Legacy Transitional Care & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of the electronic medical record (EMR) for R243 revealed he was admitted to the facility with diagnoses including but not limited to gastrostomy status, acute respiratory failure, seizures, encephalopathy. Review of the most recent admission Minimum Data Set (MDS) dated [DATE] documented R423 had a Brief Interview for Mental Status (BIMS) score of 00, indicating resident was severely cognitively impaired. Review of the Care Plan for R243 revealed a care plan dated 3/12/2025 that documented the resident to Monitor/document/report to MD PRN (as needed): aspiration- fever, SOB, tube dislodged, Infection at tube site, self-extubation, Tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. Provide local care to gastrostomy site (G-Tube) as ordered for signs and symptoms of infection. Review of the Physician orders for R243 dated 4/4/2025 documented Enteral feed order…

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, staff interviews, and review of the facility's policy titled Dating, Labeling, and Discarding Food, the facility failed to discard food items by the expiration or use-by date, failed to discard food items with a fuzzy green substance on it, and failed to ensure dietary staff wore beard coverings while in the kitchen. The deficient practice had the potential to place the 176 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility's policy titled Dating, Labeling, and Discarding Food, revised January 2023, included Dating, labeling, food stored in the coolers, dry storage and freezers ensure the safety of the food that will be served to the residents. According to the 2022 Food Code, food that is RTE (Ready to Eat), Refrigerated and/or Time/Temp Control Food (food that contains ingredients that may cause food poisoning) MUST have an OPEN (or Prepared) Date and a USED BY (or DISCARD) date on each of these foods. The USED BY date that the FOOD CODE is referring to is not the use by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Administration of Medications, the facility failed to ensure one of 60 sampled residents (R) (R684) was assessed to safely self-administer medications. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the policy titled Administration of Medications reviewed October 2024 revealed under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Revealed under Procedure: All medications are administered accurately and safely, and free of errors. 1. Only licensed nurse or person permitted by the state to prepare, administer, and document the administration of medications may do so.14. Patient may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have…

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, staff and resident interviews, and review of the facility's policy titled, Advance Beneficiary Notice Policy, the facility failed to appropriately provide the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to one of 60 sampled residents (R) (R125). This failure had the potential for R125 not to be able to express her right to make an informed choice about Medicare services as well as being provided with appeal instructions. Findings include: Review of the facility's policy titled Advance Beneficiary Notice Policy revised May 2018 revealed under Policy Statement: It is the policy of this facility to issue Advance Beneficiary Notices (ABN) per CMS Guidelines to inform Medicare Beneficiaries of items or services that Medicare may not pay. Review of the electronic medical record (EMR) for R125 revealed she was admitted to the facility with diagnoses of but not limited to orthopedic aftercare following surgical amputation. 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 observations and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment for two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on two of four units. Specifically, room [ROOM NUMBER] contained a circulating fan with gray substances on its blades and a privacy curtain caught in the fan blades, and room [ROOM NUMBER] had a dirty, damaged bathroom ceiling with black stains. The facility census was 181 residents. Findings include: 1. Observations during initial screening on 11/5/2024 at 11:05 am and on 11/6/2024 at 3:28 pm revealed a personal circulating fan blowing towards bed A in room [ROOM NUMBER], with thick, gray substances on its blades and a privacy curtain caught in the fan blades. Interview and observations during walking rounds on 11/8/2024 at 12:30 pm and 2:30 pm with the Maintenance Director (MD) and Administrator confirmed a circulating fan with gray substances on its blades and a privacy curtain caught in the fan blades in room [ROOM NUMBER], and…

