Atlantic Specialty Care

Based on observation, interview and policy review the facility failed to ensure that medications were secured to prevent residents from access. In an observation the survey team found an unlocked, unattended medication cart in the hallway of resident rooms. The facility reported a census of 61 residents. Findings include: In an observation on 3/24/25 at 11:31 AM, it was discovered that an unlocked, unattended medication cart was at the end of a hallway of resident rooms. At 11:33 AM Staff I, Certified Medication Aide (CMA) came around the corner from the nurse's stations at the opposite end of the hallway. She said that she had been in a resident's room administering medications, then went down the hallway to talk to the nurse. She acknowledged that she failed to lock the drawers before she walked away from the cart. On 3/27/25 at 11:59 AM, the Director of Nursing (DON) said that the nurses and CMA's were expected to have the medication cart locked if/when they ever walk away from it and it's not within eye site. According to facility policy titled: Security of Medication Cart,…

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, document review, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 1 of 61 residents reviewed. The facility reported a census of 61 residents. Findings include: Continuous observation on 3/25/25 at 12:05 AM of Staff C, Cook, prepared modified barbeque (BBQ) pork for the noon meal. Staff C indicated needed 8 ground servings of BBQ pork. The staff removed 8 servings of the BBQ pork and placed 4 servings twice in the lid of the Robot Coupe food processor to transfer to the bowl of the Robo Coupe. The staff placed the lid on the processor, turned the machine on, and walked away. Staff C removed the BBQ pork from the processor and poured it into a measuring cup. The Registered Dietitian (RD) intervened as the BBQ pork appeared as pureed consistency rather than mechanical soft. The RD instructed Staff C to place it back in the processor, add BBQ sauce 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, resident interview, clinical record review, staff interview and policy review the facility failed to maintain accurate medical records for 1 of 16 residents reviewed. Staff documented that the vital signs for Resident #61 had been completed and the chart lacked documentation of those vitals. The facility reported a census of 61 residents. Findings include: The Care Plan for Resident #61, updated on 2/5/25, showed that she had diagnoses that included Congestive Heart Failure (CHF), acute respiratory failure, and weight fluctuation due to diuretic use and document signs and symptoms of Coronary Artery Disease (CAD) such as dependent edema. The Progress Note dated 2/5/25 at 4:47 PM, showed that Resident #61 was admitted for skilled nursing services from the hospital after Atrial fibrillation (AFib) with rapid ventricular response RVR (condition characterized by an irregular heartbeat with a rate exceeding 100 beats per minute.) The Progress Note dated 2/5/25 at 6:38 PM, showed that Resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 (intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility policy review the facility failed to ensure that staff used appropriate infection control practices to prevent the spread of pathogens for 1 of 3 residents reviewed. Staff failed to change gloves after adjusting a soiled brief for Resident #27 she then touched other surfaces with the same gloved hand. The facility reported a census of 61 residents Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #27 had an indwelling catheter and a colostomy. He was totally dependent on staff for transfers, showers and personal hygiene. The resident had diagnoses that included: heart failure, renal insufficiency, multiple sclerosis and benign prostatic hyperplasia. The Care Plan last updated on 7/29/24 showed that Resident #27 had a Foley catheter and was at risk for a potential skin and soft tissue infections. Staff were instructed to use enhanced barrier precautions when performing high-contact care activities. On 3/25/25 at 7:04 AM, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, clinical record review, and facility policy review the facility failed to provide dignity by staff swearing in the hallways outside the residents' rooms for 2 of 6 residents (Resident #2 and #5) reviewed. The facility reported a census of 57 residents. Findings Include: 1. Record review of the Minimum Data Set (MDS) for Resident #2, dated 8/8/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive functioning. The document revealed the resident had adequate hearing and did not utilize hearing appliances. On 10/22/24 at 12:43 PM Resident #2 stated he had heard staff using swearing when having conversations in the hall. The resident confirmed it was not another resident using swear words. Resident #2 stated the language that he heard did bother him. 2. Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The document revealed the resident had adequate hearing, and did not utilize a hearing appliance.…

