Pompano Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure adequate medication for 1 of 6 residents, Resident #39, reviewed for medication reconciliation.The findings included:On [DATE] at 11:50 AM, a review of the North medication care was conducted with Staff G, Licensed Practical Nurse (LPN) for Resident #39. Record review reveled Resident #39 was admitted on [DATE] with diagnoses that included Parkinson's Disease, and Dementia Review of the physician's order, dated [DATE], documented Alprazolam Oral Tablet 0.25 MG (Alprazolam), a *Controlled Drug,*Give 1 tablet by mouth every 12 hours as needed for Anxiety/Agitation for 14 Days and was discontinued on [DATE]. Review of the Controlled Drug Declining Inventory Sheet for Resident #39 for the Alprazolam .25mg tablet documented the medication was signed out on [DATE] at 8:24 PM. Review of medication administration record from 0701/25 to [DATE] revealed no documentation of Alprazolam 0.25mg being administered. Review of the nurse progress notes from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure medication were secured, for 1 of 27 sampled residents, Residents #99, reviewed for medications. The findings included:Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Cerebral Infarction Due to Embolism of Left Middle Cerebral Artery, Other Lack of Coordination, and Aphasia. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status could not be conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #99 revealed no order for ointments or gels to be applied topically. Record review revealed no assessment for self-administration of medication(s). On 09/29/25 at 10:39 AM, an observation was made of 2 over the counter medications (Ultra Strength Muscle Rub with active ingredients: Camphor 4%, Menthol 10% and Methyl Salicylate 30% and triple…

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 ensure they implemented an effective infection control program, as evidenced by failure to follow enhanced barrier precautions guidelines for 1 of 42 residents on enhanced barrier precautions, Resident #25.The findings included:Review of the facility's policy titled, Barrier Precautions dated August 2025, included the following: During high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting for Residents on Enhanced Barrier Precautions, Personal Protective Equipment (PPE) is required. PPE consists of wearing gloves and gown prior to the high contact care activity.Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gowns and gloves.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 sampled residents, Resident #60 and Resident #126.The findings included: 1. Record review for Resident #126 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Muscle Wasting and Atrophy and Pneumonia. Review of the Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the Physician's Orders for Resident #126 revealed an order dated 10/02/25 for Inactivated Influenza Quadrivalent Vaccine 0.5 ML (Inactivated Influenza Quadrivalent Vaccine) Inject 0.5 ml intramuscularly one time only for Immunization for 1 Day Please employ the appropriate VIS for Flu vaccines. Please obtain consents for vaccines as well as enter information under the immunization tab. Review of the Vaccine Consent Form with no date for Resident #126 revealed it was signed by 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 ensure a physician order for a special study was scheduled and completed in a timely manner for 1 of 3 sampled resident reviewed, Resident #1.The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Dysphagia, Oropharyngeal Phase, Traumatic Hemorrhage of Cerebrum and Gastrostomy Status. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment and that the resident had a feeding tube. The resident's care plan titled Tube Feeding documented, The resident is receiving enteral nutrition r/t (related to) gastrostomy status and Dysphagia initiated on 05/10/25 with interventions to include obtain and review lab (laboratories) / diagnostic work as ordered, report results to MD [physician] and follow up as…

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 the residents' medical records that are accurately documented in accordance with accepted professional standards and practices for 1 of 3 sampled resident reviewed, Resident #1. The findings included: Review of Resident #1's clinical record revealed an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Traumatic Hemorrhage of Cerebrum, Obstructive and Reflux Uropathy, Unspecified. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 04 indicating severe cognition impairment. Review of Resident #1's clinical record documented a physician order dated 08/06/25 for remove foley catheter.Review of Resident #1's clinical record August 2025 Treatment administration Record (TAR) documented a foley catheter was removed on 08/07/25. On 08/28/25 at 9:21 AM, an interview was conducted with the Director 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 review of policy and procedure, observation, interview and record review, the facility failed to ensure it obtained a current physician order for an Intravenous (IV) dressing and IV site; and failed to change the Intravenous (IV) dressing to the right upper chest for 1 of 1 sampled resident observed, Resident #4. The findings included: Review of the facility policy and procedure, titled, Dressing Change for Vascular Access Devices, provided by the Director of Nursing (DON), reviewed 2011, documented in the Policy Statement Purpose: To prevent local and systemic infection related to the IV catheter. Policy: A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular access device securement .3. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further…

