survey Resident #1's location is unknown. The findings include: Observational tour of the facility's exterior revealed the facility is in a residential area with high volume of traffic and cross streets; the facility is not gated 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 record review, the facility failed to honor their policy for Foods brought in by family/visitors for one (Resident #13) out of three sampled residents as evidenced by the facility's staff refuse to warm Resident #13's food brought in by family. The findings included: During observation on 06/25/25 at 12:55 PM Resident #13 was observed seated in her wheelchair at the bedside. Resident #13 revealed she had a recent disagreement with the dietary manager about her food that had been brought in by her brother being too burnt when staff warmed it up in the kitchen .As a result the Dietary Manager is unwilling to warm her food in the kitchen. The resident further explained the microwaves were removed and residents must warm up outside food in the kitchen. Interview on 06/25/25 at 02:25 PM, the Dietary Manager reported there is currently no microwave on each floor, as the previous ones were removed due to repeated damage and have not been replaced. Per facility policy, staff are not permitted to reheat outside food brought in by residents or their…

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 develop and implement a discharge care plan for one (Resident # 1) out of three resident whose discharge care plans were reviewed. There were 106 residents residing in the facility at the time of this survey. The findings included: Record review of Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE] and discharged on 03/08/2025. Clinical diagnoses include Displaced Tri malleolar Fracture of Right Lower Leg, Subsequent Encounter for Closed Fracture with Routine Healing, Encounter for Other Orthopedic Aftercare. Record review of orders dated 03/07/2025 indicated the resident was to be discharged home with family on 08/08/2025. Review of the admission Minimum Date Set (MDS) Section C for Cognitive Patterns dated 02/11/2025 revealed the Brief Interview of Mental Status (BIMS) summary score was 07 out of 15 indicating severe cognitive impairment. The section for Functional Abilities dated 02/11/2025…

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 indwelling catheters are secure for two (Residents #7, and Resident #8) out of two residents reviewed for indwelling urinary catheter. As evidenced by Resident #7's was observed in the hallway carry his catheter bag in his hand and at times placing it on the floor. Resident # 8 was observed with the catheter's drainage bag on his lap and the tubing on the wheelchair's wheels. These deficient practices increases the risk for catheter related urological trauma if the indwelling urinary catheter is unintentionally pulled resulting in dislodgement. The findings include: Resident #7 On 03/27/2025 at 10:05 AM, Resident#7 was observed in the hallway with his indwelling catheter resting on his lap. At the time of the observation, there was no privacy bag in use to cover the catheter. (Photographic evidence) On 03/27/2025 at 11:28 AM, Resident#7's indwelling catheter was observed on the floor, the catheter was not properly secured 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 records reviewed and interviews; the facility failed to ensure Drug Regimen Reviews were completed for one (Resident # 13) out of three residents reviewed as evidenced by Resident #13 who was admitted to the facility has been receiving a combination of antidepressant, blood pressure medication, muscle relaxer, and atypical antipsychotic medication that has the potential to cause serious interactions and side effects has not received the Drug Regimen Review within the required time frame. The findings include. On 03/25/2025 at 10:15 AM Resident # 13 was observed smoking at the designated smoking patio located on the second floor interacting with staff. On 03/26/2025 at 11:19 AM Resident #13 was observed in the elevator going up to the third floor. It was noted that another resident made fat shaming remarks directed at Resident #13. Who did not respond and held her head down. On 3/27/2025 at 9:35 AM Resident # 13 was observed on the smoking patio and interacted with staff. On 3/27/2025 at…

