Parkside At Budd Terrace Operating Company LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for two of two residents (Residents (R) 349 and R299) reviewed for activities out of a total sample of 63 residents. This deficient practice had the potential to negatively affect the quality of life for the affected residents. Findings include: Review of a facility's policy titled Activities dated April 2025 indicated, . It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. 1. Review of R349'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 observations, resident and staff interviews, record review and review of facility policy, the facility failed to ensure splints were consistently applied for two Residents (R)11 and R299) out of three residents reviewed for positioning and mobility. The facility's failure to ensure splints were applied consistently as ordered for these residents created the potential for the residents to experience a decline in range of motion (ROM). Findings include:Review of the facility's policy titled, Prevention of Decline in Range of Motion dated April 2025 indicated, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. 1. Review of R11's admission Record dated 03/23/2026 and located in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke,…

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 facility policy review, the facility failed to ensure an admission weight was obtained for one resident (Resident (R) 224) out of eight residents reviewed for nutrition. The failure to obtain an initial baseline weight for residents could cause the facility to not accurately determine weight loss or gain during the resident's stay. Findings include:Review of a facility's policy titled Weight Monitoring dated April 2025 indicated, . weight can be a useful indicator of nutritional status. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status' Assessments should include the following information.Weight. Review of R224's electronic medical record (EMR) titled admission Record indicated the resident was admitted on [DATE] with a diagnosis of chronic kidney disease.Review of R224's EMR titled Weights located under the Wts (Weights) & Vitals tab failed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, review of facility policy, the facility failed to ensure two Resident (R) R76 and R311 out of three residents reviewed for Intravenous (IV) Nutrition (i.e., Total Parenteral Nutrition (TPN)) received appropriate care related to the administration of their TPN. The facility's failure to ensure appropriate administration of TPN for R76 and R311 created the potential for these residents to experience a decline in physical status. Findings include: The facility's policy titled, Total Parenteral Nutrition (TPN) dated December 2024 indicated, The facility may administer and monitor residents receiving total parenteral nutrition (TPN) consistent with current standards of practice.Definition: Total Parenteral Nutrition (TPN) is a nutrient solution, including lipids, that is administered through a central venous access device. This solution usually consists of proteins, carbohydrates, electrolytes, vitamins, trace minerals, and lipids (as directed) .…

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, staff interviews, and review of facility policy, the facility failed to ensure bed rails were necessary and a consent was obtained prior to the use of bed rails for two (Residents (R)11 and R299) out of eight residents reviewed for accident hazards in the sample of 63 residents. The facility's failure to ensure bed rails were necessary for these residents created the potential for these and other residents to experience potential negative outcomes such as becoming entrapped in bed rails.Findings include:Review of the facility's policy titled, Proper Use of Bed Rails or Enabler Bar dated April 2025 indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails and/or the use of an enabler bar. Appropriate alternative approached are attempted prior to installing or using bed rails or an enabler bar.Informed consent from the resident or resident representative must be obtained (prior to use of the bed rails) .Upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure a medication error rate of less than five percent. There were four errors from 26 opportunities for one of eight residents (R) (R311) observed, for a medication error rate of 15.38 percent. The facility's failure to ensure a medication error rate of less than five percent created the potential for R311 to experience negative physical effects related to medication errors. Findings include:Review of the facility's policy titled, Medication Administration dated January 2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Ensure the six rights of medication administration are followed: a. Right Resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right…

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 facility policy, the facility failed to ensure one resident (R) (R311) out of eight residents reviewed for medication errors was free from a significant medication error. The facility's failure to ensure that R311 was free from significant medication errors created the potential for the resident to experience negative physical effects related to the medication errors. Findings include:Review of the facility's policy titled Medication Administration dated 01/2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Ensure the six rights of medication administration are followed: a. Right Resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation. Review of R311's admission Record dated 03/27/2026 in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, record review, and review of facility policy, the facility failed to ensure infection control practices were followed for one (Resident (R)311) of eight residents observed during medication administration. Specifically, the nurse administering the resident's medications failed to sanitize her hands and change her gloves after administering oral and inhaled medications, and before administering medication through a Peripherally Inserted Central Catheter (PICC) line. The facility's failure to ensure proper infection control during medication administration created the potential for cross-contamination and infection. Findings include:Review of the facility's policy titled, Medication Administration dated 01/2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and the facility's policy titled, Safe and Homelike Environment, the facility failed to ensure the residents' living area was safe, clean, and comfortable in four of 165 rooms (Rm 515, RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were free of buildup and debris and failed to ensure that a broken mirror was not stored on the floor in one of six Central bath areas. Findings include: Review of the facility's undated policy titled, Safe and Homelike Environment, revealed under Policy Explanation and Compliance Guidelines: 1. The facility will create and maintain, to the extent possible, a homelike environment that emphasizes the institutional character of the setting. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Initial screening observation on 5/27/2025 at 8:10 am in room…