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

Based on record review and staff interview, the facility failed to attempt to obtain fingerprint checks for four of 10 files reviewed and reference checks for two of 10 employee files reviewed. Findings include: Review of the employee files on 11/7/2024 at 1:00 pm with the Assistant Nursing Home Administrator and the Assistant Director of Nursing (ADON) revealed that there were no fingerprint results for staff who required completion of the GCHEXS (Georgia Criminal History Check System) (fingerprint background check). In addition, there were also no reference checks completed for staff who did not require GCHEXS fingerprint of the 10 staff reviewed. 1. The Administrator was hired on 9/18/2023, no evidence of reference checks performed. 2. Certified Medication Aide (CMA) GGG was hired on 1/16/2024, no evidence of GCHEXS fingerprint results and no references checked. 3. Certified Medication Aide (CMA) HHH was hired on 8/9/2024, no evidence of GCHEXS fingerprint results and no references checked. 4. Certified Nursing Assistant (CNA) III was hired on 7/16/2024, no evidence of GCHEXS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of the facility policy titled, Preadmission Screening and Annual Resident Review (PASRR) (Preadmission Screening and Resident Review), the facility failed to refer a Level Il PASRR to the appropriate state-designated authority for evaluation and determination of specialized services for one of 60 sampled residents (R) R171) reviewed with serious mental illness. The deficient practice had the potential to affect the appropriate level of care and services provided for R171. Findings include: Review of the facility's policy titled, Preadmission Screening and Annual Resident Review (PASRR), revised November 2017 states that Annually and with any significant change of status, the facility will complete the PASRR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure that ADLs were provided for two of 60 sampled residents (R) (R65 and R154) related to nail care. Specifically, nail care was not provided for R65 and R154. Findings include: Review of the policy titled Activities of Daily Living (ADLs) dated November 2022, the intent of policy indicated based on the comprehensive assessment of a resident and consistent with resident's needs and choices this facility will provide necessary care and services to ensure that a resident's ability in activities of daily living will not diminish unless the circumstances of the individual's clinical and medical condition demonstrate that such diminution was unavoidable. Also, the bath will be given for cleanliness, increased circulation, and comfort of the residents at least weekly, the skin will be observed during bath. 1. Review of the electronic medical 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.

Based on observations and staff interviews, the facility failed to ensure the dumpster area was maintained in sanitary conditions. The deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food, leading to foodborne illness. Findings include: During the initial observation on 11/5/2024 at 8:15 am, the dumpster area had discarded items such as gloves, plastic forks, cardboard, a chair, and combs on the ground surrounding the two dumpsters. In an interview on 11/5/2024 at 9:15 am, during the observational walk-through with the Dietary Manager (DM), the DM confirmed the dumpster area had discarded items on the ground. The DM stated that everyone used the dumpsters, but the maintenance department was responsible for overseeing the site to make sure the area was maintained in a sanitary manner. In an interview on 11/8/2024 at 9:07 am, the Maintenance Director stated everyone shared the responsibility of ensuring the dumpster area was clean and maintained in sanitary conditions. He stated no one department or person was responsible 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 and staff interviews, the facility failed to ensure reusable medical equipment was cleaned between use for residents. The deficient practice had the potential lead to the spread of infection and illness. The facility census was 181 residents. Findings include: Observation on 11/6/2024 at 8:05 am during medication administration revealed Certified Medication Aid (CMA) DD obtained a blood pressure machine from the hallway, checked a resident's blood pressure with the machine, and returned the blood pressure machine to the hallway without cleaning the cuff or equipment. Observation on 11/6/2024 at 8:44 am during medication administration revealed CMA EE checked a resident's blood pressure with the unit blood pressure cuff and returned the blood pressure cuff to the medication cart drawer without cleaning the equipment. Continued observation revealed CMA EE used the same blood pressure cuff to check another resident's blood pressure without cleaning the equipment. In an interview on 11/6/2024 at 8:05 am, CMA DD revealed all reusable medical equipment should 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, staff interviews, and review of the facility's policies titled, Receiving and Storage and Service Line Refrigerated Leftover Storage, the facility failed to ensure food items were properly labeled, discard expired foods, and to ensure the inside of the ice machine was clean and free from residue. Specifically, the facility failed to ensure opened and frozen food items were properly labeled and dated and leftover food was properly covered and to ensure that kitchen equipment used for food preparation and storage was kept clean and sanitary. The deficient practice had the potential to affect 179 of 179 residents receiving an oral diet from the kitchen. Findings include: Review of the undated facility policy titled Receiving and Storage under the section titled Policy, Receiving revealed Receiving is the point at which foodservice operation inspects and take legal ownership and physical possession of items ordered. Its purpose is to ensure that the food and supplies delivered match the established quantity and quality specifications. The section titled Storage…