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

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for potentially 107 facility residents. the findings included: 1) During the initial kitchen/food service observation tour conducted on 08/26/24 at 8:50 AM, the following were noted: (a) The exteriors of 2 kitchen utility carts were noted to be heavily soiled, stained, and areas of peeling paint. * Photo Evidence Obtained (b) Large areas of the kitchen floor and walls were cracked stained, and in disrepair. * Photo Evidence Obtained (c) The floor area of the dry/canned food storage area was heavily soiled, stained, and areas of rust. * Photo Evidence Obtained (d) Staff clothing and purses (2) were noted to be stored directly onto clean food storage shelving. * Photo Evidence Obtained (e) A chemical test of 3 of 3 cleaning cloth buckets noted extremely high concentration of Quaternary Chemical * Photo Evidence Obtained (f) The entry door of the walk-in refrigerator was noted 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 interviews and record review, the facility failed to ensure the facility designated Infection preventionist who is responsible for the facility's Infection Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The findings included: Review of the facility's job description titled, Infection Preventionist, included the following: The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Infection Control and Prevention Program in accordance with current federal, state, and local standards, guidelines, and regulations that govern our center and as may be directed by the Medical Director or Director of Nursing to ensure that the center provides a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases and infections. Experience: Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of employment. Record review of the infection…

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

Based on observation and interview, it was determined that the facility failed to provided 6 non-sampled resident's and 1 of 1 (Resident #62) residents reasonable access to the use of a phone and in a place in the facility where calls can be made without being overheard. The findings included: During the screening of residents on the second floor on 08/26/24 at 10:00 AM it was noted that 6 residents who resided on the second floor were using the facility telephone located at the nurses station desk. Further observation noted these residents just walking up to the phone and dialing without any staff intervention to use a phone in a private area. The resident's conversations could be overheard by numerous staff and residents located within the nurses station area. Random observations conducted on 08/8//27/24 noted residents again utilizing the facility nurses station phone, however in addition it was noted that outside calls were being routed into the nurses station and residents were brought to the nurses station to voice aloud in a non -private setting. On 08/28/24 at 12:30 PM it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included observation of 2 of 2 residential room areas (second floor and third floor), 1 of 2 dining room (second floor) areas, 1 of I elevators, and 4 of 4 wheelchairs Resident's #7, #9, #17, and #54. The findings included: During the resident screening performed by the surveyors on 08/26/24 to 08/27/24 and the Environment Tour conducted with the Administrator and Corporate Maintenance Director on 08/28/24 at 2:00 PM and on 08/29/24 at 1:00 PM, the following were noted: The Elevator's interior floors and walls were noted to be heavily soiled and stained. Exposed sharp piece of plastic noted near the handrails. The entry/exit door to the elevator was noted to be heavily soiled and stained. The metal handrail to the side of the elevator entry/exit was heavily worn down to the bare metal surface. Observation on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment observation period of the Minimum Data Set (MDS), the observation period (also known as the Look-back period) is the time period over which the resident's condition or status is captured by the MDS for 3 of 3 residents sampled for resident assessment (Residents #48, #100, and #59). The findings included: 1) Resident #48 was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part: Cardiac Arrythmia Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Epilepsy, Cognitive Communication Deficit, and Dementia. Review of the MDS for Resident #48 dated 07/13/24 documented in a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Documented in Section N under High-Risk Drug Classes: Use 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 interviews and record reviews the facility failed to ensure a comprehensive care plan for smoking was revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 1 residents sampled for smoking (Resident #59). The findings included: Review of the Facility's policy titled, Care Plan - Comprehensive with an effective date of 09/01/22 included in part the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part: Chronic Obstructive Pulmonary Disease, Other Lack of Coordination, Muscle Weakness, Need for Assistance with…

