Perimeter Rehabilitation Suites By Harborview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, and policy review, the facility failed to ensure one of three residents (Resident (R) 13) reviewed for nutrition was served thickened liquids as ordered by the physician. This deficient practice had the potential to place R13 at risk of choking or aspiration of liquids into the lungs Findings include:Review of the facility's policy titled Therapeutic Diet Orders, dated 02/01/26, revealed, All diet orders are to be communicated to the dietary department in accordance with facility procedures. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of R13's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including malnutrition and dysphagia. Review of R13's admission MDS with an ARD of 01/02/26 and located under the MDS tab of the EMR, revealed a score of ten out 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 and staff interviews, the facility failed to ensure the clinical records were complete for one of one resident (R) 79) reviewed out of a total sample of 34 residents. This deficient practice had the potential to create the opportunity for inaccurate medical records to be accessible to staff. Findings include: Review of the facility policy titled Medication Administration with a revision date of 05/01/25, provided by the facility, indicated 20. Sign the MAR after administered. Review of a facility's policy titled Documentation in Medical Record, dated 03/01/25, indicated that .Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of Resident (R)79's admission Record found under the Profile tab of the electronic medical record (EMR) indicated an admission date of 12/27/25 with diagnoses of appendicitis, hemiplegia and hemiparesis, type 2 diabetes, major depressive…

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 facility policy review, the facility failed to adhere to infection control practices and policies during incontinence care for two of three residents (Resident (R) 172 and R181) observed for incontinence care in the sample of 51 residents. The deficient practice had the potential to place R172 and R181 at risk of cross-contamination and infection.Findings include: Review of the facility's policy titled Perineal Care with a revision date of 01/01/26 provided by the facility indicated that: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Review of the facility's policy titled Handwashing/Hand Hygiene with a revision date of August 2019 provided by the facility indicated that: 7. Use an alcohol-based hand rub containing at least 62% alcohol; 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 record review, observation, staff interviews, review of maintenance documentation, and review of facility policy, the facility failed to ensure siderails were securely attached to the bed for one (Resident (R) 190) of six reviewed for side rails out of a sample of 51 residents. The deficient practice had the potential to place R190 at increased risk of injury related to side-rail use. Findings include:Review of the facility's policy titled, Side Rail Safety, revised 03/01/25, indicated, Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth, checking bedrails regularly to make sure they are still installed correctly, and have not shifted or loosened over time. Review of R190's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R190 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and a review of the policy titled Resident Rights, the facility failed to ensure one of 18 sampled residents (R) (R16) was informed of their rights regarding treatment, financial liability, and resident rights upon admission to the facility. The deficient practice resulted in a resident not having informed consent, not knowing their financial liability, or what their rights were.Findings included:A review of the facility's policy titled Resident Rights dated 2/1/2025, indicated The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities.A review of R16's admission Record in the electronic medical…

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, document review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect the rights of one of eight residents (R) (R6) reviewed for abuse. Specifically, to be free from exploitation by a staff member. This failure had the potential to cause emotional distress or financial burden for R6.Findings included:A review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/15/2025 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. 'Exploitation' means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion.A review of R6's admission Record located in the electronic medical record (EMR) revealed she was admitted to the facility 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.

Based on interviews, document review, and review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three staff, Floor Technician (FT) (FT1), completed and documented a criminal background history, including a history of abuse, neglect, or exploitation, before employment. This failure had the potential to contribute to a substantiated allegation of exploitation for a facility resident (R) (R6). Findings included:A review of the facility's Abuse, Neglect and Exploitation policy dated 7/15/2025 revealed, The components of the facility abuse prohibition plan are discussed herein:I. ScreeningA. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.1. Background, reference, and credentials checks shall be conducted on potential employees,contracted temporary staff, students affiliated with academic institutions, volunteers, andconsultants.2. Screenings may be conducted by the facility itself, a third-party agency, or an academic institution.3. The facility will maintain…

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 a review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure an allegation of misappropriation of resident property was thoroughly investigated for two of eight residents (R) (R5 and R28) reviewed for abuse. This failure had the potential to contribute to further misappropriation of property in the facility. Findings included:A review of the facility's policy titled Abuse, Neglect and Exploitation dated 7/15/2025 revealed, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Written procedures for investigations include: 1. Identifying staff responsible for the investigation.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/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 interviews, record reviews, a review of the policy titled MDS 3.0 Completion, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code the quarterly Minimum Data Set (MDS) assessment for one of 52 sampled residents (R) (R20) related to a urinary tract infection (UTI) that was not coded when a resident returned from the hospital. This failure had the potential to result in incomplete care planning. Findings included:A review of the facility's policy titled MDS 3.0 Completion, revised/reviewed 03/01/24, revealed Policy: Residents are assessed, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional…