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, resident and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for 11 of 84 resident rooms and 10 of 48 bathrooms and for two of 66 sampled residents (R) (R128 and R428), R128 who had mobility issues from loose handrailing and R428 who had food splattered on their tube feeding pump. Specifically, resident bathrooms contained gaps behind the toilet, stopped up sinks, sinks loose from the wall, damaged faucet, ceiling damage, holes in the floor, and leaks around base of toilet and broken paper toilet paper dispenser with a sharp edge, Additionally, resident rooms and hallways contained stains on the ceiling, broken lighting behind the bed, dim lighting, wall scratches behind the bed, broken bedside table, damaged base boards, damaged packaged terminal air conditioner (PTAC) unit, drawer to dresser missing, loose handrails, door frame damage, privacy curtain off hooks, call light not working, several floor tiles missing, damaged ceiling, missing…

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

Based on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Policy, the facility failed to ensure pre-employment screening, specifically fingerprints for two of 10 staff reviewed. Findings include: Review of the facility policy titled Abuse Prevention Policy last reviewed May 2024 revealed Background, reference and credential's checks should be conducted on employees prior to or at the time of employment by the facility administration, in accordance with applicable person having knowledge that an employee's license or certification is in question should report such information to the administrator. Review of the facility employee files revealed the following: 1. Certified Nursing Assistant (CNA) NN was hired on 2/1/2024 with no fingerprint process completed. 2. Certified Medical Assistant (CMA) OO was hired on 1/16/2024 with no fingerprint process completed. CNA NN and CMA OO had active, unencumbered CNA certifications. There were no concerns identified related to abuse or neglect within the facility. Interview on 5/15/2024 at 12:40 pm 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 record review and interviews the facility failed to develop a baseline care plan for one resident (R) (R172) that included goals and interventions to meet the immediate care needs present upon admission. The deficient practice had the potential for R172 not to have care needs met. Findings include: Review of the electronic medical record (EMR) for R172 revealed he was admitted to the facility with diagnoses including but not limited to pressure ulcer to left heel, unspecified stage, pressure ulcer of sacral area. Review of R172's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section GG-Functional Abilities and Goals revealed resident required limited assistance with all care. Section M-Skin Conditions did not indicate that the resident had a surgical wound. Review of the baseline care plan dated 5/3/2024 revealed there was not a completed plan of care that included the goals and interventions…

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, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Therapy, the facility failed to provide respiratory care consistent with professional standards of practice for two of fourteen Residents (R) (R1 and R281) receiving O2 therapy, related to ensuring O2 filters were cleaned and the O2 nasal cannula (NC) was stored in a plastic bag when not in use, and failing to obtain a physician's order for O2. The deficient practice had the potential to cause respiratory distress. Finding include: 1. Review of the facility policy titled Oxygen Therapy stated under the section titled Policy Statement that Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Under the section titled Standard of Practice it stated the following but not limited to 1. Oxygen therapy is to be used with a written order by a physician. A physician's order for O2 therapy is to contain liter flow per minute (LPM) via mask…

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 review, staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to ensure the medication error rate was less than five percent (%). There were two medication errors with a total of 28 opportunities observed for two of four Residents (R) (R27 and R91) for a medication error rate of 7.14%. Findings include: Review of the policy titled Administration of Medications revision date 11/15/2022 revealed under the Standards section, Medications shall be administered in a safe and timely manner, and as prescribed. Review of the electronic medical record (EMR) for R27 revealed diagnosis including, but not limited to spinal stenosis, alcohol abuse, esophagitis, and muscle weakness. Review of the care plan dated 4/11/2024 included R27 has nutritional problems and is at risk for malnutrition related to alcohol abuse. Review of the Physician Orders for R27 included thiamine 100 mg (milligrams), senna tablet 8.6 mg, multivitamin oral tablet (multiple vitamin), and folic acid 1 mg. Review of the EMR for R91 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to properly store medication for two of 66 sampled Residents (R) (R27 and R32). This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. Findings include: 1. Review of the policy titled, Storage of Medications and Biologicals revision date 3/11/2024 revealed under Practice Guidelines, Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. During observation of medication administration on 5/15/2024 at 9:20 am revealed a container of 'brand name' nasal saline on a bedside…