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

Based on record review interviews and observations, the facility failed to ensure minimum nursing staff was provide daily related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population affecting resident census of 111 out of 120 bed facility . 1) Review of the facility's State Minimum Nursing Staffing from 06/23/24 to 08/24/24 revealed on 06/30/24 the daily average for nursing (Registered Nurses and Licensed Practical Nurses) was 0.9899 (below the minimum 1.0). On 08/30/24 at 3:00 PM the administrator provided updated Minimum Nurse Staffing forms. During an interview conducted 08/27/24 at 11:00 AM with the Administrator who stated she is the person responsible for completing the Nurse Staffing Calculations. When asked what the minimum should be, she said the daily average total Nursing hours should be 1.0, the daily average CNA 2.0 , and 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 and interviews the facility failed to post Nurse Staffing Data daily with current date and in a prominent place readily accessible to residents and visitors. The findings included: On 08/26/24 from 10:00 AM to 11:00 AM during an initial tour of the facility, an observation was made on the second floor. The nurse staffing data posted was dated 08/23/24 (Photographic Evidence Provided). There was no other nurse staffing data posted in the facility. During an interview conducted on 08/26/24 at 11:25 AM with Staff CC Registered Nurse. When asked if there is nursing staffing data posting in the facility with the number of all staff and all nurses, she said no, and she only knows about her floor (3rd), and they just have the white board that they write the assignments for this floor.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based onrecord reviews and the facility failed to administer medications in a timely manner for 1 of 5 residents sampled for medication administration (Resident #70) and failed to ensure medications administered as ordered for 1 of 6 residents sampled for medication reconciliation (Resident #52) and failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 4 of 6 residents sampled for medication reconciliation (Residents #52, #54, #16, #42). The findings included: Review of the facility's policy titled, Medication Administration Policy - General with an effective date of 08/07/23 included in part the following: Procedure: 3.7 Verify that the medication name and dose are correct when compared to the medication order on the medication administration record. 4. Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct…

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 behaviors were adequately monitored for residents on psychotropic medications for 4 of 5 residents reviewed for unnecessary medications (Resident #76, Resident #306, Resident #307, and Resident #56). The findings included: Review of the facility's policy titled, Behavior Monitoring, dated 09/01/23, included the following: Residents who have not used psychotropic medications are not given these medications unless the medication is necessary to treat a specific condition as diagnosed, documented in the clinical record and per physician order. Procedure: 1.Resident(s) receiving psychotropic medication should have specific condition documented indications in the medical record. 4. Monitor behavior and side effects every shift utilizing the electronic Behavior Monitoring Flow Record. 11. Care plan to include person centered goals and non-pharmaceutical interventions. Update Care Plan as indicated. 1) Record review for Resident #76…

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 ensure medications were secured at bedside for 1 of 43 sampled residents (Resident #28), failed to secure medications in 1 of 1 clean linen closet located on 2nd floor, and failed to secure wound treatment cart for 2 of 2 wound treatment carts. The findings included: Review of the facility's policy titled, Medication Storage with an effective date 12/08/23 included in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Procedure: 4. The facility shall not use discontinued, outdated, deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 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 observation, interview, and record review, it was determined that the facility failed to provide 107 of 111 facility residents with a nourishing, palatable, well-balanced diet that meet dietary needs and taking into consideration of food preferences of the residents. The findings included: 1) During the observation of the Breakfast meal of 08/28/24 at 7:30 AM, it was noted that all resident meal trays include a 4 ounce serving of a light colored pink liquid. A review of numerous resident meal tray tickets were noted to have documentation of a preference of a Orange Juice serving. A review of the approved menu for the breakfast meal of 08/28/24 noted documentation of a 6 ounce portion of Vitamin C Juice to be served. On 08/28/24 at 9:30 AM the surveyor went into the main kitchen to investigate the juice that was served for the 08/28/24 breakfast meal. During an interview with the Diet Aide's (Staff C & D) a container of Tropical Punch (63 ounce powder) was given to the surveyor. The staff stated that 6-7 scoops of the powder is mixed with approximately 1 gallon of water,…

