The Bristol Care Center

Based on observations, interviews and record review the facility failed to follow infection control standards related to hand sanitizing during medication administration and use of gloves when cleaning equipment for five residents (#52, #63, #58, #31, and #219) out of sixty-five residents sampled. Findings included: During an observation on 06/23/2025 at 9:05 a.m., Staff B, Registered Nurse (RN) was administering medications to Resident #52. Staff B stated she had already washed her hands. She opened her computer, then the medication drawer and removed the Dorzolamide HCL solution 2% eye drops inside a baggie. She removed the eye drop bottle from the baggie and placed it on a plate/barrier. Staff B applied gloves and entered the resident's room. She gave the resident a tissue. She placed a drop of eye medicine into each eye. She placed the eye drop medication back on a plate/barrier. She took the tissue from the resident and threw it away. Staff B, RN removed her gloves and threw them away, she did not perform hand hygiene. Staff B, RN exited the room to the medication cart. She…

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 patient care equipment to include mechanical lifts were maintained in a safe operating condition for one resident (#142) of 65 sampled.Findings included: On 6/23/25 at 3:52 p.m., an interview was conducted with Resident #142. She was observed sitting up in bed, watching television. She stated she had an incident about a month and a half ago. Resident #142 said she fell from the Hoyer lift. She stated, The Hoyer locked, and the certified nursing assistant (CNA) didn't realize it. She said she went to hospital as a result of the fall as she was in a lot of pain. Resident #142 confirmed the Director of Nursing (DON) said the Hoyer needed to be removed, but it was not. She said the same Hoyer that was used during the incident was being used currently. She said the CNAs complained to her about that Hoyer lift. Resident #142 stated, It's happened where it's locked, they have to kick the wheel to align it. It [Hoyer lift] has jerked before, but this was a hard jerk. A review of Resident #142's admission record revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one resident (#1) out of three residents sampled were assessed immediately by a nurse after being found on the floor by facility staff. Findings included: Review of an admission Record dated 5/6/2025 showed Resident #1 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to nontraumatic intracerebral, hemorrhage in hemisphere, subcortical, and flaccid hemiplegia affecting right dominant side. Review of a Nurse Progress note dated 4/22/2025, authored by Staff A, Registered Nurse (RN), showed The [Certified Nursing Assistant,] CNA found the resident lying in the resident restroom. The CNA stated that two CNA placed the resident on the toilet as resident requested and 5 min[utes] later they found the resident on the floor in the resident restroom. It was noted when the nurse entered the resident's room, she observed the CNA lifting the resident to bed. The nurse assessed Resident #1 for pain or injuries after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide physician ordered medication for one resident (#1) out of three residents reviewed. Findings included: Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and discharged on 4/23/25. His medical diagnoses included nontraumatic intracerebral hemorrhage in hemisphere, subcortical and flaccid hemiplegia affecting the right dominant side. Review of Resident #1's hospital discharge medication list revealed Pregabalin 75 mg [milligrams] oral capsule three times a day. Next dose: 4/21/25 at 8:00 PM. Review of Resident #1's April 2025 physician orders revealed an order with a start date of 4/22/25 and an end date of 4/23/25 for Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth three times a day for neurogenic pain due to central nervous system. Review of Resident #1's April Medication Administration Record revealed in five out five medication administration opportunities, Resident #1 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for five (#228, #145, #163, #25 and #60) of eight residents reviewed for PASRRs. Findings included: 1. Review of Resident #228's admission record revealed an admission date of 12/23/24 with the following diagnoses: Generalized anxiety disorder, upon admission dated 12/23/24 Bipolar disorder diagnosis upon admission dated 12/23/24. Depression diagnosis upon admission dated 12/23/24. New diagnosis of brief psychotic disorder was added on 01/22/25. The review showed the level I PASRR was not updated, and a level II was not submitted for consideration. On 01/28/25 at 3:38 p.m., an interview was conducted with the Social Services Director (SSD). She stated the expectation was to review PASRRs upon admission, and update when the resident has a new…

