Nurse Care Of Buckhead

Based on observations, staff interviews, records review and review of the facility policy titled Infection Prevention and Control Program (IPCP), the facility failed to minimize the risk of influenza and pneumococcal disease by ensuring that four of four newly admitted residents (R) (R48, R54, R96 and R217) residents (R) and staff were educated on the risks and benefits of immunizations; were provided opportunities to receive immunizations; and failed to maintain documentation of the information/education provided, the administration of, or the refusal of vaccinations. This failure placed the entire facility at risk for increased complications or even death related to an outbreak of the influenza or pneumococcal virus. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program revealed the following: Immunization is a form of primary prevention. Widespread use of the influenza vaccine in the nursing facility is strongly encouraged. Policies and procedures for immunization include the following: Process for administering the vaccines,…

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, records review, and a review of the facility's policy titled Infection Prevention and Control Program, the facility failed to develop and implement policies and procedures to ensure the availability of Coronavirus disease (COVID-19) vaccine to all staff and residents, offer COVID-19 vaccine, educate staff and residents/resident representatives regarding the risk, benefits and potential side effects of the COVID-19 vaccine and keep proper documentation surrounding vaccination, refusal or contraindications for four of four sampled residents (R) (R48, R54, R96 and R217). Findings included: A review of the undated facility policy titled Infection Prevention and Control (IPC) Program revealed that, The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying, recording and correcting IPC incidents, investigating and reporting communicable diseases and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of facility policies titled Safe Environment and Maintenance service, the facility failed to maintain a safe, functional, and sanitary environment in 14 of 108 resident rooms (214, 217, 218, 224, 225, 226, 322, 325, 326, 405, 417, 421, 505, and 526) related to resident rooms containing debris in packaged terminal air conditioner (PTAC) units, dirty air vents in common areas, and holes/cracks in drywall and doors. Findings included: A review of the facility policy titled Safe Environment revealed the following: Policy Statement: The facility will provide (9)(a) housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A review of the facility policy titled Maintenance service dated 3/6/2018, under Policy Statement revealed: Maintenance Service shall be provided to all areas of the building, grounds, and equipment. Under Policy Interpretation 2. (d) Maintaining the heat/cooling system, plumbing…

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 AMENDED Based on staff interviews, resident interviews, and record review, the facility failed to ensure that routine and as-needed (PRN) medications were available for administration to three of 106 sampled residents (R) (R2, R55, and R394). This deficient practice had the potential to cause delays in physician-ordered medical interventions. Findings included: 1. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE], and pertinent diagnoses included but were not limited to Alzheimer's Disease, chronic pain syndrome, sickle-cell disorder, and fusion of the spine in the cervical region. A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R2 was cognitively intact, and that R2 was taking an antidepressant and an opioid medication. A review of R2's care plan, revised 5/8/2025, indicated a focus on R2 being at risk for pain/discomfort related to generalized pain and sickle…

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 and resident interviews, facility records, and review of facility policy titled Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance, and provide meals that were palatable, attractive, and held at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for breakfast were at or above 135 degrees Fahrenheit (F). These deficient practices had the potential to affect 207 of the 212 residents receiving an oral diet. Findings included: A review of the undated facility policy titled Temperatures revealed that All hot food items must be cooked to appropriate temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Food should be transported as quickly as possible to maintain the temperature for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures…

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 reviews of the he facility policies titled General Food Preparation and Handling, Uniform Policy, and Food Brought in from the Outside, the facility failed to properly discard expired food and ensure that food items were labeled and dated in the kitchen refrigerator, freezer, dry storage, and emergency supply area. The facility also failed to maintain sanitary practices concerning hand hygiene, covering of hair with restraints, and up-to-date sanitizer test strips for dietary staff in the kitchen. These deficiencies had the potential to impact 207 out of the 212 residents who were on an oral diet. Findings included: A review of the undated policy titled General Food Preparation and Handling indicated in section Food Preparation-H. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact with prepared foods. A review of the undated policy titled Uniform Policy indicated that all employees will adhere to the Food & Nutrition policy on the proper wearing of a…

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

Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. The facility census was 212. Findings included: During an observation and interview were conducted on 5/27/2025, at 9:53 am, following the initial tour of the kitchen area. It was noted that the area surrounding the dumpster was littered with trash, discarded food, bedding, and various other debris. Additionally, the presence of gnats and flies was observed around the dumpster. During the interview with the Dietary Manager, it was clarified that the kitchen does not bear responsibility for the dumpster; it is the maintenance responsibility. She also mentioned that trash collection occurs on Mondays and Fridays. During an observation on 5/29/2025, at 7:13 am, the dumpster was observed with the presence of discarded food, a white plastic facility fixture, and a red broom lying in the debris. Additionally, gnats and flies were observed surrounding the dumpster. During an observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and a review of the facility's policies titled Assistance with Meals, the facility failed to provide a dignified existence for three of 106 sampled residents (R) (R187, R159, and R108) related to exposed catheter bags for R187 and R159, and during meals for R108. This deficient practice had the potential to negatively impact the residents' sense of self-worth and overall well-being. Findings included: 1. The policy regarding the Foley catheter bag was requested from the facility, and it was not provided by the exit date of this survey. A review of the facility's electronic medical records (EMR) revealed that R187 was re-admitted to the facility on [DATE] with a diagnosis including, but not limited to, urinary retention. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R187 presented with a Brief Interview of Mental Status (BIMS) score of 15, which indicated R187 was cognitively intact; had an active diagnosis of Neurogenic…