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, staff interviews, and review of a facility document titled, Preventing Infections While Providing Personal Care and the facility policy titled, Infection Prevention and Control, Cleaning, and Disinfection of Resident-Care Items and Equipment, the facility failed to ensure staff implemented appropriate hand hygiene during the passing of trays at mealtime, before and after each resident's meal consumption for one of 66 sampled Residents (R) (R425), and failed to sanitize point of care equipment after use for two of 66 sampled Residents (R27 and R114). The deficient practice had the potential to expose residents to infection. The census was 179 residents. Findings include: Review of a document titled Preventing Infections While Providing Personal Care, not dated, revealed Proper handwashing is essential to making sure that the skin is free of contamination by potentially infectious microorganisms. When soap and water are not available, an alcohol-based hand cleanser can be used, and you must rub hands thoroughly until they are dry. Your facility will have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment on two of four floors (Third Floor and Fourth Floor). Findings included: A review of the facility's resident rights revealed that each resident has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely. During an observation tour on the Fourth Floor on 2/20/2024 at 2:00 pm, double occupancy rooms and quad occupancy rooms were observed. The quad shared rooms were set up with four beds lined up in a row with curtain dividers in between them on one side of the room. Clothing closets were on the opposite side of the room near the door entrance for all four residents; these closets are not located near the resident's living space. These rooms appear to be set up institution-like. room [ROOM NUMBER]D was observed to have a broken and peeling bed stand. The divider privacy curtains were…

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, record review, the facility failed to provide Activities of Daily Living (ADL) care for eight of 30 sampled residents (R) (R4, R21, R29, R23, R25, R26, R27, and R28) related to toileting and nail care. Findings included: A review of the facility policy titled Activities of Daily Living (ADLs) Bath Shower Hygiene Care, revised November 2022, policy documented showers will be given for cleanliness, increased circulation, and comfort. The policy did not address nail care. 1. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that R4 presented with a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact and that R4 was assessed to require substantial to maximum assistance with personal hygiene. A review of R4's care plan, initiated on 10/8/2019, documented that R4 had an ADL self-care performance deficit related to a decline in ADL Self Care. Staff documented that R4 required extensive 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 observations, interviews, and record reviews, the facility failed to ensure that the call light communication system was functioning to alert staff that residents required assistance on one of four floors (Fourth Floor) in the facility. Findings included: A review of the facility policy titled Call System/Light, last revised 10/20/2022, documented that the call system shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member at a centralized staff work area. The bedside call light and the emergency call light shall be in functioning order. A review of the Maintenance Care Log records dated 2/13/2024, revealed that an unknown staff documented the following concerns: 1. Task Number 28680: room [ROOM NUMBER] . call light not working. 2. Task Number 28673: room [ROOM NUMBER] call light not working. During observation and interview on 2/22/2024 at 10:15 am, R4 was observed sitting sideways across his bed. A strong odor emanated from 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 Based on observation, staff interview, and record review, the facility failed to monitor and document behaviors for one resident (R1) who was involved in multiple resident-to-resident physical altercations due to wandering on the unit. The sample size was 30 residents. Findings included: A review of the Behavioral Management Program policy last revised 10/22/2022 revealed that it is the policy of the facility that each resident must receive, and the facility must provide the necessary behavioral health care and services and medically related social services to attain or maintain the highest practicable physical mental and psychosocial well-being. The objective of the Mood and Behavior Policy and Procedure is to provide a plan of care that is individualized to the residents' needs based upon the comprehensive assessment by the interdisciplinary team. The plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable…