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 interviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 3 wings in the facility, [NAME] wing. The findings included: On 05/28/24 at 9:53 AM, an observation was made in Resident #67's room of an offensive urine-like odor noted in the resident's room. On 05/28/24, a side-by-side observation of Resident #67's room bathroom was conducted with the Housekeeping Manager and District Housekeeping Manager. They both acknowledged the offensive odor. The Housekeeping Manager stated that the Certified Nursing Assistants (CNAs) inform them when the room has odors, they do use deodorizers, and clean the room as necessary. The District Housekeeping Manager stated they were aware of other rooms which are in their focus cleaning list and will add Resident #67's room to the list. On 05/30/24 at 1:00 PM, an observation was made of an overwhelming smell of urine in the hallway between rooms 60 to 62. An interview was on 05/28/24, at 9:55 AM with Staff E, CNA,…

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 properly document and thoroughly investigate an injury of unknown origin for 1 of 1 sampled resident reviewed for skin discoloration, Resident #120. The findings included: Review of the facility's policy, titled, Abuse Prevention Program, dated August 2022, included, in part, the following: These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. Injury of Unknown source: An injury should be classified as an injury of unknown source when all of the following criteria are met: No person observed the source of the injury. The resident could not explain the source of the injury. The injury is suspicious because of its extent or location. Procedure: The facility has implemented the following processes: The Administrator is responsible for designating an Abuse Coordinator. The designed shift supervisor is identified as responsible for immediate initiation 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, interviews, and record review, the facility failed to initiate a comprehensive care plan for psychotropic medications with measurable objectives and interventions for 2 of 25 sampled residents, Resident #40 and Resident #63. The findings included: Review of the facility's policy, titled, Care Plan - Interdisciplinary Plan of Care from Interim to Meeting, dated February 2024, included, in part, the following: The facility shall support that 'each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care'. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to, monitoring resident condition, and responding with appropriate interventions. 1, Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that residents receive wound care consistent with professional standards of practice for 1 of 1 sampled resident reviewed for wound care, Resident #48. The findings included: Review of the facility's document provided by the Director of Nursing (DON), titled, Clean Dressing Change Competency Checklist, documented, in part, .wash hands and apply gloves .remove dressing and discard, remove gloves, wash hands, apply gloves .clean wound using circular motion starting from the center toward the outside (clean to dirty) .remove gloves, wash hands, don gloves and apply treatment as ordered . Review of Resident #48's clinical record documented an admission on [DATE] and readmission on [DATE]. The resident's diagnoses included Cachexia, Adult Failure to Thrive, Peripheral Vascular Diseases, Pressure Ulcer of Sacral Region and Chronic Pain Syndrome. Review of Resident #48's Minimum Data Set (MDS) significant change assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interview, the facility failed to ensure staff followed proper indwelling (foley) catheter care consistent with accepted standards of practice; failed to insert the appropriate catheter size and failed to date the urinary drainage bag as per physician order for 1 of 1 sampled resident reviewed for urinary catheter care review during foley care provided for Resident #48. The findings included: Record review for Resident #48 documented an admission on [DATE] and readmission on [DATE]. The resident's diagnoses included Cachexia, Adult Failure to Thrive, Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), Chronic Kidney, Pressure Ulcer of Sacral Region, and Chronic Pain Syndrome. Review of Resident #48's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 indicating the resident had severe cognition impairment. The resident's 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, interviews, and record reviews, the facility failed to provide nutritional interventions in a timely manner for 1 of 3 sampled residents reviewed for nutrition, Resident #63. The findings included: Review of the facility's policy, titled, Nutrition Assessment and Progress Note, dated January 2023, revealed, in part, the following: Initial nutrition assessment will be completed within 14 days of admission, and reassessment is completed quarterly, annually, and with significant change or readmission as needed. Record review showed Resident #63 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychosis, and falls. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #63 has a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. In an observation conducted on 05/30/24 at 9:03 AM, Resident #63 received her breakfast tray. The tray was filled with crispy bacon, cereal, fortified oatmeal, juice, and coffee.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure controlled substance medication reconciliations were accurate for 4 of 6 sampled residents reviewed during the controlled substance record review at the facility's west and south wings, for Residents #48, #82, #93 and #117; failed to obtain a physician's order for a psychotropic medication for Resident #93, reviewed for controlled substance use; failed to properly dispose of a controlled substance medication for Resident #117; failed to provide and document a scheduled medication as ordered for sampled Resident #83, as evidenced by it not being available; and failed to administer a scheduled medication to 1 of 3 residents observed for medicaiton administration, Resident #6. The findings included: Review of the facility's policy, titled, Medication Administration General Guidelines, with no revision date, provided by the Director of Nursing (DON) documented under documentation .the resident's MAR (Medication Administration Record)…