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, observation and interview, it was determined that the facility failed to prepare in advance and follow the approved menu menu for 107 of the facility's 111 residents. The findings included; 1) During the review of the approved menu for the lunch meal on 08/26/24, the following were noted to be served to Regular, Mechanical Soft, Pureed, and No Concentrated Sweets Diets: * Homemade Chili (6 ounce portion = 2 ounce protein) * Watermelon Cubes (#8 scoop = 1/2 cup) * Cornbread (1 piece) Observation of the lunch meal in the main kitchen on 08/26/24 at 11:30 AM noted the following were being serve to the facility residents: * Homemade Chill - (#10 scoop - 2 ounce portion was being served) * Watermelon Cubes (no water melon available - canned pineapple substituted) * Cornbread ( pureed regular bread served to the pureed diets) Interview with the facility cook ( Staff A) at the time of observation; Staff A noted to state that she did not review the approved menu for the lunch meal of 08/26/24 and thought that a 2 ounce portion be served and was also not aware 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, it was determined that the facility failed to prepare foods by the use of standardized recipes to ensure nutritive value, flavor, appearance, and food that is attractive and appetizing for 107 of the facility's 111 residents. The findings included: During the review of the approved menu for the lunch meal on 08/27/24 noted documentation for the entree, Turkey Burger Patty Melt to be served as the entree for Regular, Mechanical Altered (Mechanical Soft and Pureed), and No Concentrated Sweets Diets. A review of the resident's Diet Census for 08/26/24 noted 107 of there facility's 111 residents were to receive Regular, Mechanical Altered, and No Concentrated Sweets Diets. At the request of the surveyor a copy of the facility's standardized recipe for Turkey Burger Patty Melt was requested from the Dietary Manager (CDM). A review of the standardized recipe noted the following: Turkey Burger Patty Melt (recipe) Ingredients: Turkey Burgers Margarine Sautéed Onions Swiss Cheese Bread Directions: 1) Arrange burgers on sheet pan and cook…

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

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe/clean/comfortable/homelike environment, F755 Pharmacy Srvcs/Procedures/pharmacist/records, F867 Qapi/qaa Improvement Activities, and F925 Maintains Effective Pest Control Program. These deficiencies have the potential to affect 111 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 05/19/2023, F755 Pharmacy Srvcs/Procedures/pharmacist/records, F867 Qapi/qaa Improvement Activities, and F925 Maintains Effective Pest Control Program and a complaint survey with exit date 10/03/2023 F584 Safe/clean/comfortable/homelike environment were cited. Review of the Policy and procedures revealed; The Center organization has a comprehensive, date-drive Quality Assurance Performance Improvement Program that focuses 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 observations, interviews, and record review, the facility failed to ensure residents have functioning communication system to call for staff assistance from their room (including bathroom) to a centralized staff work area for 5 of 43 residents reviewed for call lights (Resident #6, Resident #9, Resident #19, Resident #83, and Resident #88). The findings included: Review of the facility's policy titled, Call Lights, dated 09/01/23, included the following: The purpose of this policy is ensuring residents' requests and needs are responded to. Procedure: 2. Answer the resident's call as soon as possible. 5. Report malfunctioning call lights to Maintenance, ED, and/or DON promptly. 6. Offer stationary bells and/or round frequently on residents if the call light system is malfunctioning. 1)Record review for Resident #6 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis; Generalized Anxiety Disorder; Need for Assistance with Personal Care. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that the call lights were within reach for 4 of 43 sampled residents (Resident #88, Resident #11, Resident #15 and Resident #306). The findings included: A review of the facility's policy titled Call Lights dated 09/01/23 showed that the purpose of this policy is ensuring residents' request and needs are responded to. The call light should be within reach of the resident. 1. A chart review revealed that Resident #88 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #88 had a Brief Interview of Mental Status (BIMS) score of 12, which was a slight cognitive impairment. In a phone interview conducted on 08/25/24 at 11:33 AM with Resident #88's family stated that Resident #88 fell in the facility last week trying to go to the bathroom on his own with no assistance. The call light was not within reach and Resident #88…