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 resident and staff interviews, record review, and review of the facility's policy titled Coordination with PASAAR Program, the facility failed to provide Preadmission Screening and Resident Review (PASARR) Level II for two of six residents (R) (R54 and R75) with qualifying diagnoses. Findings include: Review of the facility undated policy titled, Coordination with PASAAR Program revealed under Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serios mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 5b. The Level II resident review must be completed within 40 calendar days of admission. Record Review revealed R54 was admitted to the facility with a diagnosis of but not limited to bipolar disorder current episode, aphasia, major depressive disorder, epilepsy, anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R54 has Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 59 sampled residents (R) (R36, R61, and R75) related to not receiving showers/baths, fingernails care and ADLs care. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs) indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. 1. Review of R36's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Section GG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled, Resident Self-Administration of Medications and Medication Storage, the facility failed to adequately assess two of 59 sampled residents (R) (R56 and R515) for self-administration of medication; failed to ensure one room was free from accident hazards. Specifically, medication was found in an unoccupied room (room [ROOM NUMBER]) on the second floor. The deficient practice had the potential to cause serious safety issues for residents, staff and visitors. Findings include: Review of the undated facility's policy titled Resident Self-Administration of Medications documented under the Policy Explanation and Compliance Guidelines section revealed, 1. Each resident if offered the opportunity to self-administer medication during the routine assessment by the facility's interdisciplinary team (IDT). 2. Resident's preference will be documented on the appropriate form and placed in the medical chat. 3. When determining…

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, resident, and resident family interviews, record review, and review of the facility's policy titled, Oxygen Concentrator, the facility failed to ensure physician orders for oxygen (O2) therapy were followed for two of eight residents (R) (R43 and R564) receiving oxygen. The deficient practice had the potential to cause abnormal respiratory function and adverse clinical outcomes. Findings include: Review of the undated facility's policy titled Oxygen Concentrator revealed under Section four, Use of Concentrator, subsection (a) The nurse shall verify the physician's orders for the rate of flow and route of administration of oxygen (e.g., mask, nasal cannula). Subsection (g) Plug in the unit, turn it on to the prescribed flow rate, and assess for proper functioning. 1. Review of the electronic medical record (EMR) revealed R43 was admitted to the facility with pertinent diagnoses including, but not limited to COVID-19, chronic pulmonary edema, obstructive sleep apnea, chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Pain Management, the facility failed to ensure adequate pain management for two of 59 sampled residents (R) (R371 and R43). Findings include: Review of the facility's undated policy titled Pain Management revealed the Policy stated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The Pain Assessment section included, 2. c. Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. 1. Review of R371's admission Record revealed R371 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified fracture of shaft or tight femur (thigh bone), fracture of right pubis (pelvis bone),…

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 Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were five errors from 40 opportunities observed for a medication error rate of 7.5 percent. This deficient practice had the potential to place resident (R) R12 at risk of medical complications and a diminished quality of life. Findings Include: Review of the facility's undated policy titled Medication Administration, revealed the Policy section included, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Observation on 5/28/2025 at 9:36 am of medication pass with Registered Nurse (RN) GG revealed R12's prescribed medications included losartan potassium 50 milligrams (mg)(a medication used to treat high blood pressure), Flonase 50 micrograms (mcg) (a medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review and review of the facility's policy titled, Residents' Rights & Responsibilities, the facility failed to ensure call lights were answered and care provided for one of three residents (R) (R1). Specifically, the facility failed to ensure R1 care needs were met after the initiation of the call light system. Findings include: Review of the facility's policy titled, Residents' Rights & Responsibilities dated September 28, 2023, under the Purpose statement revealed, [Facility Name] respects the rights of the patients / residents; recognizes that each patient / resident is an individual with unique healthcare needs, values, and cultural perspectives; and because of the importance of respecting each patient's / resident's personal dignity, provide considerate, respectful care focused on the patient's / resident's needs. Review of R1's admission Record revealed diagnoses of but not limited to unspecified osteoarthritis, other chronic pain, asthma,…