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 needed care and services for one resident (#200) of three residents reviewed with an immune deficiency syndrome, one resident (#170) of two residents reviewed for therapy services, and one resident (#60) of two residents reviewed for maintaining routine lab work. Findings included: 1. During an interview on 01/27/25 at 10:37 a.m., Resident #200 stated, the last time the doctor was at the facility, I had to beg the doctor to order blood work to see if my antiretroviral therapy medication was working for my [immune deficiency syndrome]. The facility completed my blood work, but I still have not heard any results yet. Review of the admission Record showed Resident #200 was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified cirrhosis of liver, severe protein-calorie malnutrition, immune deficiency syndrome, pancytopenia, acute kidney failure and candidal stomatitis. Review of the Medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to screen one (#123) resident for orthotic use and failed to apply orthotics for two (#14 and #31) of 23 residents. Findings included: 1. On 1/27/25 at 10:22 a.m., Resident #123 was observed lying in bed with the head of the bed raised. The observation showed a left-hand brace/splint lying on the bedside dresser out of reach of the resident. The resident reported previously wearing the orthotic device when on therapy. The resident stated nobody puts it on now, don't have anyone to put it on me, and reported his niece put it on him last Thursday. On 1/28/25 at 8:55 a.m., Resident #123 was observed lying in bed with orthotic on bedside dresser. Review of Resident #123's admission Record revealed the resident was admitted on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, unspecified rheumatoid arthritis, and unspecified site unspecified…

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

Based on observations, interviews and record review, the facility failed to ensure the medication error rate was less than five percent. Twenty-nine medication administration opportunities were observed, and four errors were identified for two residents (#135 and #220) out of five residents observed. These errors constituted a 13.79% medication error rate. Findings included: 1. On 01/29/25 at 9:15 a.m., an observation was made of Staff G, Licensed Practical Nurse, (LPN). Staff G dispensed the following medication for Resident #135: - Calcium Carbonate 750 milligram (mg) chew tablet Upon entering the resident room, Resident #135 was alert. Staff G administered the medication, performed hand hygiene, and exited the room. Review of Resident #135's Active orders revealed the following order related to the observed administration of medications: - Calcium Carbonate Oral Tablet 600 mg (Calcium Carbonate) Give 1 tablet by mouth one time a day for supplement On 01/30/25 10:50 a.m., an interview with the Director of Nursing (DON) was conducted. She stated during medication administration,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to obtain consent prior to utilizing funds for one resident (#46) of two reviewed. Findings included: During a telephone interview on 01/27/25 at 2:05 p.m., Resident #46's Responsible Party (RP) and POA (Power of Attorney) stated he was upset. He said, The facility owed her [Resident #46] $3000. They bought her a new chair without consent. The RP stated the resident was incapacitated and she did not move, she was in bed 24 hours a day, 7 days a week and does not utilize the new chair. He stated, the facility had to spend her money, for whatever reason and thought they could decide on their own. The RP stated he was the designated RP. He stated the facility did not ask if they could purchase the chair. The RP stated he wanted the facility to reimburse the account because that was not a wise use of Resident #46's money, as she was recently enrolled in hospice. The POA said, I did not authorize the purchase. He stated he had spoken with the Business Office…

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 act upon a resident's concerns and grievances for one (#102) of four residents reviewed. Findings included: During a facility tour on 01/27/25 at 10:11 a.m., Resident #102 stated she was missing some clothes. The resident said she had a closet full of clothes and was missing a couple pairs of pants and undershirts. Resident #102 said, They are gone. I told the laundry lady. The resident stated it had been a while ago, may be three weeks or so. 01/28/25 at 2:23 p.m., Resident #102 stated her clothes were still missing. She stated the family had brought them in. Review of the admission record showed Resident #102 was admitted to the facility on [DATE] with a primary diagnosis of unspecified fracture of right femur. Review of a quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #102 had a Brief Interview for Mental Status (BIMS) Score of 11, which indicated moderate impairment. On 01/29/25 at 4:30 p.m., an interview was conducted with 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, review of reported incidents, and interviews, the facility failed to ensure a thorough investigation was conducted for one (#188) of four allegations of abuse related to a staff member allegedly slapping the resident. Findings included: On 1/27/25 at 9:48 a.m. Resident #188 was observed lying in bed, on a long-term care unit, with a blanket over her head and body, one foot was observed outside of the blanket. On 1/27/25 at 1:59 p.m., Resident #188 was observed and interviewed in her room with her significant other at the bedside and roommate lying in the next bed. The resident voiced nobody had hit or talked bad to her. The resident's significant other left room and the resident covered her head with a blanket, allowing for the interview to continue. The resident reported no concerns with care as the significant other returned. Review of a facility reported incident (Nursing Home Federal Report Form v1.0), showed on 12/2/24 at 3:52 p.m. Resident #72 (the roommate of Resident #188) informed…