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 adequately monitor residents' behaviors for those residents receiving psychotropic medications for 4 of 25 sampled residents, Residents #63, #40, #99 and #113. The findings included: Review of the facility's policy, titled, Behavior Monitoring Record, dated October 2021, included in part, the following: Procedure 1. Enter the following information into electronic medical record. 2. Describe the specific behavior to be monitored. 3. Code the interventions determined to address the specific behavior. 4. Enter the frequency of the behavior on each shift. 5. Enter the letter code (or # code) of the intervention(s) chosen to address the behavior. 6. Enter the outcome code of the intervention(s). 1. Record review for Resident #63 revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur, Unspecified Dementia Unspecified Severity with Other…

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 address physician ordered 'As Needed' (PRN) psychotropic medications that had 'no stop date' in a timely manner for 3 of 25 sampled residents, Residents #48, #82, and #99. The findings included: Review of the facility's policy, titled, Use of Anti-Psychotic Medication, dated [DATE], included, in part, the following: To assess, monitor and manage a resident receiving an antipsychotic medication. PRN antipsychotic medications will be discontinued after the 14th day post the initial order. If the prescriber wishes to continue the medication: A face to face evaluation Documentation to include the reason the prn medication is required The benefit to the resident and ways in which the residents condition improved as a result of the prn This documentation must be in the medical record. 1. Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Unspecified Dementia…

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 medications and medication carts in a secure and sanitary manner for 2 of 3 medication carts observed during facility tours and medication administration opportunities; and failed to dispose of expired eyedrops as observed during medication storage tours. The findings included: Review of the facility's policy, titled, Storage of Medication, dated 09/2018, included in part the following: Medications and biologicals are stored properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by 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 follow their menus to meet the nutritional needs of the residents for 1 of 2 observations completed in the main kitchen. This has the potential to affect 40 residents on a regular diet. The cnesus at the time of survey was 124 residents. The findings included: Review of the facility's menu cycle, week 2, 2024 diet menu, showed the following food items on the regular diet: 3 ounces of corn beef, ½ of braised cabbage, ½ cups of boiled new potatoes, dinner roll, and pudding parfait. In an observation conducted on 05/30/24 at 11:30 AM, Staff A, Cook, was observed plating a piece of corn beef on a regular diet plate during the lunch tray line. The surveyor proceeded to request the weight of the corned beef on the plate be taken. Continued observation showed the Food Service Manager (FSD) taking the weight of the corned beef using a facility's food scale. The corned beef measured 1 ounce, which was plated earlier by Staff A on the regular diet. Another piece of corn beef was taken and placed on the food scale,…