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 a review of the policy titled Diagnostic Testing Services, the facility failed to ensure a change of condition requiring immediate attention was addressed on time for one of seven residents (R) (R4) reviewed for change of condition. This failure had the potential to lead to increased pain or internal damage related to R4's dislocated left hip arthroplasty.Findings included:A review of the facility's policy titled Diagnostic Testing Services dated 10/1/2025 revealed, Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering Physician within 24 hours of receipt unless the report results falls outside of clinical reference ranges and require immediate attention at which time the Physician will be notified upon receipt . Documentation of diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.A review of R4's admission Record located in…

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

Based on interviews, record review, and a review of the facility's policy titled Resident and Family Grievances, the facility failed to acknowledge family concerns as grievances via email and failed to investigate grievances for one out of 48 sampled Residents (R) (R384). In addition, the facility failed to provide results for the concerns and grievances reported by residents during the Resident Council Meetings. The facility census was 214 residents. Findings included: A review of the facility's policy titled Resident and Family Grievances dated 3/1/2025 revealed that it is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Prompt efforts to resolve, including facility acknowledgement of a complaint/grievance. 1. (Name and Title) has been designated as the Grievance Official and can be reached at (contact information). 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion;…

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 the facility policy titled Nursing Services and Sufficient Staff, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility census was 214. Findings included: 1. An observation of the third floor, on 6/8/2025 at 10:15 am, revealed that the medication cart beside the nurse station was unlocked. No nurses were on the floor at the time of the observation. Resident (R) (R422) was sitting by the unlocked medication cart. The medication cart was unlocked from 10:15 am until 10:35 am, when a Certified Medication Aide (CMA) CCC locked the cart.An interview with CMA CCC, on 6/8/2025 at 10:35 am, revealed they believed the nurse was on break. The CMA attempted to contact the nurse by phone but was unsuccessful. The CMA locked the cart at 10:35 am and stated they would have the Licensed Practical Nurse (LPN) come and speak with me when she was back on the floor.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, interviews, and resident council minutes reviews, and staffing record reviews, the facility failed to provide a registered nurse (RN) to provide care for eight hours a day during the weekends. This failure to provide an RN eight hours a day during the weekends could result in reduced quality of care and one-star staffing levels. Findings included:During a record review of the Resident Council Minutes, not dated, revealed Multiple residents say that the call light response sometimes takes up to three hours and that the RCA's (Resident Care Assistants) will come and turn off without resolving their issue. [Resident Council President] says that he has witnessed nurses coming in and leaving medications on tray tables without making sure that the resident has taken them.During an interview with the Scheduler Coordinator SS, on 5/27/2025 at 10:38 am, said, Capacity for the facility is 240 residents. There is a bad staffing shortage for nurses. Nurses have a full template, meaning they work three days a week and every other weekend. The second floor has two nurses.…

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 post the nurse staffing data daily at the beginning of each shift. The facility did not ensure the nurse staffing data was posted daily in a prominent place readily accessible to residents, staff, and visitors. This practice had the potential to affect all residents in the facility. The facility census was 205. Findings included:1. During observation of the facility lobby on 6/8/2025 at 10:05 am revealed that nurse staffing data was posted by the front door, dated 6/6/2025.An interview with the Interim Director of Nursing (IDON) on 6/8/2025 at 12:15 pm revealed that the staff schedule from 6/6/2025 should not be posted. The IDON stated that a new staffing sheet should be posted daily. The IDON stated she would look into where the staff posting for 6/8/2025 was and why it was not posted. An interview with the IDON on 6/12/2025 at 3:00 pm revealed that the front desk receptionist who was at the facility on Fridays was usually given the weekend staffing to leave for the weekend receptionists to post. This receptionist…