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 initiate and resolve grievances for 4 of 43 residents reviewed for grievances (Resident #6, Resident #9, Resident #19, and Resident #206). The findings included: Review of the facility's policy titled, Complaint/Grievance, dated 09/07/23, included the following: The Center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The center will inform residents of the right to file a grievance orally and in writing, the right to obtain a written decision regarding the grievance. Procedure: 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Form. Complaint/Grievance forms will be available 24 hours per days 7 days a week in an unsecured common area. 2. Original grievance forms are…

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 implement a Comprehensive Care Plan for antipsychotic medications for 3 of 43 sampled residents (Resident #56, Resident #306, and Resident #94) and a Comprehensive Care Plan for an Advance Directive for 1 of 43 sampled residents (Resident #100). The findings included: A review of the facility's policy titled Care Plan-Comprehensive, dated 09/01/2022, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are developed through an interdisciplinary process. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about 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 observation, interview, and record review, it was determined that the facility failed to provide necessary services to maintain good nutrition for 1 (Resident #45) of 6 sampled residents that are unable to eat without staff assistance. The findings included: During an observation of Resident #45 on 08/28/24 at 12:20 PM, it was noted that the resident's lunch tray had been placed on the over-bed table directly in front and in reach of the resident. It was also noted that a large container of non -thickened water with drinking straw was also placed in reach of the resident. It was noted that the resident was scooping large portions of pureed foods with bare hands above her head and dropping the pureed foods into her mouth. It was noted that the resident started coughing and regurgitation the pureed foods from her mouth onto her chest. The surveyor immediately requested the nurse to come to Resident #45's room. The Director of Nursing (DON) was noted to come to the room and observed the surveyors findings…

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 it was free from accident/hazard as evidenced by not providing direct supervision for 1 of 23 residents who smoke (Resident #59), paper trash observed in 1 of 1 red smolder cigarette butt bin on the smoking patio and excess lint in 1 of 2 dryers in the laundry room. The findings included: 1) On 08/28/24 at 4:08 PM an observation was made of several residents on the smoking patio, with Staff NN, a Certified Nursing Assistant who was present on the inside of the facility watching residents on the smoking patio through the window. Visibility of entire smoking patio and all residents smoking was not visible from inside the facility through the window. Resident # 59 was smoking on the smoking patio at the far end away from the glass door and window and not visible from the inside of the facility. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part: Chronic…

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 a performance review of every Certified Nursing Assistant (CNA) was completed at least every 12 months. The findings included: On 08/27/24 at 9:00 AM the Director of Nursing (DON) was asked for the performance review for the following Certified Nursing Aides: Staff II Certified Nursing Assistant with hire date of 11/04/20 Staff JJ Certified Nursing Assistant with hire date of 11/09/21 Staff KK Certified Nursing Assistant with hire date of 01/19/22 Staff LL Certified Nursing Assistant with hire date of 02/22/24 Staff MM Certified Nursing Assistant with hire date of 08/23/23 During an interview conducted on 08/29/24 at 9:50 AM with the DON who stated they are not able to provide any performance review evaluations for the 5 CNAs that was requested due to transition of ownership this week. When asked if he could try to request the information requested from the previous owner, he said Human Resources informed him it is not available to be requested.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents are free of any significant medication errors for high-risk medications for 1 of 4 residents reviewed for medication administration (Resident #9). The findings included: Review of the facility's policy titled, Medication Administration Policy-General, dated 08/07/23, included the following: Procedure: 3. Dose Preparation: take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 3.7 Verify that the medication name and dose are correct when compared to the medication order on the medication administration record. Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Hemiplegia, Type 2 Diabetes Mellitus, Hypertension. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview for Mental Status of 15, which indicated that she was cognitively intact. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to prepare food in a form designed to meet individual needs that included; Thickened Liquids for 1 of 1 sampled resident (Resident #45) and Purred Diet for 10 facility residents that included 5 sampled residents (Resident #17, #45, #211, #193, and #301). The findings included: During an observation of Resident #45 on 08/28/24 at 12:20 PM, it was noted that the resident's lunch tray had been placed on the over-bed table directly in front and in reach of the resident. It was also noted that a large container of non -thickened water with drinking straw was also placed in reach of the resident. Further observation of the resident noted to be scooping large portions of pureed foods with bare hands above her head and dropping the pureed foods into her mouth. It was noted that the resident started coughing and regurgitation the pureed foods from her mouth onto her chest. The surveyor immediately requested the nurse 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 Based on observations, interviews, and record review, the facility failed to follow the diet orders as per Physicians' orders for one of 7 residents reviewed for nutrition (Resident #84). The findings: In an observation conducted on 08/28/24 at 8:03 AM, Resident #84 was in his room with the breakfast tray. The meal ticket showed no concentrated sweets (NCS), no added salt, and a (NAS) diet with double portions (no fortified meals noted on the meal ticket). The breakfast tray revealed oatmeal, eggs (regular serving), muffin, and a glass of 4-ounce juice. The breakfast meal did not have the double portions and the fortified foods as per doctor's orders. In this observation, Resident #84 told this Surveyor that he wanted more meat and that what they served him this morning was not enough. Resident #84 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes and Iron Deficiency. The Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #84 had a Brief Interview of Mental Status (BIMS)…