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 food choices and preferences for 3 of 25 sampled residents during dining observations, Resident #28, Resident #64, and Resident #110. The findings included: 1. Record review showed that Resident #28 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognition was intact. In an interview conducted on 05/28/24 at 10:10 AM with Resident #28, she stated that they often make mistakes on her meal trays and do not give her the correct food items she requested. In an observation conducted on 05/29/24 at 9:00 AM, Resident #28 was in her room with the breakfast tray. The meal ticket on the tray showed the following food items: Two individual hard-boiled eggs Home fried potatoes Bagel with cream cheese A fruit plate. The continued observation showed a breakfast plate with a bagel and cream cheese, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide the correct fluid restriction for 1 of 1 sampled resident reviewed for dialysis, Resident #58. The findings included: Record review revealed Resident #58 was admitted on [DATE] with diagnoses of End-Stage Renal Disease (ESRD) and dependence on dialysis. Review of the physician's orders revealed an order for 1200 milliliters (ml) of fluid restriction with a diet of 260 ml at breakfast, 240 ml at lunch, and 120 ml at dinner for a total of 720 ml a day, dated 01/18/24. Further review of orders revealed no water was to be left at the bedside, which was also dated 01/08/24. In an observation conducted on 05/29/24 at 12:58 PM, Resident #58 was in her room with her lunch tray that consisted of the following: 8 ounces of tea and 16 ounces of water noted in a white Styrofoam cup near the lunch tray. The meal ticket for Resident #58 stated the following: Renal diet, with fluid restriction of 720 ml a day and 8 ounces of tea for lunch. 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.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 observations conducted in the central kitchen. The findings included: The first initial visit to the main kitchen was conducted on 05/28/24 at 7:25 AM. The following concerns were observed: 1. A round garbage can with an opened lid was noted in the food production area. 2. The floor around the food production area and behind the stove was noted with debris and dirt. 3. Another round garbage can with an opened circle created on top of the lid was noted in the food production area. 4. The reach-in refrigerator was noted with a large plastic container with a green lid that was not dated or labeled with the type of food inside. 5. The reach-in refrigerator had an internal thermometer located near the reach-in refrigerator indoors, which had an internal temperature of 51 degrees Fahrenheit (F) and not the recommended 40 degrees and below Fahrenheit for cold food items. 6. The reach-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.

Based on observation, interview, and record review, the facility failed to prepare an approved menu in advance and follow an approved menu to ensure the residents' nutritional needs are met for 109 facility residents in the facility, that included potentially 30 of 30 sampled residents. The findings included: 1. During the observation of the lunch meal in the main kitchen on 05/01/23 at 11 AM, the surveyor requested the approved menu for the lunch meal from the cook (Staff B). The cook replied there was not an approved menu for any of the 4-week menu cycle. The cook stated the entree for the lunch meal was Swedish Meatballs and the alternative entree was stuffed shells. The cook also stated the required entree protein serving portion of the meatballs was 3 ounces and Staff B did not know the protein portion of the Stuffed Shells. The surveyor requested the standardized recipe for the preparation of the Swedish Meatballs and Stuffed Shells. The cook stated the entrees were fully prepared frozen and required heating. The cook also stated that meatballs required a gravy to be prepared…