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 of the facility assessment and staff interview, the facility failed to complete the facility assessment. This deficient practice has the potential to affect all residents. The facility census was 214 residents.Findings included:The Facility Assessment for Perimeter Rehabilitation Suites, dated 10/25/2024 by the Executive Director [Administrator] and reviewed by QAA (Quality Assessment and Assurance) Committee on 10/25/2024, section titled Information about our staffing patterns indicates Five Star Staffing Level is a 1 star. Administration- Staffing as described above is adequate as evidenced by: The resident's administrative needs are met. Information about our Staffing Patterns: Individual staff assignments are determined in order to promote continuity of care for residents within and across the assignments in the following ways: Maintaining the same staff on every floor as much as possible. Maintaining the staff based on the budgeted PPD and census. Staffing goals based on the information described above: The goal is to have actual PPD to be the same as…

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

Based on record review and staff interviews, the facility failed to maintain staffing requirements by receiving a one-star staffing rating and having excessively low weekend staffing. The deficient practice could result in a lack of needed care provided to the residents.Findings included:A record review of the Payroll Based Journal (PBJ) submitted to CMS (Centers for Medicare and Medicaid Services) revealed the facility had a one-star staffing rating and excessively low weekend staffing. A review of the CASPER report (essential tool provided by CMS for healthcare facilities to assess quality measures and improve patient care based on data from the Minimum Data Set (MDS)) provided to the facility on the first day of the survey (5/5/2025) revealed the facility had a one-star staffing rating and excessively low weekend staffing.A review of an All Staff Meeting dated 8/30/2024 revealed under 2d.1 star on staffing. i. As you all know, staffing is not where we want it to be. ii. The goal is to have a full staff in the building: 8 CNAs (Certified Nursing Assistants) on each floor, morning…

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, record review, and review of the facility's policies titled Infection Surveillance and Laundry, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure an ongoing system of surveillance for infections and failed to ensure the laundry room and equipment were kept clean, ensure washers were functioning properly, and ensure clean and dirty linens were stored appropriately. The deficient practices had the potential to affect all residents in the facility. The facility census was 212. Findings included: A review of the facility policy titled Infection Surveillance dated 6/1/2024 revealed that under Policy, A system of infection surveillance serves as a core activity of the facility's infection prevention and control programs. Its purpose is to identify infections and to monitor adherence to recommended infection prevention 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 and staff interviews, the facility failed to have handrails that were firmly secured and affixed to the corridor walls on three of the three resident floors of the facility (Second Floor, Third Floor, and Fourth Floor). Specifically, handrails were loose and crooked throughout each floor. The deficient practice had the potential to affect the residents who can use handrails on all floors. Findings included:The Director of Maintenance job description, revised in October 2020, revealed that the facility will conduct ongoing inspections to identify areas and equipment requiring improvement/repairs. Examine equipment, systems, and physical plant (i.e., buildings) to determine needed installations, services, or repairs.During an observation of the Third Floor on 6/8/2025 at 10:20 am, the handrails across from the Third Floor nurse station were loose and hanging crooked on the wall. The handrails across from room [ROOM NUMBER] were loose and hanging crooked on the wall. The handrails across from…

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

Based on resident and staff interviews, record reviews, and a review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure that resolutions were provided for concerns discussed in the Resident Council meetings. Findings included: A review of the policy titled Resident and Family Grievances, with an implementation date of 3/1/2022 and a revision date of 3/1/2025, included Prompt efforts to resolve include facility acknowledgment of working toward resolution of that complaint/grievance. A review of the Resident Council Meeting minutes dated January 2024 showed that during the meeting, a resident requested that her showers be scheduled between 7:00 am and 3:00 pm instead of between 3:00 pm and 11:00 pm. There was no resolution documented for the concern. A review of the Resident Council Meeting minutes dated February 2024, a resident voiced that his linens were not getting changed often enough, and he was having an issue with his sink. No resolution was documented for the concerns. A review of the Resident Council Meeting minutes dated March…

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 policies titled Notification of Changes, and Change of Room or Roommate, the facility failed to notify two of five sampled residents (R) (R381and R6) responsible parties of changes; and failed to notify one resident's (R) (R194) physician of a change in condition and transfer to the hospital. Findings included: During a review of the facility policy titled Change of Room or Roommate, revised 3/1/2025, revealed that .6. The social services designee or Licensed Nurse should inform the resident's sponsor/family in advance of a change in the resident's room or roommate. Review of the facility policy titled Notification of Changes dated 4/1/2024, revealed that the purpose of this policy is to ensure the facility promptly informs the resident and consults the resident's physician when there is a change requiring notification. These notifications include a significant change in the resident's physical, mental, or psychosocial condition and a transfer…