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

Based on observation, interview, and record review, it was determined that the facility failed to provide special eating equipment (Divided Plate) 5 of (Resident's #16, #30, #34, #42, and #45) sampled residents who need them when consuming meals. The findings included: During the observation of the lunch meal conducted in the second floor dining room on 08/26/24, it was noted that the meal tray ticket for Resident #16 and Resident #19 both documented that a Divided Plate be provided with the meal. Further observation noted that that the no Divided Plate was provided for either resident and further noted that the resident's attempt to eat independently and the use of a Divided Plate would assist the resident with self feeding. On 08/27/24 at 7:30 AM a second observation of the breakfast meal was conducted in the second floor dining room. It was noted again that the meal tray tickets documented a Divided Plate be provided, however the adaptive plate was not included on the resident's meal tray. Following the 08/27/24 observation the surveyor interviewed kitchen staff concerning…

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, it was determined that the facility failed to dispose of garbage and refuse properly. The findings included: Observation tour of the outside garbage/refuse area on 08/26/24 at 9:45 AM noted the following: (a) A large body of stagnant water was noted to be located between garbage dumpster and cardboard recycling dumpster. Further observation noted that the area was approximately 10-12 feet wide and approximately 12 inches deep in the center. Further observation noted large areas of stagnant algae in the water along with what appeared to be medical waste that included medication bottles, medication inhaler tubes, disposable gloves, disposable masks, disposable gowns, and other unidentifiable waste. The area also contained numerous large and small piece of garbage and trash. The areas behind the dumpster and the walkway to and around the rear of the building were also noted to be littered with the same type of medical waste and garbage /trash. Also located next to the dumpster's were 4 large tires which were filled with stagnant water and a potential…

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 maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents reviewed for closed record (Resident #104). The findings included: Record review for Resident #104 revealed the resident was originally admitted to the facility on [DATE] with a readmission on [DATE] and left against medical advice (AMA) on 08/07/24. Review of the Minimum Data Set for Resident #104 dated 07/20/24 documented a Brief Interview of Mental Status (BIMS) score was 15 indicating a cognitive response. Review of the BIMS Evaluation for Resident #104 dated 08/07/24 documented a BIMS score of 14 indicating a cognitive response. Review of the AMA form for Resident #104 revealed the resident signed the form on 08/07/24. Review of the Nursing notes for Resident #104 from 08/06/24 to 08/07/24 revealed no documentation the family being notified of resident leaving the facility and signing himself out AMA. During an interview conducted 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 interviews, and record review, the facility failed to offer influenza and pneumococcal vaccinations for Resident #72 and to properly document immunization records for 3 of 5 residents reviewed for immunizations (Resident #72, Resident #89, and Resident #210). The findings included: Review of the facility's policy titled, Resident Influenza Vaccine, dated 09/25/23, included the following: Residents who have no medical contraindications will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Procedure: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. 4. A resident's refusal of the vaccine shall be documented in the medical record. Review of the facility's policy titled, Pneumonia Vaccine, dated 09/07/23, included the following: Procedure: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are…