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's policies titled Self-Administration of Medication and Administering Medications, the facility failed to assess one of 106 sampled residents (R) (R2) for self-administration of medications. Findings included: A review of the facility's policy titled Self-Administration of Medication, dated April 2022, under section titled General Guidelines, number one documented, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of the facility's policy titled, Administering Medications, revised April 2019, under section titled Policy Interpretation and Implementation, number 27 documented, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have 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, resident and staff interviews, record reviews, and a review of the facility's policy titled Residents' Rights, the facility failed to honor the resident rights for one of 25 sampled residents (R) (R12) related to the choice to be transferred out of bed daily. This failure had the potential to cause a decrease in the residents' mental and emotional progress. Findings included: A review of the facility's policy titled Resident Rights dated 10/8/2022 revealed that all activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident, goals, preferences, and choices. A review of the electronic medical record (EMR) revealed that R12 was admitted on [DATE] with diagnoses that included bipolar disorder, schizoaffective disorder, morbid obesity, anxiety disorder, drug-induced subacute dyskinesia, and drug-induced secondary Parkinsonism.…

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 AMENDEDBased on record review, staff interviews, and review of the facility policy titled Advance Directives, the facility failed to ensure one of 106 sampled residents (R) (R48) Advance Directives was completed and followed up on. Findings included: A review of the facility policy titled Advance Directives dated April 2022 documented that a resident's choice about Advance Directives will be respected. Prior to or upon admission, the Care Plan Team will ask residents/their family members about the existence of any Advance Directives. A review of the electronic medical records (EMR) revealed that R48 was admitted to the facility on [DATE] with diagnoses including, but not limited to, medically complex conditions, vascular dementia, moderate, with agitation, hypertension, non-Alzheimer's dementia, depression (other than bipolar), bipolar disorder, and schizophrenia. A review of the annual Minimal Data Set (MDS) assessment dated [DATE] revealed that R48 had a Brief Interview for Mental Status (BIMS) score of 00,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to notify the responsible party and attending physician about a change in residents' condition for two of 106 sampled residents (R) (R371 and R170). Specifically, the facility failed to notify R371's responsible party and attending physician following a fall and failed to notify R170's responsible party of a change in condition. Findings included: A review of the policy titled Change in a Resident's Condition or Status with a revised date of February 2021 revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Unless otherwise instructed by the resident, a nurse will notify the resident's…

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 staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations and investigations of abuse, including injuries of unknown source, were reported timely to the State Survey Agency (SSA) for one of five sampled residents (R) (R128) reviewed for abuse. Findings included:A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, was conducted, and under section titled Policy Interpretation and Implementation, subsection titled Follow-Up Report, number one documented, Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.A review of R128's electronic medical record (EMR) revealed he was admitted to the facility on [DATE], and his pertinent diagnoses included but were not limited to aphasia following nontraumatic…

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 staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations of abuse, including injuries of unknown source, were thoroughly investigated for two of five sampled residents (R) (R128 and R379) reviewed for abuse. Findings included: 1. A review of the policy titled Reporting and Investigating, revised September 2022, revealed that the individual conducting the investigation, as a minimum, documents the investigation completely and thoroughly. A review of the electronic medical record (EMR) revealed R128 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to aphasia following nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side, and generalized muscle weakness. A review of the quarterly Minimum Data Set (MDS) assessment…

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 interview, record review and review of the facility policy titled Coordination- Pre-admission Screening and Resident Review (PASARR) Program and MDS Error Correction, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for four of 106 sampled residents (R) (R12, R104, R117 and R33, and 133). Findings included: A review of the undated facility policy titled Coordination Pre-admission Screening and Resident Review (PASARR) Program revealed that the facility will coordinate assessments with the PASARR program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and efforts. Coordination includes incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a residence assessment, care planning, and transitions of care. A review of the facility policy titled MDS Error Correction dated June 2025 revealed that if an error is discovered after the encoding and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and review of the facility's policy titled Care Plan, the facility failed to revise care plans for three of 106 sampled residents (R) (R96, R214, and R159) regarding denture care for R96, regarding diabetes mellitus for R214, and related to for midline dressing for R159. Findings included:A review of the facility's policy titled Care Plan dated August 2022 documented that it is the policy of the facility to create Care Plans in accordance with State and Federal regulations. Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential. A review of the facility's Electronic Medical Records (EMR) revealed that R214 was admitted to the facility on [DATE] with diagnosis included but not limited to type 2 diabetes mellitus, R159 was re-admitted to the facility on [DATE] with diagnosis included but not limited to sepsis and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Food and Nutrition Services, the facility failed to serve the correct diet for one of 11 residents (R) (R2) ordered to receive a puree diet. Findings included: A review of the facility's policy titled Food and Nutrition Services with a revised date of October 2017 revealed that food and nutrition services will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE], and pertinent diagnoses included, but were not limited to, Alzheimer's Disease. A review of R2's quarterly Minimum Data Set (MDS) assessment…

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 reviews, and review of the facility's policy titled Pain and Administering Medications, the facility failed to ensure that one of 106 sampled residents (R) (R80) received her pain medication in a timely manner. Findings included: A review of the facilities policy titled Pain with a revised date of October 2022, revealed that the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent…