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 clinical record review, resident and family interviews, staff interviews and facility policy review the facility failed to provide the needed services in accordance with professional standards by not completing neuroogical assessments after falls for 2 of 2 residents (Resident #1 and #5) reviewed. Resident #1 self reported an unwitnessed fall from bed on 8/24/24 and sustained a hematoma on the right side of his forehead. Resident #5 had a witnessed fall involving a motorized scooter, and sustained a hematoma on the forehead and 3 skin tears on 9/12/24. The facility reported a census of 57 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment for Resident #1, dated 8/29/24 documented a Brief Interview for Mental Status (BIMS) score of 8 indicating a moderate cognitive impairment. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS documented diagnosis of hypertension, non-Alzheimer's Dementia, seizure disorder or epilepsy. 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 clinical record review, interviews, and facility policy reviews, the facility failed to provide adequate nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents (Resident #2, #3, #5, and #6). The facility reported a census of 57. Findings include: 1. Record review of the Minimum Data Set (MDS) assessment of Resident #2 dated 8/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating normal cognitive functioning. The resident had diagnoses of displaced intertrochanteric fracture of left femur with routine healing, osteoarthritis, difficulty in walking, and low back pain. Resident #2 required partial/moderate assistance with transfers, lying to sitting on the edge of bed, and dressing. The resident was dependent on toileting. Resident #2 utilized a manual wheelchair (w/c) for mobility. The resident was always continent of bowels and bladder. On 10/22/24 at 12:43 PM Resident #2 stated he has waited longer than 30 minutes for a call light to be answered. The resident stated if he had to wait…

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, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during medication administration (Resident #8, #7, and #3). The facility reported a census of 63. 1. During continuous observation of medication administration on 8/12/24 at 11:40 AM Staff A, Certified Medication Aide (CMA) did not consistently complete hand hygiene between 4 residents. 2. During continuous observation of medication administration on 8/12/24 at 11:55 AM Staff B, CMA, did not complete consistent hand hygiene between 16 residents. 3. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive function, and the resident independent with toileting and transfers. Resident #8's Care Plan revealed the resident would transfer to the floor and independently use the toilet. At 12:55 PM on 8/12/24…

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, clinical record review, and staff interviews, the facility failed to protect residents from possible accidents and injuries for 2 of 3 residents (#3, #9). The facility reported a census of 63 residents. Findings include: 1. Review of Resident #3's Minimum Data Set ( MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating normal cognitive function. The resident used a manual wheelchair (w/c) and could propel up to 150 feet independently. Resident #3's care plan revealed the resident used a w/c for mobility. On 8/12/24 at 1:06 PM Staff B, Certified Medication Aide, pushed Resident #3 from the dining room to her room without the use of foot pedals. On 8/12/24 at 2:36 PM the resident stated she normally self propels her w/c. On 8/13/24 at 11:15 AM Resident #3 self propelled her w/c in the hallway. 2. Review of Resident #9's MDS assessment dated [DATE] revealed a BIMS score of 11/15 indicating moderate cognitive impairment. The resident utilized a…

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

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 65 residents. Findings include: The PBJ Staffing Data Report run date 5/31/24 triggered for Excessively Low Weekend Staffing - submitted weekend staffing data is excessively low. Review of Facility Daily Assignment Sheets for each day of the months of October, November and December 2023 staffing revealed staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. The month of December reflected 3 CNA's frequently on the overnight shift during the week and on weekends. On 6/5/24 at 12:06 PM the Administrator confirmed the submission of the data for the PBJ was not submitted correctly. The Administrator stated she spoke with Corporate. The Administrator stated Corporate told him that the report triggers this response because…