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 and interview, the facility failed to provide a safe, clean, and comfortable environment for residents receiving showers in two of the three shower rooms (Third Floor Shower room and Fourth Floor Shower room) in the facility. The shower rooms contained unsecured doors, soiled linens, resident gowns on the floor, unmarked toiletry items, trash, masks, and gloves on the floor, in addition to unclean toilets and equipment. Findings included: 1. Observation on 5/29/2025 at 10:55 am of the Third Floor Shower room revealed, the shower room door was propped open. There were no staff or residents in the shower room at the time of the observation. The shower room contained six wet and visibly soiled wash cloths scattered throughout on the floor, three wet bath towels scattered throughout on the floor, three used and unmarked bars of soap on the floor in the main shower stall, 12 pairs of gloves, inside out, scattered about the floor in multiple areas, multiple visible soiled tissues lying beside the toilet on the floor, and two shower chairs that had brown substance 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, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure medication carts were locked and secured when unattended by authorized staff. This failure had the potential to allow unauthorized access to medications and biologicals by staff, residents, and visitors. The facility's census was 214 residents. Findings included:A review of the facility's policy titled, Medication Storage, implemented 3/1/2022 and last revised 3/1/2025, included . 1: 1a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 1b. Only authorized personnel will have access to the keys to locked compartments. 1c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 1. During an observation on 5/22/2025 at 5:07 am, medication administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of facility policy titled Standardized Menus, the facility failed to serve food that was palatable, attractive, and hot for four of seven sampled residents (R) (R62, R114, R472, and R473) reviewed for food palatability. This failure had the potential to affect 203 of 214 residents who consumed food prepared from the facility's kitchen.Findings included:A review of the facility's policy titled, Standardized Menus revised 3/30/2025, revealed that the facility shall provide nourishing, palatable meals to meet the nutritional needs of the residents based on the Recommended Daily Allowances (RDA) of the food and Nutritional Research Council, of the National Academy of Sciences, standardized cycle menus are planned in advance and utilized. The policy continued that the facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents. A review of the Resident Council Meeting Minutes dated 2/2/2024 at 10:10…