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's policies titled Storage of Medications and Control of Drugs, the facility failed to remove expired items from the second and third floor medication rooms and the 200 and 300 hall medication carts. The facility also failed to have an open date on glucometer strips and failed to have all signatures on the 400 hall narcotic count sheets. This deficient practice had the potential to cause worsening of medical conditions for the residents. The facility's census was 212. Findings included: A review of the facility's policy titled Storage of Medications dated April 2022 documented Policy: Drugs and biologicals should be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this Center. All such drugs are destroyed. A review of the facility's policy titled Control of Drugs dated April 2022 documented Policy Interpretation and Implementation: 7. Controlled drugs must be counted at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and the review of the facility documents titled, admission Packet, admission Packets & Compliance Advance Directive Audit, the job description, admission Marketing Director (non-clinical), and emails, the facility failed to provide and obtain signatures of six of 31 sampled Residents (R) (R24, R25, R26, R27, R28, and R31) admission packets that contained written information about how to apply for and use Medicare and Medicaid benefits. Findings include: Review of the document titled admission Packet Table of Contents revealed the packet included but not limited to: admission agreement, Medicare and Medicaid programs, arbitration of disputes, Grievances, and resident rights. Review of the document titled admission Packets & Compliance Advance Directive Audit dated 2/3/2025 provided to the surveyor revealed sixty-one residents do not have a signed admission packet that includes but not limited to Medicare and Medicaid programs. Six residents were selected 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 staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia, the facility failed to provide evidence of implementation and maintenance of an effective training program for three of thirty Certified Medication Aide Techs (CMAT LL, CMAT MM, and CMAT NN) selected for review of their medication administration skills competency check off. The deficient practice had potential to adversely affect the care given to all residents in the facility. The facility census was 208 residents. Review of the facility's Nursing Care Center Pharmacy Policy and Procedure Manual dated January 2024 revealed under Consultant Pharmacist Services Provider Requirements: Observe medication administration pass as outlined in the contract to assist in the assessment and improvement in nursing staff medication administration and submit a report to nursing administration. Review of the Facility Assessment dated 8/5/2025 revealed a listed acuity - diseases, conditions and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation of Residents, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for two of 31 sampled Residents (R) (R29 and R30). Findings include: Review of the policy titled Abuse, Neglect and Exploitation of Residents revised date of 10/24/2022 revealed under Policy Statement: It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal abuse. Under Responsibilities: Residents will not be subjected to abuse by anyone, including but not limited to staff. All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. If abuse is suspected, personnel will report their observations to their supervisor…

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 staff interviews and review of the facility policies titled, Abuse, Neglect and Exploitation of Residents and Background Screening and Investigation, and the Human Resource Director Job description, the facility failed to have two of fourteen employee files selected on site for review, failed to ensure that a criminal background check was completed for one of two Registered Nurses (RN) and one of one Licensed Practical Nurse (LPN), failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for two of two Administrators, three of three Certified Medication Aide Techs, one of one Certified Nursing Assistants (CNA), one of one Regional Director of Business Development, and one of one Maintenance Director. The facility also failed to re-fingerprint two of two CNAs whose fingerprint checks had not been retained under Rap Back per the Rules and Regulations of the State of Georgia. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure physician's orders were followed for two of 31 sampled Residents (R) (R1 and R29) to obtain laboratory tests. Findings include: 1. Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to nonrheumatic aortic (valve) insufficiency and chronic systolic (congestive) heart failure. Review of the resident's most recent quarterly assessment Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 14, which indicated R1 was cognitively intact. Review of R1's Electronic Medical Record (EMR) Order Summary Report revealed a physician order for Coumadin oral tablet 7.5 milligrams (mg) (warfarin sodium) Give 7.5 mg orally in the evening for blood thinner. Review of the Clinical Physician Orders PT/INR on 2/6/2024 for R1 revealed no documented results were located in R1's EMR. Review of the Clinical Physician Orders obtain PT/INR…

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's policy titled, Abuse, Neglect and Exploitation of Residents and the Human Resource Director Job description, the facility failed to ensure that one of six employee files selected for review had evidence they were verified with the State of Georgia's Nurse Aide Registry. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure: A. Seven Components of Prevention and Detection: 1. Screening: The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: CNA Registry is contacted to confirm the aides' enrollment and status on the registry. Review of the facility's Human Resource Director Job description revealed: Pre-Employment Functions: Conduct reference checking, abuse registry checks, and certification/ licensure checks (if applicable), prior to giving job offer. During a record review of the employee files revealed the 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.

Based on Staff/Resident interviews, record review, and review of the facility's policies titled, Resident Grievances and Resident Council and Family Group, the facility failed to ensure that resident grievances were resolved within 72 hours. Findings included: During a review of the facility's policy titled, Resident Grievances, revised 12/20/2020, it was revealed that the intent of this policy is to support each resident's right to voice grievances of any nature with the assurance that the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress towards resolution. The policy continued to state, the grievance review period will be completed within 72 hours, unless explanation is provided to the induvial as to why the review period requires an extension period. During a review of the facility's policy titled, Resident Council and Family Group, revised 5/8/2024, it was revealed that the facility will consider the views of a resident or family group and act promptly upon the grievances and recommendations of such group concerning issues of…