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 each resident with individual closet space in the resident room and ensure closets had privacy doors for 5 out of 43 sampled residents (Resident #79, Resident#20, Resident #15, Resident #212 and Resident #90). The findings included: In a tour of the facility conducted on 08/28/24 at 3:00 PM, the following were noted: 1. room [ROOM NUMBER] had Resident #79 by the door with a closet that did not have a door for privacy, and his roommate, Resident #81, did not have a closet on his side of the room. In this observation, Resident #79 said that he was sharing his closet with just about everyone on the floor and that his roommate did not have his own closet. 2. room [ROOM NUMBER] had Resident #20 by the door, with a closet that did not have a door for privacy, and his roommate Resident #211, who did not have a closet on his side of the room. In this observation, Resident #20 said that his roommate did not have a closet on his side 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 and interviews, the facility failed to ensure handrails are securly affixed to wall on 1 of 3 floors (3rd floor hallway). The findings included: On 08/26/24 from 9:45 AM to 11:00 AM during an initial tour of the facility, the handrails on 3rd floor were found to be loose at the following locations: Next to room [ROOM NUMBER] (Photographic Evidence Obtained). Next to the 3rd floor elevator near nursing station (Photographic Evidence Obtained). Next to room [ROOM NUMBER]. Across from room [ROOM NUMBER]. Across from room [ROOM NUMBER]. During an interview conducted on 08/30/24 at 1:00 PM with the Administrator who was informed of the loose handrails on the 3rd floor, she stated, they had had an issue with the handrails on the 2nd floor and those had been secured to the wall.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for second floor resident rooms. The findings included: Observation on the Second Floor 10/03/2023 from 8:02am to 9:15am revealed: Rooms #221 - Under the sink a container, the toilet paper holder was on the floor, the shower floor was dirty, and on the ceiling a water marks. The cover sheet under air conditioner (AC) unit was collecting the moisture and was wet. Water was running from the shower head on the bathroom floor. room [ROOM NUMBER] - At the entrance there was a dead roach, bathroom walls were in disrepair, the shower was observed to rusty and dirty. In the hallway across from room [ROOM NUMBER] another roach was observed. Room#223 - Under the Air Conditioner unit, there was a blanket to collect the moisture. In the bathroom a live roach was observed and the wall was in disrepair. Room#229 - At…

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 an effective pest control program so that the facility is free of pests as evidenced by live roaches, dead roaches and small black bugs observed in eleven different locations in the facility. The findings included: On 10/3/23 at 8:02 AM to 9:15AM, during an observation of the facility's second floor the following was observed: The second-floor dining room: There were seven residents in total and five were in a wheelchairs. There was a live roach crawling on the wall. room [ROOM NUMBER]: A dead roach was near Bed A. [See photo evidence]. room [ROOM NUMBER]: A live roach was seen crawling in the bathroom. [See photo evidence]. room [ROOM NUMBER]: 2 dead roaches were seen and smashed into the wall. [See photo evidence]. room [ROOM NUMBER]: A dead roach was found in front of Bed B in the room. room [ROOM NUMBER]: One live roach was seen crawling on the wall. room [ROOM NUMBER]: Multiple roaches were found stuck to a glue traps…