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 assess a resident within the three months required for one (#196) of three residents reviewed for submission of the quarterly Minimum Data Set (MDS). Findings included: Review of the admission Record showed Resident #196 was admitted to the facility on [DATE] with diagnoses that included but not limited to cerebral infarction, confusional arousals, white matter disease, cognitive communication deficit and major depressive disorder, recurrent mild. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed a completion date of 01/03/25. During an interview on 01/29/25 at 5:44 p.m., Staff A Registered Nurse (RN) Minimum Data Set (MDS) Coordinator stated Resident #196's quarterly MDS dated [DATE] was closed late. Staff A stated there was a certain date that the MDS had to be closed by and if it was closed even one second past midnight, it was considered late. Staff A stated the Quarterly MDS dated [DATE] was closed on 01/03/25 and then not…

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

Based on observations, record reviews, and interviews, the facility failed to submit one (#188) of forty-one initially sampled residents for a Level II Pre-admission Screening and Resident Review (PASRR). Findings included: On 1/27/25 at 1:59 p.m., Resident #188 was observed lying in bed with significant other at bedside. The resident allowed an interview regarding an abuse allegation and when the significant other left the room, the resident covered up her head with a blanket. Review of Resident #188's admission comprehensive assessment, dated 6/18/24 revealed the resident had not been evaluated for a Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The assessment revealed active psychiatric/mood admission diagnoses of depression other than bipolar and manic depression (bipolar disease). Review of Resident #188's Level I PASRR, dated 12/15/23 uploaded into clinical documents showed the resident had been requesting admission to another non-local facility. The PASRR had been completed by the requested non-local facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#123 and #283) of four sampled for Activities of Daily Living received showers per plan of care and choice. Findings included: 1. On 1/27/25 at 10:24 a.m., Resident #123 was observed lying in bed. The resident reported wanting a shower, as bed baths don't get it. The resident stated his last shower was before transferring to his current room and he stopped asking why he could not have a shower. Review of Resident #123's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, unspecified rheumatoid arthritis, and unspecified osteoarthritis unspecified site. Review of Resident #123's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 of 15, which indicated intact cognition. The functional ability of the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure urinary drainage bags and tubing for two (#91 and #18) of 16 residents with urinary catheters were stored in a manner to prevent infections. Findings included: 1. On 1/27/25 at 1:46 p.m., Resident #91 was observed sitting in a wheelchair in the unit's common area. The resident's urinary drainage bag was hanging from the wheelchair frame under the seat with the catheter tubing lying on the floor. Staff O, Registered Nurse (RN) confirmed the tubing was dragging on the floor as the staff member began to assist the resident into the unit's shower room to adjust the tubing. Review of Resident #91's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to presence of urogenital implants and other retention on urine. Review of Resident #91's January Treatment Administration Record (TAR) revealed staff were to ensure the resident had a securing device for urinary catheter, were to perform…

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 a physician order was available prior to providing oxygen administration for one resident (#150) of three residents reviewed for oxygen administration. Findings included: An observation on 01/27/25 at 11:00 a.m., revealed an oxygen concentrator with nasal cannula hanging from the concentrator located at Resident #150's bedside. Review of the admission Record showed Resident #150 was admitted to the facility on [DATE] with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD), unspecified, ataxia, heart failure and major depressive disorder, recurrent, moderate. Review of the physician orders showed no current physician order for oxygen administration. Review of the care plan showed Focus- [Resident #150] has a potential for complications of respiratory distress related to dx (diagnosis) of: COPD and [head of bed] HOB elevated becomes shortness of breath while lying flat. Goal: - Resident will be…