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

Based on staff interviews, record reviews, and a review of the facility's Assessment tool the facility failed to have sufficient direct care staff coverage to achieve the highest practicable level of well-being for all residents. The facility census was 189. Findings included: A review of the Facility Assessment Tool included a staffing plan to ensure sufficient staff met the needs of the resident at any given time. The positions for the staff needed for the facility census/population included Licensed and Registered Nurses providing direct care, Nurse aides, and other nursing personnel (e.g. those with administrative duties such as staff developer, case manager, Director of nursing, unit managers, PPS, MDS (Minimum Data Set), and Restorative Nursing), staff needed for behavioral healthcare services such as social services and Administrator, Dietician kitchen supervisor, food service director, cooks, and Dietary Aids. A review of the December 2023 and January 2024 Facility two-week staffing Grid provided by the Staffing Coordinator and reviewed by the Administrator revealed no RN…

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 ensure that essential equipment was maintained in a safe and operable manner related to wheelchairs, ice machines, and the walk-in freezer. Findings included: A record review of the facility policy titled, Maintenance Service last revised in April 2022, revealed the following: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at, all times. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards. 1. During an interview on 7/1/2024 at 11:10 am R49 stated she had been unable to utilize her wheelchair for months due to the brakes not working. She stated that despite her repeated efforts and notifications to the maintenance department, nothing had been done to repair her wheelchair.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that handrails were securely affixed to the wall and had end caps on four of five floors (Second Floor, Third Floor, Fourth Floor, and Fifth Floor). Findings included: A review of the facility policy titled, Maintenance Services, dated April 2022, revealed that maintenance services shall be provided to all areas of the building, grounds, and equipment . Maintaining the building in good repair and free from hazards. During an initial observation on 7/18/2024 at 9:05 am on the Fifth Floor, the following issues were identified: ~The handrail under the sign 510-518 had a loose end cap, and the handrail was unsecured at that point at the wall. ~The handrail under the sign 519-527 was missing an end cap to the handrail and had exposed metal. ~The handrail under the dayroom sign had a missing end cap with exposed metal. The handrail was loose and not secured tightly to the wall. ~The handrail on the left side of the hall, as you enter the day room 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 observations, record review, interviews, and review of the facility policy titled facility policy, titled Pest Control Policy, the facility failed to have an effective pest control program in place. The census was 189. Findings included: A review of the facility policy titled Pest Control Policy last reviewed on 11/15/2022, documented that the policy aims to ensure that, as far as possible, pests (rats, mice, roaches, ants, fruit flies, silverfish, etc.) within the premises are kept to an absolute minimum with the ideal being eradication but due to the resilience and persistence of some species this ideal is impossible to achieve. The Pest Control Contractor shall rid the premises of pests using only approved pesticides and maintain the locations to the required standard for the duration of the contract. The contractor will also respond to unscheduled requests to effectively rid the premises of further pests. The contractor will supply all goods and materials to carry out the service. A review of the…

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

Based on staff interviews and record review, the facility failed to have residents' funds available for withdrawal after hours and on weekends. This failure has the potential to affect 122 residents who have trust fund accounts. The facility census was 189. Findings included: During an interview on 7/17/2024 at 9:36 am, the Business Office Manager (BOM) stated that the residents do not have access to their funds on the weekends and have been like that since before she got here. The residents were notified in a memo and resident council meeting by the previous Social Service Director. The BOM stated the residents are provided funds on Fridays to cover their weekend spending. When asked why this had been the process, the BOM stated it had been like this before the BOM's tenure at the facility. They currently don't have someone secure enough to handle resident funds on the weekends. In a phone interview on 7/22/2024 at 10:59 am the Former Administrator (FA) WWW stated that they had a Business Office Manager who had been at the facility for approximately six to seven years that…

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

Based on observations, interviews, record review, and review of facility policies, the facility failed to provide a safe and sanitary homelike environment, when staff failed to provide residents clean bedding, clean clothing, and clean bath linens on the second and fifth floor; failed to maintain the ceiling/roof in good repair on the second floor and failed to provide an environment free of persistent odors on the third floor. The census was 189. Findings include: 1. Facility Policy Statement titled Supplies and Equipment, last reviewed August 2023 documented, staff must use assigned equipment and supplies with care to promote safety, and equipment and supplies must be ready for use at all times of the day and night to serve the residents' needs. A review of the facility policy titled, Residents Rights last revised in 2016 documented the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. The resident has a right to a safe,…

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, and review of facility policy titled, Hydration and the Elderly and High-Risk Population, the facility failed to ensure hydration was easily accessible for four of eight sampled residents (R) (R34, R37, R38, and R48) reviewed for hydration. This failure placed the residents at risk of dehydration and increased health complications. Findings included: A review of an undated facility policy titled, Hydration and the Elderly and High-Risk Population, revealed that residents with physical limitations, dementia, or Alzheimer's Dementia may not understand they feel thirsty and may not have the ability to request a drink. They may not have the physical ability to reach for a glass of water .Dehydration can affect the overall physical and nutritional status .A resident may become more confused, may fall, or develop a urinary tract infection if he/she becomes dehydrated. The facility team must work closely to address concerns as they are identified, have fluids available,…

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

Based on record reviews and interviews, the governing body failed to ensure that the facility had adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meals for residents in a timely manner. The facility census was 189. Findings included: A review of the contract between the facility and (name) Care Services Group for dietary services revealed that the agreement was established on 7/1/2023. The agreement outlined that, Commencing on 7/1/2023 (the 'Start Date'), (name) will provide such dining management, supervision, labor, materials, and supplies as (name) as required, to provide the services identified on Exhibit A hereto ('Services') in accordance with the terms of this Agreement. A review of the contract between the facility and (name) Care Services Group for housekeeping and laundry services revealed that the agreement was established on 7/1/2023. The agreement outlined that, Commencing on 7/1/2023 (the 'Start Date'), (name) will provide management and consulting services to Client in connection with Client's performance of…