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, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received adequate assistance and support from social services with receiving urgent dental services. Findings included: Review of the facility's dental service policy dated 11/28/2017, and review date of 11/21/2021, revealed routine and emergency dental services are available to meet the residents of oral health service in accordance with the resident's assessment and plan of care. Further review revealed that social service personnel will be responsible for assisting the resident with making appointment transportation as needed. Review of R8 electronic medical record (EMR) admission Record, revealed he was admitted to the facility on [DATE] and is a current resident. Some of his admitting diagnoses included congested heart failure, diabetes type 2, paranoid schizophrenia, bipolar disorder and bruxism. Review of the physician order dated 11/29/2023 revealed a dental consult…

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, record review, and policy review, the facility failed to ensure one resident (R8) of 30 sampled residents received dental services timely, after multiple requests and complaints of mouth pain. Findings included: Review of the facility's dental service policy dated 11/28/2017, and review date of 11/21/2021, revealed routine and emergency dental services are available to meet the residents of oral health service in accordance with the resident's assessment and plan of care. It further reveals that those services will be provided to the residents through a contract agreement with the local dentist a referral to a personal dentist a referral to community dentist or referral to any other Health Organization that provides dental care. It further reveals that selected dentists must be available to provide follow-up care. It also reveals that dental assessments will be conducted at a minimum on a quarterly basis through the MSDS assessment process. Social service personnel 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and resident and staff interviews, the facility failed to maintain a safe, clean, comfortable, homelike environment in twelve of 84 Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) were found to have unclean conditions, broken tile, and unsafe surfaces. In addition, the third floor west and east shower room floors were unclean, and a mechanical door was left open and unlocked. The findings include: The facility did not provide a housekeeping policy for the survey team. Observation 10/10/2023 at 10:35 am revealed the third-floor mechanical room door was open, and no staff was present in the room. A sign on the door read, Door to Remain Locked at All Times. Interview on 10/10/2023 at 10:37 am with Licensed Practical Nurse (LPN) LL revealed the mechanical room door should always 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure medications were documented and administered for two of 35 sampled residents (R) (R 7 and R 100) according to professional standards. The findings include: Review of the facility's Administration of Medication policy, last review dated 11/15/2022, noted the standard of the policy was to administer medications in a safe and timely manner as prescribed: Procedure 1. Only licensed nurses or people permitted by the State to prepare, administer and document the administration of medications. 2. Only licensed nurses may administer IV push/Bolus medications following their individual state board of nursing standard of practice. 3. Medications must be administered in accordance with the orders, including any required time frame .8. During administration of medications. The medication cart is kept closed and locked when out of sight of the medication cart. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to appropriately store medications in three of six medication carts (Fourth Floor Medication Cart #1, Fourth Floor Medication Cart #2, and Third Floor Medication Cart #2) and one of three medication rooms (Third Floor Medication Room). Findings included: A review of the facility's policy titled Storage of Medications and Biologicals date of issue 9/1/18, last reviewed on 10/3/21, revealed the facility should ensure medications are stored appropriately and securely at any given time. A review of the package insert for the insulin Lantus, (revised May 2019) in section 16.2 titled Storage revealed once the 10 ml (milliliter) vial is opened, it may be stored refrigerated or at room temperature for 28 days. A review of the package insert for the insulin Levemir, (revised January 2019) in section 16.2 titled storage revealed Levemir vials can be stored unrefrigerated at room temperature, below 30 degrees Celsius (86 F) (Fahrenheit) as long…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to provide a functioning call system for 19 of 84 rooms (415A, 406A, 406B, 406C, 406D, 408A, 408B, 408C, 408D, 413A, 413B, 414A, 414B, 415A, 415B, 212A, 212B, 224A, and 224B) in the building. Findings included: A review of the policy titled Call Light Policy, .Resident Call System date of issue 11/28/17, and last revised 10/20/22, revealed the call light is to provide a system for the resident to call for assistance. Under the section titled Standard of Practice revealed: Step 2 was to ensure all residents have access to the call light and Step 7 revealed that any defective call lights should be reported to the charge nurse and maintenance department immediately. 1. During an observation on 8/8/23 at 1:09 p.m. the call light in room [ROOM NUMBER]A was observed to not be functioning when an attempt was made to activate the system. During an interview with the resident in 415A, he stated that he had told multiple staff members that he…

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.