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 dignity during dining for one (Resident #81) out of 28 residents who need assistance with eating. As evidenced by one facility staff member standing while feeding the resident. The findings included: In an observation on 05/16/23 at 12:02 PM. In the dining room, there were 12 residents and 2 staff sitting down while assisting residents to eat lunch. Staff I, a Registered Nurse was seen pulling resident up in the chair. Staff I, fed resident #81 from his regular diet tray, while standing and resident #81 was observed feeding himself at times. On 05/16/23 at 02:35 PM, during an interview with Staff I, Registered Nurse, when asked, How was lunch for resident #81 and the reason for standing while feeding the resident? Staff I stated, The resident was sliding down in the chair. I'm supposed to be sitting when I'm feeding a resident. When asked, The reason for not sitting down? Staff I stated, I'm an active person, I walk around, 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 observation, record review and interview, the facility failed to provide adequate and appropriate health care, related to restorative therapy services for one (Resident # 7) out of one resident who needs to have splints on both hands. This practice has the potential to increase the risk of negative resident outcomes and to affect all in-house residents residing in the facility who need to wear splint devices. The findings included: Observation of Resident # 7 on 05/16/2023 at 09:03 AM. The resident was observed with both hands contracted and not wearing splints or hand rolls. Observation of Resident # 7 on 05/17/2023 at 10:15 AM. The resident was observed lying in his bed. The resident was not wearing splints or hands rolls in his contracted hands. Observation of Resident # 7 on 05/18/23 at 10:31 AM. The resident was observed lying in his bed. The resident was observed with both hands contracted. The resident was not wearing any splint or devices. The resident was not able to respond to questions asked.…

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 pharmaceutical procedures were followed during medication administration and medication storage observation for two (3) out of four (4) medication carts observed and 3 residents observed for medication administration with 28 opportunities. This affected Residents #22, #32 and #73. There were 81 residents residing in the facility at the time of this survey. The Findings Included: During medication administration observation on 05/17/2023 at 8:30 AM with Registered Nurse (Staff I) on unit two (2) west medication cart, the medication Calcitriol Capsule 0.25 Microgram (MCG)-one (1) capsule by mouth once daily was not available to be given to Resident #73, the medication was last signed out in the Medication Administration Record (MAR) as given on 05/16/2023 at 9AM. Interview on 05/17/2023 at 8:30AM with Registered Nurse, Staff I, when asked about the policy on reordering the medication for resident's Staff I stated, I reordered 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, record review and interview, the facility failed to ensure a Graduate Practical Nurse met the qualifications required for the job title. There were 81 residents residing in the facility at the time of this survey. The Findings Included: On 5/17/23 at 9:06AM, prior to the medication administration observation, the surveyor introduced herself to Graduate Nurse (Staff E) at the medication cart, Staff E stated, her name and title as a graduate nurse. Staff E stated, there is a program here in the facility for graduate nurses. On 05/18/23 at 02:32 PM, the Nursing Home Administrator (NHA) was asked about Staff E's graduate nurse qualifications, it stated Staff E was hired as a Certified Nursing Assistant (CNAs), I am aware that she has a certificate stating she can sit for the nursing state boards as a Licensed Practical Nurse (LPN). I will find out from Human Resources (HR) when Staff E graduated from nursing school and if she has a Graduate Practical Nurse letter from the State of Florida. On 05/18/23 at 04:00 PM, received from the NHA, Staff E's Authorization to…

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

Based on record Review and interview, the facility failed to demonstrate effective plans of action were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F550 Resident Rights/Exercise of Rights and F688 Increased/Prevent Decrease in Range of Motion/Mobility. This practice has the potential to increase the risk of negative resident outcomes that could affect all 81 residents residing in the facility at the time of this survey. The finding included: Record review of the facility's survey history revealed, during a recertification survey with exit 3/10/2022, Resident Rights/Exercise of Rights was cited related to the facility failed to treat 1 out of 24 sampled residents in a dignified manner. Moreover, Increase/Prevent Decrease in ROM/Mobility was cited related to the facility failed to provide adequate care and treatment for one resident with a contracture as evidenced by the facility's failure to apply elbow extension and splint devices as per physician's order. During record review of the quarterly meeting sign-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.