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, policy review, and interviews, the facility failed to ensure dishes and utensils were air dried and food trays were in good condition in one of one kitchen. Findings included: On 11/27/23 at 9:25 a.m. an initial tour of the kitchen was conducted. There were four black food trays (two each stacked on top of one another) and on each food tray there were 8 oz cups with visible water spots sitting on the food preparation table across from the steam table. Underneath the food preparation table was a stack of worn black and blue food trays. The middle of the sides and lips of the trays were observed to have a cream and brown caked corrosive type substance on them. (Photographic Evidence Obtained) Staff A, Cook, stated the trays were used for desserts. On 11/29/23 at 11:10 a.m. a staff member was observed placing utensils (forks, spoons, and knives) with visible water spots on food trays during lunch. The utensils (forks, spoons, and knives) were observed on a gray cart in individual compartments, and they were all wet. The Certified Dietary Manager (CDM) confirmed…

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

Based on interview and record review, the facility failed to follow-up on concerns, complaints and/or grievances identified during three Resident Council meetings (September 2023, October 2023, and November 2023) of five Resident Council meeting minutes reviewed. Findings included: During a Resident Council meeting conducted on 11/28/2023 from 10:00 a.m. to 11:00 a.m. with Residents #83, #88, #166, #6, #133, #155, #53, and #30, the residents said when a grievance or concern is identified at a Resident Council meeting, the facility does not follow-up. Review of the Resident Council meeting minutes revealed the following: -September 2023: Resident expressed her tray was missing an item - she was encouraged to notify the CNA [certified nursing assistant] or Nurse. Resident expressed concern with room furniture. -October 2023: Resident expressed missing belongings from her room. Resident was advised to put in a grievance. -November 2023: Resident expressed concern for lost cell phone. Resident advised to put in a grievance. Resident expressed missing a piece of clothing. Resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis and/or ensure the accuracy of a PASRR Level I for eight residents (#27, #48, #68, #92, #140, #154, #188, #200) of 10 sampled residents with mental health diagnoses. Findings included: 1. Review of the admission Record revealed Resident #68 was admitted to the facility on [DATE] and with a readmission on [DATE] with a primary diagnosis of orthopedic aftercare following surgical amputation. Further review of the admission Record revealed subsequent diagnoses that included recurrent major depressive disorder as of 04/24/2023 and bipolar disorder as of 04/18/2023. Review of the admission Minimum Data Set (MDS), dated [DATE], for Resident #68 under Section I - Diagnoses showed diagnoses of depression and bipolar disorder; and Section N - Medications revealed antidepressant medications were received during…

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 Review of admission Record showed Resident #57 was initially admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Embolism and Thrombosis of other specified veins, Difficulty walking, not elsewhere classified, Chronic Obstructive Pulmonary Disease, Insomnia and Parkinson's Disease. A physician order dated 04/07/21 showed, Oxygen 2 L/min per nasal cannula as needed to keep oxygen sats above 92% A second physician order dated 04/14/23 showed May leave on LOA [leave of absence] independently. The Quarterly Minimum Data Set (MDS) showed a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). Review of Resident #57's care plan showed a focus of [Resident #57] has a history of smoking in the community and wants to continue smoking while at the facility. Smoking with supervision. The goal showed, [Resident #57] will safely smoke in designated areas at scheduled times through next review date. The interventions included: Assist him with lighting his…

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 7. Review of the admission Record for Resident #48 showed an admission to the facility on 8/29/23 with diagnoses to include unspecified dementia, unspecified severity without behavioral disturbance, major depressive disorder, and unspecified mood (affective) disorder. Review of the Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating severe cognitive impairment and or nonsensical verbal response. Review of Resident #48's active physician orders as of 11/30/23 revealed: - an order with a start date of 8/29/23 for Donepezil HCL 10 milligrams (mg) with the following instructions: Give one tablet by mouth at bedtime for dementia. - an order dated 8/30/23 for Duloxetine HCL delayed release particles 60 mg with the following instructions: Give two tablets by mouth one time a day for depression. - an order dated 9/29/23 for Seroquel 100 mg tablet with the following instructions: Give 100 mg by mouth two times a day for…