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

Based on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program to resolve ongoing concerns related to resident grievances and laundry services. The facility census was 189. Findings included: A review of the updated facility policy titled, Quality Assurance Performance Improvement Plan documented this facility's leadership intends to conduct an ongoing quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified programs and identify opportunities for improvement. A review of Resident Council minutes dated 9/27/2023, 10/24/2023, 11/29/2023, 12/27/2023, 2/28/2024, 3/27/2024, 4/24/2024, and 5/29/2024 revealed continued concerns related to laundry, missing clothing items, linen, and diaper shortage, and shortage of personnel and supplies. A review of the QA Committee Minutes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during care for one of three residents (R) (R53) reviewed for high-contact care. Findings included: A review of facility in-service training titled, Enhanced Barrier Precautions, dated March 2024, revealed, .Enhanced Barrier Precautions (EBP)- include the use of gloves and gown when caring for residents with chronic wounds or indwelling medical devices during high-contact resident activities .Residents requiring EBP (gowns and gloves for care) include chronic wounds, wounds with dressings . Gloves and gowns are to be worn when providing the following high-contact resident activities. Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting. Any care that requires close contact . A review of the admission Record located in the Profile tab of the electronic…

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 resident, and staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation the facility failed to protect the residents' right to be free from misappropriation of property by facility staff for one of four sampled residents (R) (R32). Findings included: During a review of the facility's policy titled, 'Abuse, Neglect and Exploitation revised on 3/1/2024, it is documented that misappropriation of resident's property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money with the resident's consent. A review of R32's Electronic Medical Record (EMR) revealed an original admission date of 5/13/2021 with multiple diagnoses of but not limited to chronic obstructive pulmonary disease, heart failure, anxiety hypertension, type II diabetes, and chronic pain. R32's Brief Interview for Mental Status (BIMS) was 15; indicating R32 was cognitively intact. A review of the Facility Reportable Incident (FRI) dated 1/23/2024 revealed that R32 notified social services of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and a review of the policy titled Abuse Prevention Policy Instruction, the facility failed to ensure that one of five sampled residents (R) (R11) was free from involuntary seclusion. Findings included: A review of the facility policy titled, Abuse Neglect and Exploitation - Work Instruction last revised on 11/15/2022, documented that Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The resident has the right to be free from . Involuntary seclusion. Involuntary Seclusion means separation of a resident from another resident or his/her room or confinement to his/her room (with or without roommates) against the resident's will or the will of the resident's legal representative. A review of the clinical record revealed that R11 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease Dementia with Psychotic disturbance and a history of falls. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital for one of five sampled residents (R) (R15). Findings included: A review of the facility's policy titled, Admission, Transfer and Discharge Registry Policy dated 11/28/2017 and last revised on 10/20/2022, documented that the facility office shall maintain a current Admission, Transfer, and Discharge Register and updates in the electronic health record. The facility must document in the discharge notice the reason for the transfer/discharge, the place to which the resident was transferred/discharged , and the length of the resident's stay. The discharge plan will be monitored and revised as necessary throughout the patient /resident stay. Initiation of a discharge while a resident is in the hospital must be based on the resident's current condition when the resident seeks to return to the facility. The facility must have evidence that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide timely respiratory care consistent with professional standards of practice for one of six residents (R) (R45) requiring tracheostomy care. Findings included: Resident (R) 45 was admitted to the facility on [DATE] with the diagnoses to include, Encephalopathy, Acute and Chronic Respiratory Failure with Hypoxia, and Encounter for attention to Tracheostomy. A review of the admission Minimum Data Set (MDS), for R45, dated 7/9/2024 revealed no Brief Interview of Mental Status (BIMS) score conducted, resident is rarely/never understood. Section O.-Special Treatments, Procedures, and Programs documented resident received oxygen therapy, suctioning, and trach care. A review of R45's Progress Note dated 7/20/2024 at 4:55 pm revealed that nurse observed resident was showing s/s (signs/symptoms) of SOB (shortness of breath) 02 (oxygen): 79-84 percent, nurse asked CNA to call 911, while that was being done resident received suction after nurse listened 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, record reviews, and a review of facility policy titled Activities of Daily Living (ADL), the facility failed to ensure incontinent care was provided promptly for two of 10 residents (R) (R35 and R36) sampled for ADL care. This failure placed the residents at risk for skin breakdown and a diminished quality of life. Findings included: A review of the facility policy titled Activities of Daily Living (ADLs) dated November 2022 documented the following: Each resident shall receive care and services to sustain and maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan. Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including hygiene bathing, grooming and oral care, mobility, transfer, ambulation, elimination/toileting, dining, eating, and communication functions. The facility will create and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, the facility failed to ensure the tube feeding pump was turned on during the hours that the resident was to receive nutrition, per the physician's orders for one of one sampled resident (R) (R53) with parental nutrition. This failure placed the resident at risk for weight loss. Findings included: A review of an updated facility policy titled, Enteral Feeding, revealed, .A resident who is fed by a gastrostomy tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal eating skills . A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE] with diagnoses that included dementia, urinary tract infection, and pressure ulcers. A review of the Physician Orders located in the Orders tab of the EMR revealed, Enteral Feed .Jevity 1.5 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy titled Dialysis, Care of the Resident Receiving Dialysis, the facility failed to ensure the pre/post dialysis communication form was provided to two of two sampled residents (R) (R14 and R52) upon leaving for dialysis. Findings included: A review of the facility policy titled, Dialysis, Care of the Resident Receiving Dialysis, revised July 2020 revealed, .To prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage in residents receiving dialysis .Arrange for dialysis as ordered. Send Dialysis Information Transfer Form with resident . 1. A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R14 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dialysis dependent. A review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 12/7/2023 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 interviews, record review, and review of facility policy, the facility failed to ensure physician visits were done every 60 days, per the requirement, and documentation of those visits was in the medical record for one of five sampled residents (R)(R53). Findings included: A review of the facility policy titled, Staff Privileges, dated April 2024 revealed, .Each physician desiring to participate in staff privileges must abide by the following conditions .Provide medical information necessary to maintain continuous medical care and treatment .Provide the Center with medical information concerning the resident in accordance with admission policies .Prepare and maintain a complete medical record for each resident in accordance with current medical record policies and procedures .Provide regularly scheduled physician visits in accordance with physician services . A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the 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.

Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for three days in January 2024. Findings included: A review of the December 2023 and January 2024 Facility Two-Week Staffing Grid provided by the Staffing Coordinator and reviewed by the Administrator, revealed that there was no RN coverage for 1/6/2024, 1/7/2024, and 1/20/2024. During an interview on 7/1/2024 at 1:43 pm, the Administrator stated the facility was using a lot of agency employees so a major goal when she began in March 2024 was to get rid of agency staff and hire full-time employees. During an interview on 7/17/2024 at 10:29 am, the former Director of Nursing (DON) OOO revealed that s/he had made multiple attempts to reach out to the management company about the lack of staff and RN coverage on multiple shifts. DON OOO stated there were several days s/he had to work multiple shifts to ensure weekend RN coverage and confirmed that there were multiple occasions that no RN was available for 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 staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure that three of five residents (R) (R13, R32, and R67) were free from significant medication errors. Findings included: A review of the facility policy titled Administration of Medications last reviewed on 11/15/2022 stated that medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's electronic medication administration record on the appropriate line entry after giving each medication and before administering the next one, or document in wet ink. As required or indicated for a medication, the individual administering the medication will record in the resident's Electronic Medication Administration Record (eMAR): The dates and time the medication was administered; the dosage; the route of administration; The signature and title of the person administering the drug. 1. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy titled Influenza and Pneumococcal Immunizations, the facility failed to assess for eligibility and ensure residents were offered and/or administered influenza and pneumococcal vaccines; and failed to provide documentation that the resident and/or resident representative were informed of the risks verse benefits of refusing the vaccines for two residents of five sampled residents (R) (R28 and R55) reviewed for immunizations. This failure placed residents at risk of complications from being unvaccinated. Findings included: A review of the facility policy titled, Influenza and Pneumococcal Immunizations, revised November 2022 revealed, .It is the standard of practice of this facility to offer and administer immunizations to the resident unless it is medically contraindicated to prevent and minimize house acquired infection, unnecessary hospitalization, and even death in the elderly population associated with influenza and incidence of pneumonia .All…

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, record review, and review of the facility policy titled Testing of Resident and Staff for COVID-19, the facility failed to offer/administer or provide documentation of consent or refusal by the resident representative for the COVID-19 vaccines for one of five sampled residents (R) (R28) reviewed for COVID-19 vaccinations. This failure placed the resident at risk for complications related to being unvaccinated. Findings included: A review of facility policy titled, Testing of Resident and Staff for COVID-19, revised in May 2023 revealed, .It is the policy of [facility] to maintain and attain best practices in the prevention and spread of infection. The facility follows all recommendations from CMS (Center for Medicare/Medicaid Services), CDC (Center for Disease Control), and state and local regulatory agencies . A review of the electronic medical record (EMR) revealed that R28 was originally admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) assessment with…

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

Based on resident and staff interviews, record review, and review of the facility policies titled, Call System/Light and Food Preferences, the facility failed to ensure the facility made prompt efforts to resolve continued resident grievances regarding food choices and call light response time. This failure affected the resident council and six residents who voiced concerns (Resident (R) 433, R14, R435, R434, R20, and R21) of 47 sampled residents. The deficient practice created the potential for care needs to go unmet or a lack of staff response in case of emergency. Findings include: A. Call Light Response Grievances 1. Resident Council Grievances Review of the Resident Council Minutes from February 2023 to August 2023, provided on paper, revealed continued grievances regarding call light wait times: -The 7/26/2023 minutes documented, Lights not being answer [sic] in a timely manner. -The 5/31/2023 minutes documented, Call light is staying on for a long period of time. -The 2/22/2023 minutes documented a resident stated she laid without some assistant [sic] from staff. 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.