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, prepare, distribute and serve food in accordance with professional standards for food service safety that potentially affected 109 of the 113 facility residents and included 30 of 30 sampled residents. The findings included: 1. During the initial kitchen/sanitation tour conducted on 05/01/23 at 9:00 AM and accompanied with the Dietary Manager (DM), the following were noted: (a) A chemical test of cleaning cloth buckets noted 1 of 3 did not contain the required level of Quaternary chemical as per regulatory requirement (200 PPM). Photographic Evidence Obtained. (b) The internal cavity and internal door of the convection oven were covered with a black carbon substance and were not being cleaned on a regular basis. The DM stated the oven should have been cleaned over the last weekend. Photographic Evidence Obtained. (c) Observation of the walk-in refrigerator noted that 12 food storage shelves were heavily rust laden. It was discussed with the DM that the shelving was in need of replacement. Photographic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 2 of 3 sampled residents, Resident #36 & Resident #43, received the Notice of Medicare Non-Coverage (NOMNC) informing them of their rights to appeal termination of Medicare supported skilled services. The findings included: 1. Record review revealed Resident #36's was admitted to the facility on [DATE] with diagnoses to include: Dementia, Psychotic disturbance, and Benign Prostatic Hyperplasia. Review of the minimum data set (MDS) section C revealed that Resident #36 was rarely understood, so the Brief Interview for Mental Status (BIMS) could not be assessed. record review documented Resident #36's rehabilitation skilled services started on 03/02/23 and ended on 04/02/23. On 03/30/23, the facility issued the notice of Medicare non-coverage (NOMNC) that intended to inform the resident or representative that skilled services would be terminated. Further review of the document showed that the NOMNC was signed by the Social Service Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for activities that included measurable objectives and timeframes to meet the needs for 1 of 3 sampled residents, Resident #103, reviewed for psychosocial needs. The findings included: Record review documented Resident #103 was admitted to the facility on [DATE] with diagnoses to include Nontraumatic Subdural Hemorrhage and Respiratory Failure. Review of the Minimum Data Set assessment (MDS), section C dated 03/31/23, revealed the Brief Interview for Mental Status (BIMS) score could not be assessed, indicating severe cognitive impairment. On 05/01/23 at 10:44 AM, Resident #103 was observed in bed with no personal sensory stimulation equipment in the room. On 05/02/23 at 11:42 AM, Resident #103 was observed in bed with no activities. There were no sensory stimulation in his personal space. Review of the comprehensive care plans dated 02/10/23 and updated 04/07/23 revealed there was no plan…

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 records review, the facility failed to provide adaptive equipment to maintain, restore or improve the functional abilities of 2 of 4 sampled residents, Resident #45 and Resident #103, as evidenced by: no splint for Resident #103, and no weighted utensils and lip plate for Resident #45. The findings included: 1. Review of the Minimum Data Set (MDS) dated [DATE], for Resident #103, under section G (functional Status) and G0110 for ADL (Activities of Daily Living) Assistance documented the resident was totally dependent on staff for all ADLs. Review of the care plan dated 04/17/23 revealed: RANGE OF MOTION: The Resident has a risk or actual limitations in Range of Motion as evidenced by; Requires Splinting Application to left hand (resting hand splint). The Resident: Will have none to minimal pain, discomfort at acceptable level, Limitation will not interfere with daily functions. Will remain free of injuries or complications related to limitations of range of motion. Will…

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 upon interview, record review, and observation, the facility failed to provide fingernail care for 2 of 2 sampled residents observed for Activities of Daily Living (ADLs), related to lack of fingernail care for Resident #103, and Resident #315. The findings included: The facility Policy and Procedure, titled, ADL [Activities of Daily Living]: Assistance, effective date July 2022, had 3 steps. Step three listed the ADLs that staff may perform for or with the resident. Item d. listed Nail Care. 1. Record review documented Resident #315 was admitted on [DATE]. The Minimum Data Set (MDS) admission assessment was completed 04/18/23 that documented Resident #315 had a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating Resident #315 was cognitively intact. In Section G of the MDS, ADLs, under Item J, Personal Hygiene, Resident #315 was identified as needing extensive assistance with a one person assist. Review of the care plan for Resident #315 documented a focus, titled, SKIN INTEGRITY RISK:…

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 records review, the facility failed to provide ongoing person-centered activities designed to meet the interest and the psychosocial well-being of 3 of 20 residents, Residents #35, #36 and #103, reviewed for activities. The findings included: 1. Record review for Resident #35 documented diagnoses to include Dementia, unspecified, Major Depressive Disorder, and Schizoaffective Disorder. Review of the care plan dated 03/02/23 documented an outlined activity plan that included: Activities: The resident needs encouragement to pursue activities of choice. Little interest or pleasure in doing things, prefers to stay in room. o Resident will participate in activities of choice/ will accept materials for in room type activities. o Encourage to participate with activities of choice o Prefers/ would benefit from: General Activities Program o Prefers / would benefit from: In Room Activities o Preferred Activity Times: Morning o Preferred Activity Times: Afternoon o Preferred Activity…