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

Based on observations, interviews and record reviews the facility failed to implement and maintain an infection prevention and control program related to medication administration by four staff members (D, E, G and H) for five residents (#73, #93, #96, #103, #137) of six sampled residents; cleaning and disinfecting of a glucose monitoring machine for one resident (#137) of one sampled resident of six sampled residents; and staff failed to offer hand hygiene to residents before meals in one of one secured unit for three days (11/27/23, 11/28/23 and 11/29/23) of three days observed. Findings included: 1. On 11/29/2023 at 8:45 a.m. Staff D, Licensed Practical Nurse (LPN) was observed administering medications to Resident #103. Staff D removed the blood pressure cuff from the medication cart without cleansing it prior to or post its use. Staff D placed the cup filled with oral medications, the nebulizer medication as well as the Serevent diskus on Resident #103's overbed table without a barrier or cleansing of the table. After administering the medications, Staff D removed her 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 ensure two residents (#30 and #203) were treated with respect and dignity out of fifty eight residents sampled. Findings included: 1. During an interview on 11/30/23 at 8:50 a.m. Resident #30 stated, Staff S, Certified Nursing Assistant (CNA) woke him up at about 6:00 a.m. Staff S told me I had to get up. Resident #30 stated, I do not like to get up until about 8:30 a.m. Resident #30 reported telling Staff S No, Resident #30 stated he continued to tell Staff S he did not want to get up; however, Staff S ignored his requests and pulled him by his arms to a seated position on his bed causing bruising. Review of Staff S's, CNA witness statement, dated 11/20/23, showed, 530 AM second to last person I take care of. Usually I leave him until last because he don't like to be changed. Came in room with stuff to change him. He was sleeping and I turned on the lights [Resident #30] eyes open and repositioned himself he yelled at me turn lights off. I went 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 and interviews the facility failed to ensure housekeeping and maintenance services maintained a safe and sanitary homelike environment related to a one resident's (#149) toilet with a rust like substance and ceilings in disrepair (Southwest Wing) in a resident occupied area in one of five wings. Findings included: An observation was conducted on 11/27/23 at 10:42 a.m. of Resident #149's toilet. On the top back portion of toilet where the pipe meets the toilet there was a rust-colored substance on the toilet. The screws on the bottom of the toilet also had a rust-colored substance. Resident #149 said, I've taken pictures of it and reported it and I've had the nurses and the Unit Manager look at it. They say they're going to tell someone, and nothing happens. The resident confirmed she uses the toilet. (Photographic Evidence Obtained) Review of Resident #149's Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a prompt effort was made to resolve a grievance voiced by one resident (#137) out of one resident reviewed for grievances related to care and treatment. Findings included: During an interview on 11/27/23 at 10:12 a.m. Resident #137 stated, My family brings me diapers, but there have been times I go to sleep and they get taken. Resident #137 stated when she was in need of a brief, the ones she bought were gone, so someone must have taken them from her room while she was asleep. Resident #137 stated she had informed staff of this multiple times but no one had done anything about it. Review of the Facility's Grievance Logs from September 2023 to November 2023 showed no grievances related to Resident #137's missing briefs. Review of the admission Record showed Resident #137 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, single episode, moderate. Review of the active care plans for Resident #137 revealed:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and implement an effective discharge plan to meet the needs and goals for one resident (#190) out of the sampled four residents. Findings included: On 11/27/23 at 12:20 p.m., Resident #190 reported he wanted to leave the facility. He stated staff were looking for an Assisted Living Facility (ALF) to transfer him to, but he does not want to go to an ALF. The resident asked, Why can't I just walk out of the door? Resident #190 stated he can work and wants to work. He was working prior to coming to the facility and he was very good with his hands. Review of the admission Record showed Resident #190 was initially admitted to the facility on [DATE] with diagnoses to include hypertensive urgency and inadequate housing. Review of Section C - Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #190 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating cognitively intact. A progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the code status accurately reflected the Advance Directive wish for one resident (#219) out of 58 sampled residents. Findings included: Review of Resident #219's admission Record revealed he was admitted to the facility on [DATE]. His medical diagnoses included metabolic encephalopathy, dementia, major depressive disorder, hypertension, and urinary tract infection. Review of Resident #219's active physician orders revealed an order, started on 11/8/23 and without an end date, for FULL CODE (full resuscitative measure). Review of Resident #219's care plan, with an initiation date of 11/9/23, revealed [Resident #219] has expressed the following wishes regarding code status and has the following advance directives in place: is DNR [do not resuscitate], HCS [health care surrogate], DPOA [Durable Power of Attorney], HIPPA [health insurance portability and accountability act] and LW [living will]. The goal revealed, resident wishes regarding code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure the provision of respiratory care was in accordance with professional standards of practice for three residents (#61, #322, and #102) of the three sampled residents receiving oxygen therapy. Findings included: 1. A review of the admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD (chronic obstructive pulmonary disease), respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C - Cognitive Patterns of the Quarterly MDS, dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J - Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to monitor medication parameters for two residents (#73 and #27) out of the sampled eight residents. Findings included: 1. A review of the admission Record showed Resident #73 was initially admitted into the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hyperlipidemia, chronic pain syndrome, and hypertension. A review of the Order Summary Report indicated the following active order as of 11/30/23: Diltiazem HCl Oral Tablet 120 MG (milligram)- Give 1 tablet by mouth two times a day for hypertension. Hold for heart rate less than 65. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2023 showed parameters were not monitored prior to or at the time the medication was administered. There was no documentation related to the heart rate prior to or at the time the medication was administered at 6:30 a.m. and 4:30…