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 policy titled, Residents' Rights & Responsibilities, the facility failed to ensure one of three residents (R) (R1) the choice of time and preference for showers. Findings include: Review of the facility's policy titled, Residents' Rights & Responsibilities dated September 28, 2023, under the Purpose statement revealed, [Facility Name] respects the rights of the patients / residents; recognizes that each patient / resident is an individual with unique healthcare needs, values, and cultural perspectives; and because of the importance of respecting each patient's / resident's personal dignity, provide considerate, respectful care focused on the patient's / resident's needs. Under the section titled, Patients / Residents of [Facility Name] are entitled to the rights listed below revealed, number 10. Make informed decisions regarding his / her care. Review of R1's admission Record revealed diagnoses of but not limited to…

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

Based on observation, staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to follow professional standards of care for one of 26 Residents (R) (R134). Specifically, the facility failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR). Findings included: Review of the facility's policy titled, Medication Administration dated September 28, 2023, revealed under Purpose revealed, Medications are administered as ordered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Further review, under the Policy Explanation and Compliance Guidelines revealed, Number 17. Sign MAR after administered . Review of R134's undated admission record located in the resident's EMR under the Profile tab revealed R134 was admitted with diagnosis of 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 interviews, record review, and review of the facility's policy titled, Physician Verbal Orders, the facility failed to ensure a telephone order for one of 31 sampled Residents (R) (R290) were transcribed into the Electronic Medication Administration Record (EMAR) system which resulted in R290 not receiving the physician ordered medication. Findings include: Review of the facility's policy titled, Physician Verbal Orders, dated 9/28/2023, under the Policy Explanation and Compliance Guidelines revealed, Number three Enter the order into the medical record electronically. Review of R290's undated admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R290 was admitted with diagnosis that included dementia. Review of the admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/11/2023 revealed R290 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated severe cognitive impairment. Review of the Consultation Initial Visit note located in the EMR…

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 review, and review of the facility's policies titled, Fall Prevention and Fall Management, the facility failed to ensure a resident that required two-person assistance received adequate supervision during activities of daily living (ADL) care for one of four Residents (R) (R231) reviewed for accidents. This failure resulted in R231 falling from bed to the floor, sustaining neck pain and being transferred to the hospital. Findings include: Review of the facility policy titled, Fall Prevention dated 9/28/2023, provided by the facility, stated, . Ensure that the resident's care plan addresses her [sic] fall risk . Review of the facility policy titled, Fall Management dated 9/28/2023, provided by the facility, stated, . If you're with a resident as he [sic] falls, try to break his fall with your body and gently guide him to the floor . Review of the Progress Notes dated 10/28/2023, located in the Electronic Medical Record (EMR) under the Progress Notes tab revealed, CNA [certified nurses' aide] called writer to the room Upon arrival writer noted…

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 interview, record review and review of the facility's policy titled, Oxygen Management, the facility staff failed to maintain proper storage of a CPAP (continuous positive airway pressure) mask when not in use for one of one Resident (R) (R134) reviewed for oxygen use. Findings include: Review of the facility's policy titled, Oxygen Management, dated September 28, 2023, under the Policy Explanation and Compliance Guidelines revealed, Number 5. (e) Keep delivery devices covered in plastic bag when not in use. Review of R134's undated admission record located in the resident's Electronic Medical Record (EMR) under the Profile tab revealed R134 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. Review of R134's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/8/2023, located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R134 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.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage Rooms and Medication Carts, the facility staff failed to store physician ordered medications in a locked compartment when unattended for two of six medication carts in the facility. The facility census was 118. Findings include: Review of the facility's policy titled Medication Storage Rooms and Medication Carts dated September 28, 2023, revealed [Name of Facility] does not have medication storage rooms nor does the facility use medication carts on post-acute floors (6, and 7); however, it does use medication carts on long-term care floors (3 and 5). The facility has Omnicell cabinets which are the facility's automated medication dispensing system . During an observation on 12/21/2023 at 12:57 am, the sixth-floor medication cart was observed to have the following medications in unlocked drawers: Lactulose one (1) grams/(per) 15 ml (milliliter); 11 lancets used to perform fingerstick for blood sugars; and three Admelog (fast acting insulin) 100 units/ml and insulin syringe filled…