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 adequate supervision and assistance to prevent smoking accidents, for 1 of 1 sampled resident, Resident #20. The findings included: Review of facility's Policy and Procedure, titled, Smoking/Tobacco Use (Effective October 2021, documented, in part: Employee Expectation: < Monitor residents in the smoking area. < Ensure appropriate adaptive smoking equipment is available and in use for residents as care planned. < Clean smoking apron after each use Procedure: < Initiate and complete admission data Collection and Initial Plan of Care Quarterly Date Collection Form Smoking Safety: < Staff member assigned to the smoking area will monitor the area to conduct walking rounds to observe and intervene for safety issues and to provide oversite and intervention when appropriate. < Provide the smoker with assistance and safety devices indicated. < Donning a smoking apron that is deemed necessary by the IDT. < The assigned staff member should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to perform catheter care using appropriate professional technique, for 1 of 1 sampled resident, Resident #315. The findings included: The facility used a competency checklist instead of a policy/procedure to ensure perineal care/catheter care is performed correctly. The competency checklist step 5 stated: Cleans top of over bed table and places a barrier on tabletop. Step 9 indicates the staff is to perform hand hygiene. Steps 10 through 12 discuss positioning of the resident and preparing the wash basin with warm water. Step 13 verifies that staff has put on gloves. Step 14 verifies that staff has covered the resident with a bed sheet or bath towel. Step 15 indicated the staff is to place a protective barrier under the resident's buttocks. For a male resident the checklist indicates that the perineal area should be dried using a blotting motion from top to bottom. Resident #315 was admitted to the facility on [DATE] with an indwelling…

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 review of policy and procedure, observation and interview, the facility failed to ensure that it secured the resident's medications for 2 of 5 sampled medications carts observed, the North and South medication carts; failed to secure loose pills in one (1) of five (5) medications carts observed [NAME] medication cart; failed to discard expired wound care dressing in one (1) of three (3) treatment carts, [NAME] wing; and failed to discard expired Sunscreen lotion in Central Supply Room. The findings included: Review of the facility policy and procedure on [DATE] at 2:30 PM, titled, Medication Storage, provided by the Director of Nursing (DON), reviewed 2007, documented, in part, in the Policy Statement: Storage of Medication - Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to the licensed nursing personnel,…

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 record review, the facility failed to provide ongoing dental services to 1 of 1 sampled resident, Resident #103. The findings included: Record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses that included: Nontraumatic Subdural Hemorrhage; Respiratory Failure; and cognitive communication deficit. Review of the Minimum Data Set assessment (MDS), section C dated 03/31/23, revealed the resident had severe impaired cognition. A Brief Interview for Mental Status score could not be determined. On 05/01/23 at 10:45 AM, Resident #103 was observed with noticeable bleeding gum and concerning dental hygiene issue. Further observation conducted on 05/03/23 at 11:19 AM showed evidence of blood in the resident's mouth and blood covered Resident #103's upper incisors. Review of the Medication observation record for the month of April and May 2023 revealed that staff performed daily oral hygiene as recommended by the resident's physician (morning and night). Review 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 observation, record review, and interview, the facility failed to accommodate individual food preferences for 5 of 5 sampled residents, Residents' #10, #13, #40, #55, and #86. The findings included: 1. Review of clinical record of Resident #10 on 05/03/23, revealed an admission date of 03/30/12 with diagnoses to include DDiabetes Mellitus Type 2 (DM 2), Chronic Kidney Disease, and Left & Right Leg AKA (Above knee amputations). Review of the Minimum Data Set assessment (MDS) of 01/30/23 documented: Sec B: Understood and Understands. Sec C: Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. Sec D: Mood - Poor Appetite, Trouble Concentrating, Sec G: Eat = Supervision/Set Up Only Sec K: NO Swallow Disorder Therapeutic Diet. Review of the updated MDS - Annual / Significant Change assessment, dated 05/23/23 noted: Sec C: BIMS Score changed to a 12. Observation and interview conducted with Resident #10 on 05/03/23 at 9:00 AM, noted the resident to be alert, oriented and able…

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.