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

Based on observation, interview and record review the facility failed to ensure medications were stored in a locked medication cart and not left at bedside for one resident (#103) of six sampled residents for medication administration observations. Findings included: On 11/29/2023 at 8:45 a.m. Staff D, Licensed Practical Nurse (LPN) was observed administering medications to Resident #103. Staff D placed the cup filled with oral medications, the nebulizer medication as well as the Serevent diskus on Resident #103's overbed table without a barrier or cleansing of the table. After administering the medications, Staff D removed her gloves, left the room and returned to the medication cart without hand sanitizing. Further observation showed Staff D had left the Serevent diskus on Resident #103's overbed table after leaving the room. On interview Staff D stated she was not supposed to leave the medication in the resident's room. Staff D stated, So, sorry. Staff D re-entered the resident's room and removed the Serevent diskus and replaced it in the medication cart, without cleansing 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.

Based on observation, interview and record review the facility failed to ensure professional standards and practices were followed related to accurate documentation on a Medication Administration Record (MAR) for one resident (#137) of 58 sampled residents. Findings included: On 11/29/23 at 10:40 a.m. Staff G, Licensed Practical Nurse (LPN) was observed performing glucose monitoring for Resident #137. Staff G, LPN cleaned Resident #137's right middle finger with alcohol and pricked the area with a glucometer. The blood glucose level was 174. Staff G walked down the hallway to the other medication cart (Cart 2) to obtain the insulin needed for blood glucose coverage for Resident #137. Staff B, LPN applied gloves and removed the insulin pen from medication Cart 2 and placed it on a barrier. Staff B primed the insulin pen and drew up the ordered 2 units for coverage. Staff G, LPN returned to Resident #137's room with the insulin pen and administered the insulin into Resident #137's left arm. Staff G then walked down the hall to Staff B and medication Cart 2. The insulin was returned to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure hospice services were being provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for one resident (#191) of one resident reviewed for hospice. Findings included: On 12/01/23 at 9:24 a.m. Resident #191 stated he had no concerns with hospice and two ladies came to visit him recently from hospice. A medical record review was conducted for Resident #191 for hospice services. A review of the admission Record showed Resident #191 was initially admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of unspecified part of left bronchus or lung. Review of Section C - Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. Review of Section O - Special Treatment, Procedures, and Programs showed Resident #191 was 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.