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, review of the policy titled Reporting Abuse Allegations and staff interviews, the facility failed to ensure that the Abuse Policy and Procedures were current and implemented, which had the potential to affect all residents. Substandard Quality of Care was identified related to Develop/Implement Abuse/Neglect Policies.The census was 115. The findings include: Review of the facility policy titled, Reporting Abuse Allegations effective 11/28/2016 revealed that POLICY: The facility shall ensure that all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property, are reported to the facility's administrator AND to the State Survey Agency (SSA) immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. [sic] The Regulatory guidance provided by the…

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

Based record review, staff interview, review of the Administrator Job Description, review of grievance files and Resident Council meeting minutes for 2023, facility Administration failed to ensure there was an up-to-date and effective Abuse Prevention Program, that consistently reported allegations of abuse by residents to the State Survey Agency (SSA) and that all staff were educated utilizing the most current Center for Medicare & Medicaid Service (CMS) regulations. The census was 115. The findings include: Review of the job description titled Administrator with a revision date of 1/2021 revealed Resident Rights the Administrator should know and respects patient's rights, report allegations of patient abuse, neglect and/or misappropriation of patient property. Staff Development communicates new Policy and Procedures and regulations to staff to ensure compliance. Administrator Responsibilities ensures that facility operations comply with local, state, and federal standards, laws and licensing and certifying bodies. Oversee completion of forms, reports, etc. including State…

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

Based on interview and review of the policy titled Quality Assurance and Performance Improvement Plan (QAPI) and QAPI minutes, the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans related to Abuse Prevention Policy and Procedure and to ensure that allegations of abuse were reported to the State Survey Agency (SSA). The census was 115. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan (QAPI) policy, revised 5/1/23, revealed Policy Explanation and Compliance Guidelines: 3. Data analysis-a. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. This data is reported to the QAPI Committee. An interview and discussion with the Director of Nursing (DON) on 9/29/23 at 12:10 p.m. revealed that the QAPI committee meets monthly and included the Administrator, DON, Director of Therapy, Director of Environmental Services, Director of Activities, Director of Social…

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, the facility failed to ensure that allegations of abuse were reported to the State Survey Agency (SSA) for three of 11 sampled residents (R) (R A, R5, and R12). The findings include: 1. Review of clinical record for R A revealed resident was admitted to the facility on [DATE] with multiple diagnoses including cerebral vascular accident (CVA) with left sided hemiplegia, chronic urinary tract infections (UTI), dementia, anxiety, depression, seizure disorder, chronic pain syndrome and borderline personality disorder. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Resident was dependent on staff for all activities of daily living (ADLs) care and always incontinent of bowel and bladder. The resident was assessed on admission with a feeding tube, at risk for development of pressure ulcers, although with no current wounds, 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, staff and resident interviews, the facility failed to ensure a care plan was developed for ostomy care for one resident (R) B of 22 sampled residents. The findings include: Review of the clinical record revealed that R B was admitted to the facility on [DATE] diagnoses including history of a small bowel obstruction and ostomy, decreased mobility post cervical surgery and infection, and Parkinson's Disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident was assessed with an ostomy in Section H-Bowel, and for a [NAME] Catheter for Intravenous (IV) antibiotic infusion. Review of the resident's care plan revised 8/1/2023 revealed there was no evidence of development for focus areas addressing resident's colostomy or the [NAME] catheter. Interview on 9/26/2023 at 11:15 a.m. with R B revealed the resident was in bed, with a neck brace in…

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