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 clinical record review, facility record review, staff interviews and facility policy review the facility failed to ensure that residents received accurate and timely assessments and interventions for 5 of 6 residents reviewed. Staff failed to intervene when Resident #25 and #57 had significant weight loss. Resident #120 had a change in condition and staff failed to monitor vitals. Resident #59 was at risk for dehydration related to tube feedings and a catheter and staff failed to monitor his urinary output. Staff failed to complete the recommended neurological assessments after Resident #119 had an unwitnessed fall. The facility reported a census of 65 residents. Findings include: 1) According to the MDS assessment dated [DATE], Resident #120 had a BIMS score of 0 (severe cognitive deficits). She was independent with eating, and totally dependent on staff for toileting, dressing, bed mobility and transfers. The Care Plan revised on 3/27/23, showed that Resident #120 used a wheelchair for mobility, but…

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 interviews, staff interviews, grievance log review, clinical record review and policy review, the facility failed to ensure that call lights were answered in a timely manner for 11 of 21 residents reviewed. The facility reported a census of 65 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident was admitted to the facility on [DATE] after an acute hospital stay. He was totally dependent for toileting, transfers and lower body dressing. Resident #57 used a wheelchair for mobility and he was occasionally incontinent of urine and always continent of bowel. Diagnoses for Resident #57 included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene and necrosis of the lung. The Care Plan updated on 5/31/24, showed that Resident #57 had the potential for impairment to skin integrity related 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 observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 4 of 15 residents (Residents #7, #9, #38, and #60) reviewed. The facility reported a census of 65 residents. Findings include: 1. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. During an interview on 6/3/24 at 12:11 PM Resident #7 stated the food is cold when it should be hot, and the food is overcooked. 2. Review of Resident #60's MDS assessment dated [DATE] documented a BIMS score of 10 indicating moderate cognitive impairment. During an interview on 6/3/24 at 11:42 AM Resident #60 stated the food is cold when it should be hot. Resident #60 further stated he wouldn't feed the food to his dog. During continuous observation on 6/5/24 at 1:12 PM the room trays and assisted meals were sent out of the kitchen to be delivered to the residents.…

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 clinical record review, observations, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when providing personal care to a resident, during medication administration, and when providing care to a resident on enhanced barrier precautions (EBH) for 5 of 12 residents reviewed for infection control. The facility reported a census of 65 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #31 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the Clinical Physician Orders for Resident #31 revealed an order for a coude catheter size 18 French to be changed monthly and as needed. On 6/5/24 at 8:01 AM a continuous observation of catheter cares completed on Resident #31 revealed Staff K, Certified Nursing Assistant (CNA) completed hand hygiene, donned a gown, and donned gloves. Staff K completed all catheter cares on Resident #31 with sleeves of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, staff interviews, clinical record review and personnel record review, the facility failed to ensure that all residents were treated with dignity and respect for 2 of 4 residents reviewed. Resident #57 reported that he has been left to sit on the bed pan for over 50 minutes and he felt upset and angry because he had a sore on his bottom. Resident #35 reported that staff scolded her for drinking too much water and urinating in the bed. The facility reported a census of 65 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #57 had a Brief Interview for Mental Status score of 15 (intact cognitive ability). The resident was admitted to the facility on [DATE] after an acute hospital stay. He had moderately impaired vision, not able to see newspaper headlines but could identify objects. He was totally dependent for toileting, transfers and lower body dressing. Resident #57 used a wheelchair for mobility and he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review the facility failed to enter accurate assessment information in the Minimum Data Set (MDS) for 2 of 21 residents reviewed (Resident #36 and #33). The facility reported a census of 65 residents. Findings include: 1) According to the MDS dated [DATE], Resident #36 had a BIMS score of 9 (moderate cognitive deficit). The resident was independent with hygiene, dressing, transferring and walking. Diagnoses included hypertension, Alzheimer's Disease, anxiety and muscle weakness. The MDS documented the resident was on an antiplatelet medication. An MDS dated [DATE] showed that he was on an anticoagulant (warfarin, heparin, or low-molecular weight heparin). The Care Plan for Resident #36 revised on 10/25/23 indicated that Resident #36 was on anticoagulant/blood thinning medication related to left anterior fascicular block. The Clinical Physician Orders revealed an order for clopidogrel (Plavix, antiplatelet) 75 milligrams (mg) dated 7/28/23. 2. The MDS…