Based on record review, interviews, and review of the facility policy titled, Dialysis Care and Services, the facility failed to ensure ongoing communication between the facility and the dialysis unit following a residents hemodialysis treatment for two of three residents (Resident (R) 65 and R39) reviewed for dialysis services. The sample size was 47. Findings include: Review of the facility's policy titled, Dialysis Care and Services dated 10/20/2022, indicated the policy did not address ongoing communication between the facility and the dialysis unit regarding the resident's care. Review of the dialysis contract dated November 14, 2014, revealed . Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD (End Stage Renal Dialysis) Dialysis Unit . 1. Review of R65's admission Record from the electronic medical record (EMR) under the Profile tab showed R65 was admitted to the facility with the diagnoses of malignant neoplasm of left kidney, end stage renal disease (ESRD),…

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, resident and staff interviews, record review, the facility failed to maintain an effective pest control program regarding flies which affected all five floors of the facility, specifically for ten (Residents (R) 21, R23, R50, R57, R87, R92, R105, R123, R153, and R167) of 47 sampled residents. Findings include: Observations of the facility from 9/4/2023-9/7/2023 revealed an excessive number of flies. The flies were throughout the facility including dining rooms, resident rooms, offices, and the conference room. Observations were made from 9:00 AM to 4:15 PM on 9/4/2023; from 8:30 AM to 4:15 PM on 9/5/2023; from 6:30 AM to 5:00 PM on 9/6/2023; and from 8:15 AM to 8:30 PM on 9/7/2023. During an observation of the fourth floor on 9/4/2023 from 10:40 AM through 12:45 PM, flies were observed throughout the fourth floor, in resident rooms, in hallways, dead on windowsills, in the dining room, and in the elevator. During an observation on 9/4/2023 at 11:12 AM, R153 and R123 were in their room. When asked, each resident said they did not like the flies in the 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 and staff interviews, the facility failed to maintain a clean, comfortable, and homelike environment for 189 of 189 residents who resided at the facility. Findings include: During observations from 9/4/2023 - 9/7/2023, the fifth-floor hallway walls and dining room walls were observed to have holes, peeling paint, and scratches. [NAME] splatters were observed on the wall in the dining room closest to the nurses' station. During an observation on 9/4/2023 at 10:30 AM, the three elevators utilized to access floors one through five were observed to be very odorous of urine. During an observation in the middle elevator on 9/4/2023 at 10:48 AM, there was a strong pervasive urine odor, and the floor was very sticky. During an observation on 9/4/2023 at 11:27 AM, a Geri-chair (geriatric chair with lap table), in the hall outside room [ROOM NUMBER], was observed to have a heavy build-up of dirt, grime, and dried food particles on the back and insides of the chair. During an observation on 9/4/2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy titled, Transfer or Discharge, Emergency, the facility failed to ensure two (Resident (R) 140 and R179) of six residents reviewed for hospitalization received written notice of transfer to the hospital that included a statement of the resident's appeal rights and the contact information for the office of the Ombudsman. The deficient practice had the potential to cause a lack of understanding of appeal rights and resources should the resident not be permitted to return or disagree with the reason for transfer. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, dated 10/11/2021 and provided on paper, revealed, Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician. b. Notify the receiving facility that the transfer is being made. c. Prepare the…

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

Based on record review, staff interviews, and review of the facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) assessment for one (Resident (R) 164) of 46 sample residents accurately reflected R164's nutritional status. This failure had the potential to lead to ineffective or inaccurate care planning for R164. Findings include: Review of the facility policy titled Resident Assessment Instrument (RAI) Policy, dated 10/7/2021, revealed, The MDS Coordinator and interdisciplinary team members complete the MDs using the data collected with medical record documentation, assessments, direct observation, and communication with staff and resident and/or resident's representative . The interdisciplinary team composes or reviews and revises a comprehensive person-centered care plan using information from the Minimum Data Set (MDS), Care Area Assessment (CAA) and other information gathered during the assessment process. This information helps the interdisciplinary team to plan care that allows the resident to reach his/her…

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, record review, and review of the facility policy titled, Activity of Daily Living Policy, the facility failed to ensure staff provided the necessary level of assistance with positioning and food tray set-up to meet the needs of one (Resident (R) 173) of one resident reviewed for Activities of Daily Living (ADLs). Specifically, care plan interventions were not implemented to assist with positioning in bed and food tray set-up in accordance with accepted standards of practice, the care plan, and the resident's choices and needs and/or preferences. Findings include: Review of the facility's Activity of Daily Living Policy, dated May 2021 and last reviewed November 2022, revealed, . each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan . Review of the electronic medical record (EMR) Diagnosis tab revealed diagnoses for R173 that included hemiplegia 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 observation, staff interviews, and review of the manufacturer's guidelines, the facility staff failed to follow the proper administration process for a medication, Advair Diskus (used for treating the symptoms of chronic obstructive pulmonary disease) for one of four residents (Resident (R) 339) during the medication administration pass. Specifically, R339 was not instructed to rinse his mouth out with water then split it out into a cup after Advair Diskus administration. The deficient practice had the potential to cause a fungal infection in the mouth for R339. Findings include: Review of the instructions for Advair Diskus from the pharmaceutical company, GlaxoSmithKline (GSK) that manufactures this medication located on the website for GSK at https://gskpro.com, revealed .Rinse your mouth with water without swallowing after each dose of Advair Diskus . Review of R339's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab indicated R339 was admitted to the facility with diagnosis including but not limited to chronic obstructive pulmonary…