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 Resident Funds Management Policy and Procedure, the facility failed to ensure one of 48 sampled residents (R) (R114) responsible parties (RP) had immediate access to the resident's funds. Findings included: A review of the facility's policy titled Resident Funds Management Policy and Procedure, revised 3/1/2022, revealed that .if a resident requests a check to be cut from their resident funds account, the facility will withdraw funds from the Resident Funds Account to the petty cash account and print the request within 24 hours. A review of the Electronic Medical Record (EMR) for R114 revealed an original admission date of 5/13/2022 with multiple diagnoses of, but not limited to, metabolic encephalopathy, dysphagia following cerebral infarction, acute pulmonary edema, Type II diabetes, hemoptysis, cognitive communication deficiency, and dysphagia. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy titled Confidentiality of Personal and Medical Records, the facility failed to safeguard the personal and medical information of residents. In addition, the facility failed to ensure computer screens located on the medication carts were locked when not in use by a nurse who displayed residents' personal and medical information. This affected two out of 48 sampled residents (R26 and R213). Findings included: A review of the facility policy titled Confidentiality of Personal and Medical Records, dated 3/31/2023, revealed that personal and medical records for residents are to be kept confidential, including written documentation, video, audio, and computer-stored information. 1. Observation of the Fourth Floor, on 5/30/2025 at 8:25 am, revealed that a medication cart was unattended in the hall outside of room [ROOM NUMBER]. No nurse was in sight at the time of the observation. The computer located on top of the medication cart was opened, and 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 Abuse, Neglect, and Exploitation, the facility failed to report an allegation of abuse incident for one of 48 sampled residents (R) (R101). Findings included: A review of the facility policy titled, Abuse, Neglect, and Exploitation, with an implementation date of 3/1/2022 and a review date of 7/1/2024, included, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Further review revealed the section titled Reporting/Response stated, reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. A review of the admission record for R101 showed that the resident was admitted 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, resident and staff interviews, record review and review of the facility's policy titled, Maintaining Minimum Data Set (MDS) Assessments, and the MDS Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure MDS assessments was accurately coded for two of 48 residents (R) (R114 and R155). Findings included: In a review of the facility policy titled Maintaining Minimum Data Set (MDS) Assessments, revised 9/1/2024, it was documented that .8. MDS information will be made available to all professional staff members who need to review the information in order to provide care to the resident. Review of the facility provided document titled MDS Resident Assessment Instrument (RAI) User's Manual for coding Active Diagnosis from the CMS RAI Version 3.0 Manual CH 3: MDS Items [I] October 2024 page I-17 revealed, Section I: Active Diagnosis in the last 7 days (cont.) 4. The resident was admitted without a diagnosis of schizophrenia. After Admission, the resident is prescribed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan to include activities of daily living (ADL) and legal blindness for one out of 48 sampled residents (R) (R387). Findings included: Review of the facility's policy titled Comprehensive Care Plans implementation date of 3/1/2022, read in part, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of R387's admission Record located in the electronic medical records (EMR) section revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, burn of second degree, legal blindness, and homelessness. Review of R387's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/2024, located in the resident's EMR under the MDS tab indicated the facility assessed R387 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 staff interviews, record review, and review of the facility's policies titled Comprehensive Care Plans and Fall Prevention Program, the facility failed to ensure that care plans were updated for three of 19 sampled residents (R) (R372, R393, and R122 ). Findings included: Review of the facility's policy titled Comprehensive Care Plans implemented 3/1/2022 and last revised 3/1/2025, documented on page 2: The comprehensive plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Qualified staff responsible for carrying out the interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the facility's fall prevention policy titled, Fall Prevention Program: implemented 3/1/2022 and last revised 8/1/2024, revealed on page 2: Each resident's risk factors, and environmental hazards will be evaluated when developing 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.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure Activities of Daily Living (ADL) care was provided for one of four residents (R) (R212) reviewed. Findings included: A review of the facility's policy titled Activities of Daily Living (ADLs), implemented 3/1/2022 and last revised 3/1/2025, documented that 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. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. A review of the Electronic Medical Record (EMR) for R212 revealed an original admission date of 2/21/2025 with diagnoses including, but not limited to, multiple injuries, contusion of lung, injury at unspecified level of thoracic spinal cord, injury at unspecified level 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 and staff interviews, the facility failed to provide podiatry services for one of 48 sampled residents (R) (R 384). The deficient practice had the potential to lead to a lack of nail care and inappropriate foot care.Findings included:A review of the electronic medical record (EMR) revealed that R384 was admitted with diagnoses including but not limited to aphasia following cerebrovascular disease, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, major depressive disorder, nontraumatic intracerebral hemorrhage in subcortical hemisphere, cardiac murmur, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified psychosis not due to a substance or known physiological condition, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and vitamin deficiency.The most recent Minimum Data Set (MDS) assessment, dated 6/7/2024, revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment.A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policy titled Restorative Program, the facility failed to ensure two of eight Residents (R) (R95) and (R183) received restorative therapy. Findings included: Review of the facility's policy titled Restorative Nursing Programs, implemented 3/1/2022 and last revised 3/1/2024, revealed that it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. A resident's Restorative Nursing plan will include: a. The problem, need, or strength that the restorative tasks are to address. b. The type of activities to be performed. c. Frequency of activities. d. Duration of activities. e. Measurable goal and target date. Review of electronic health records (EHR) revealed that R183 was admitted to the facility with diagnoses that included, but were not limited to, muscle weakness, spinal stenosis lumbar, difficulty in walking, and…