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 electronic record review (EHR), observations, policy review, resident interview, and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for activities or activities of interests and documented insulin on a care plan for a resident who was not on insulin for 1 of 5 residents reviewed (Resident #61). The facility reported a census of 65 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #61 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. An observation on 6/3/24 at 2:38 PM of Resident #61 sitting at bingo by herself with no markers on the bingo card. No staff helping with the activity. On 6/3/24 at 2:39 PM Resident #61 stated she was not interested in playing bingo at that time. An observation on 6/03/24 at 3:40 PM of Resident #61 sitting in the dayroom with several other residents sleeping. An observation on 6/4/24 at 2:30 PM revealed activity staff…

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 clinical record review and facility policy review the facility failed to update resident care plans with changes. Resident #57 admitted to the facility on insulin for type 2 diabetes. The order was discontinued on 4/15/24 due to lack of use. Staff failed to update the care plan. Resident #36 was on an antiplatelet medication (Plavix). Staff failed to use the proper classification on the care plan and referred to the medication as an anticoagulant/blood thinner. The facility reported a census of 65 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #57 had a Brief Interview for Mental Status score of 15 (intact cognitive ability). The resident was admitted to the facility on [DATE] after an acute hospital stay. Diagnosis for Resident #57 included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene and necrosis of the lung. He had some coughing or choking during meals or when swallowing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, resident interview and clinical record review, the facility failed to follow physician's orders for 1 of 21 residents reviewed. Resident #57 had chronic skin damage on his gluteal area related to moisture and positioning. In an observation it was discovered that the ordered barrier cream and treatments were not in place. The facility reported a census of 65 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #57 had a Brief Interview for Mental Status score of 15 (intact cognitive ability). The resident was admitted to the facility on [DATE] after an acute hospital stay. He was totally dependent for toileting, transfers and lower body dressing. Resident #57 used a wheel chair for mobility and he was occasionally incontinent of urine and always continent of bowel. Diagnosis for Resident #57 included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene and necrosis 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 electronic record review (EHR), resident observation, policy review, resident interviews, and staff interviews the facility failed to implement resident centered activities for 1 of 5 residents reviewed (Resident #61). The facility reported a census of 65 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #61 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. An observation on 6/3/24 at 2:38 PM of Resident #61 sitting at bingo by herself with no markers on the bingo card. No staff helping with the activity. On 6/3/24 at 2:39 PM Resident #61 stated she was not interested in playing bingo at that time. An observation on 6/3/24 at 3:40 PM of Resident #61 sitting in the dayroom with several other residents sleeping. An observation on 6/4/24 at 2:30 PM revealed activity staff sitting outside with residents. Resident #61 not present at that time. An observation on 6/5/24 at 11:44 AM revealed Resident #61 sitting 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 clinical document review, resident interview, staff interview, and policy review the facility failed to provide services to increase range of motion or prevent a decrease in range of motion for 1 of 3 residents (Resident #42) reviewed. The facility reported a census of 65 residents. Findings include: Review of the Minimum Data Set (MDS) assessment for Resident #42 dated 4/25/24 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further documented diagnosis of hemiplegia following cerebral infarction affecting the left non-dominant side. Review of Resident #42's Care Plan revealed a restorative plan for omni cycle or nu step 10-15 minutes 3 times weekly and PRN (As necessary). Review of Resident #42's restorative program documents for the month of 5/2024 revealed no documentation of minutes for the month along with no signatures of completion. During an interview on 6/5/24 at 3:03 PM with Resident #42 revealed his insurance discharged him from therapy at the beginning of May of this year. Resident #42 revealed that the…