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, resident and staff interview, and the review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure one (Resident (R) 104) of four residents reviewed for range of motion (ROM) received a palm guard/orthotic as needed to address his limited range of motion in his right hand. The deficient practice had the potential for further reduction of ROM and/or mobility for R104. Findings include: Review of the facility policy titled, Restorative Nursing Program dated 11/15/2022 and provided on paper, revealed, Restorative Nursing Documentation Guidelines: Splint or Brace Assistance: Describe interventions and effectiveness of teaching interventions used to improve or maintain resident's self-performance in applying, manipulating, and caring for the brace or splint (e.g., Resident applied left leg brace with verbal cues and task segmentation). Document physician's orders that specify the type of brace, location for application, frequency, and duration. Describe activities used to maintain resident's performance in putting…

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, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to lock the medication cart when the nurse was not in attendance for one of eight carts; and failed to store medications in a locked medication cart for one Resident (R) 340 of four residents in the medication administration pass observation. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. Findings include: Review of the facility policy titled, Storage of Medications and Biologicals with a revision date of September 2017, revealed All Medication, Treatment carts must be secured/locked when not attended by licensed staff.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 by residents and visitors. 1. During the medication administration pass observation on 9/5/2023 at 9:30 AM, Licensed Practical Nurse (LPN)2 was asked by a 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.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure one (Resident (R) 21) of three residents reviewed for dental services received assistance to obtain dentures. This failure had the potential to contribute to weight loss and nutritional problems due to a dislike of a mechanically altered diet, decreased self-esteem, and increased discomfort for R21. Findings include: Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility with diagnoses including adult failure to thrive, dysphagia, and diabetes. Review of R21's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/12/2023, revealed he scored three of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. He was usually able to make himself understood and understand others. R21 had no mouth or dental problems. In an observation and interview with R21 in his room on 9/4/2023 at 11:08 AM, the resident stated he did not have any…

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 interview, and review of the facility policy titled, Documentation Policy, the facility failed to ensure the medical record for one (Resident (R) 286) of 46 sample residents accurately reflected the resident's condition. This failure had the potential to lead to care needs not being met for R286. Findings include: Review of the Documentation Policy, initiated October 2018 and reviewed 11/3/2022, revealed, The resident's medical record is a legal document and may be used as evidence in a court of law. Therefore, the record must be accurate, legible, and complete . Copy and Paste practices are discouraged to ensure accuracy of information. Review of R286's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility with diagnoses including multiple sclerosis, seizures, encephalopathy, and rhabdomyolysis (a serious medical condition that occurs when damaged muscle tissue releases its proteins and electrolytes into the blood). Review of R286's Orders tab of the EMR revealed an order for 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.

Based on observations, resident and staff interviews, and review of the facility policy titled, Call System/Light, the facility failed to ensure the call system for one (Resident (R) 7) of 47 sampled residents was functioning. This failure created the potential for R7's needs to go unmet or an inability to summon staff in an emergency. Findings include: Review of the Call System/Light policy, dated 10/20/2022, revealed, The purpose of the Resident Call System shall allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area . Equipment: 1. Bedside call light in functioning order 2. Emergency call light in working order . Report any defective call lights to charge nurse and the maintenance department immediately. Review of R7's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility with diagnoses including hypertensive heart disease, peripheral neuropathy, dementia, anemia, depression, insomnia, muscle weakness,…

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 staff interviews, the facility failed to use or discard emergency food supply prior to the expiration date and failed to discard molded food items in dry storage. In addition, the facility failed to maintain sanitary conditions of the kitchen equipment and failed to demonstrate proper use of the three-compartment sink; failed to maintain the holding temperatures of hot foods on the steam table above 135 degrees. The census was 172 and the sample size was 50. The findings included: 1. Review of the facility policy titled Dietary Considerations for Residents (Food and Water Emergency Supplies) revised June 2021, revealed the facility would maintain a minimum of food and water to last for three days in a specific location. Observation during initial tour on 12/27/2021 at 9:56 a.m. with the Dietary Manager (DM) revealed 17 cans of 71 ounces Campbell's Chicken Noodle Soup with a use by date of 1/10/2021, 12 cans of 50 ounces Campbell's Tomato Soup with a use by date of 5/30/2021, and four 5-pound cans of eggplant with a use by date of 7/30/2020.…

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 outdoor garbage and refuse area was maintained in a sanitary manner. The facility census was 172. Findings include: On 12/27/2021 at 10:15 a.m., an observation was made with the facility's Dietary Manager (DM), on a walk through to the garbage dumpster area, revealed wet debris including masks, bottle tops, and decomposing paper on the ground around the dumpster area. A review of the facility's monthly Sanitation Audit Report for the months of October 2021, November 2021, and December 2021 revealed no evidence that dietary personnel were responsible for ensuring that the dumpster area was clean and free of debris. Interview on 12/27/2021 at 10:15 a.m. with the DM, stated that she did not know who was responsible for keeping the area around the dumpster clean. Interview on 12/30/2021 at 12:17 p.m. with Administrator stated that everyone taking out trash is responsible for cleaning around the dumpster area. During further interview, she stated it is ultimately the responsibility of the dietary department 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, policy review and staff interviews, the facility failed to ensure one of four sampled residents (R) #58 with a mental illness, had a Level I Pre-admission Screening and Record Review (PASARR) accurately completed prior to admission to determine the need for specialized services. Findings included: Review of facility policy titled Preadmission Screening & Annual Resident Review (PASARR) Policy revised 11/20/2020, revealed The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The policy defined Mental Disorder/Serious Mental Disorder-An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: Diagnosis: The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,…

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.