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

Based on record review, interview, and review of the facility policy titled Nurse Aide Training Program, the facility failed to ensure each Certified Nursing Assistant (CNA) employed by the facility had a minimum of twelve hours of nurse aide training per year, for one of five CNAs reviewed for the required training. Findings included:A review of the facility policy titled Nurse Aide Training Program dated 3/1/2025, revealed that each nurse aide shall be provided 12 hours of in-service training annually. A review of the required yearly Training Transcript for CNA HHH revealed that from April 2024 to April 2025, the CNA only had 10.7 training hours.During an interview with the Interim Director of Nursing (IDON) on 6/5/2025 at 8:35 am, it was confirmed that CNA HHH did not meet the required twelve hours of CNA training from April 2024 to April 2025.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family member and staff interviews, record review, and review of the facility policy titled, Elopement Policy: Procedure for Locating Missing Resident, the facility failed to notify the State Reporting Agency and the Police of an elopement in a timely manner for one of seven sampled residents (R) (R1). Findings include: Review of the Elopement Policy: Procedure for Locating Missing Resident indicated: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. Review of admission diagnoses for R1 indicated diagnoses of mental disorder, autistic disorder, psychotropic disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, which included measurable objectives and timeframes to meet a resident's medical needs for four of 33 sampled residents (R) (R11, 72, 125, and 162) Related to (1) antidepressant medication usage for R11; (2) observing for side effects and behaviors for the resident's antidepressant medication usage for R72; (3) observing for side effects and behaviors for R125's antidepressant medication usage; (4) for risk of falls for R162. Findings included: A review of the facility policy, Use of Psychotropic Medication, dated 6/1/2023, revealed: residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 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 observation, record review, and interview, the facility failed to date and label resident food items in the refrigerator, failed to keep the refrigerator clean, and failed to keep the microwave clean in between uses. This failure had the potential to affect all residents that resided on the third-floor unit, 65 residents out of 220 residents in the building. Findings included: A review of facility policy and procedure titled, Date Marking for Food Safety, dated 4/1/2023, states the following: Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety .Policy Explanation and Compliance Guidelines for Staffing: Refrigerated, ready-to eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 [degrees] F [Fahrenheit] or less for a maximum of seven days. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for the date marking the food 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 observations, interviews, and record review, the facility failed to provide an environment that was free from accident hazards for one of 45 sampled residents (R) (R162). Findings included: The facility's policy for fall prevention titled, Fall Prevention Program, was reviewed. The policy was reviewed/revised by the facility on 3/1/2023. Step three of the policy described interventions for residents with a low to moderate risk for falls. One of those interventions read, Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. Step six of the policy indicated that each resident's risk factors, and environmental hazards would be evaluated when the comprehensive care plan was being developed, and that interventions would be monitored for effectiveness. A review of the medical record for R162 revealed an admission date of 11/22/2022 with diagnoses including Parkinson's Disease and a history of falls with fracture. 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 interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for three of seven residents (R11, R72 and R125) reviewed for unnecessary medications. Findings included: A review of the facility policy, Use of Psychotropic Medication, dated 6/1/2023, revealed: residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The record also revealed: 12. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regiment review, c. During MDS review (quarterly, annually, significant change),…

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 staff interview, the facility failed to ensure medications were secured in locked compartments when not within direct line of sight of the staff observed during medication administration on two of three floors (Fourth Floor and Third Floor). Findings included: On 10/10/2023, at 10:33 am during facility tour, an observation outside the door of room [ROOM NUMBER] on the fourth floor revealed that the medication cart was left unlocked and unattended. Certified Medication Aide (CMA) LL was in resident's room [ROOM NUMBER] administering medication and did not have a visual view of the unlocked medication cart which was not secured by the locking mechanism. There were noted to be visitors, staff, and residents who passed in the vicinity of her medication cart. During an interview on 10/10/2023 at 10:35 am, with CMA LL, she was asked if she was aware that she had left the medication cart unlocked and unsecure. She stated, Yes I am, but I don't have keys to the medication cart, the nurse has 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 reviews, the facility failed to maintain clinical records that are complete, accurate, readily accessible, and systematically organized for one of 33 sampled residents (R) (R125) reviewed for medical records accuracy. Findings included: A review of the admission Packet revealed for Personal Belongings that: all personal items brought from home and/or hospital should be documented on [an] inventory sheet. Record review of the policy Resident Personal Belongings, dated 3/1/2022, revealed: Residents and families are encouraged to inventory belongings with the Resident Care Assistants on admission. As new items are brought into the facility during the resident's stay, residents and family are encouraged to notify the social worker or designee so that the items may be inventoried. The residents and families are encouraged to refrain from keeping cash and are encouraged to bring cash to the business office to be kept in the safe. A review of R125's face sheet dated 10/12/2023 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.

Based on observations and interview, the facility failed to ensure staff administered medications in a manner to prevent the spread of infections for two of four residents (R) (R201 and R216) observed during medication administration. Findings included: During medication administration observation on 10/11/2023 at 8:25 am, Registered Nurse (RN) KK was observed preparing medications to be administered to R201. RN KK opened the drawer to the medication cart, took out medications in packaged unit dose envelopes, and began to punch each medication in a plastic medication cup. When RN KK popped three tablets of escitalopram (Lexapro) 5 mg from a bubble pack, the tablets dropped into his ungloved right hand and with his bare ungloved fingers. He then placed the tablets into the plastic medication cup and administered these medications to R201. During medication administration observation on 10/11/2023 at 8:36 am, RN KK was observed preparing medications to be administered to R216. RN KK opened the drawer to the medication cart, took out medications in a packaged bubble pack, and began 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.