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

Based on electronic health records review (EHR), staff interviews, policy review, and observations, the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not accurately administering supplemental formula according to physician's order and pushing medications with a piston syringe into feeding tube for 1 of 1 residents (Resident #59) reviewed. The facility reported a census of 65 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #59, dated 4/25/24 documented a Brief Interview for Mental Status score indicating the resident is rarely / never understood. The MDS documented a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. Review of Resident #59's Clinical Physician Orders documented PEG Tube feedings: Osmolite 1.5 Cal continuous feed at 60 mL/hr over 12 hours. Osmolite 1.5 provides 1078 kcal. 45 grams protein, and 550 mL of water. Tap water flush q1h at 60ml Start 8pm and off 8am. In an observation on 6/4/24 at 4:00 AM it was discovered that the tube feeding for Resident #59 was set for 70…

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 interview, staff interview and clinical record review the facility failed to conduct post-dialysis assessments for 1 of 1 resident reviewed (Resident #57). The facility reported a census of 65 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #57 had a Brief Interview for Mental Status score of 15 (intact cognitive ability). The resident was admitted to the facility on [DATE] after an acute hospital stay. Diagnosis for Resident #57 included diabetes mellitus, anxiety, depression, chronic kidney disease, nutritional deficiency, acute pain, gangrene and necrosis of the lung. Resident #57 had hemodialysis treatments while a resident at the facility. The Care Plan updated on 5/31/24, showed that Resident #57 was at increase nutritional risk related to chronic kidney disease and diabetes. The resident to receive hemodialysis related to end stage renal disease. Staff directed to monitor and report any signs or symptoms of renal insufficiency 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 clinical record review, staff interview and policy review the facility failed to document accurate information in the residents electronic file for 1 of 4 residents reviewed for falls. Resident #119 had an unwitnessed fall and staff began neurological assessments to determine change in status. The neuro assessments included notation that the vital signs had been completed as directed. Further review revealed the chart lacked the vital signs. The facility reported a census of 65 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #119 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive deficits). She required partial assistance with toileting, dressing, hygiene, sit to stand and toilet transfers. She did have 1 fall with minor injury since admission. The Care Plan created on 5/21/24, showed that she was at risk for falls, and interventions included encouragement to use the call light, and a physical…

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, clinical record review, resident interview and staff interviews, the facility failed to assure each resident received care in a manner that maintained privacy of a resident's body for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #4 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident had diagnoses including neurogenic bladder and Parkinson's disease. The resident had an indwelling urinary catheter. The Care Plan identified the resident had a suprapubic dated 2/15/24. The interventions included catheter care for every shift. The Care Plan identified the resident had a skin and soft tissue diabetic wound infection located right heel/side of foot revised 2/2/24. The interventions included administering treatments as ordered. The Care Plan identified the resident had a diabetic ulcer of the right heel…

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, clinical record review, and staff interviews, the facility failed to assure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers from developing, promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents reviewed (Resident #6). The facility reported a census of 67 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #6 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident depended on staff for toileting hygiene and traveling in the wheelchair, and required partial to moderate assist in chair to bed transfer, and rolling in bed. The resident did not walk. The resident had diagnoses including acute kidney failure, diabetes, and non-Alzheimer's dementia. The resident did not have pressure ulcers, but was at risk for developing pressure ulcers. The Braden scale for Predicting Pressure Sore Risk dated…

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 clinical record review, resident interviews, family interviews, staff interviews and facility policy review the facility failed to treat residents with respect and dignity for 4 of 4 residents reviewed (Resident #7, #2, #15 and #10). The facility reported a census of 67 residents. Findings include: 1. Record review of Resident #7's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status of 15 out of 15 indicating no cognition impairments. The MDS also documented she is dependent on staff to assist her with transferring to the toilet and from bed to her chair. Resident #7's active diagnoses include cancer, paraplegia, and diabetes. During an interview on 12/11/23 at 11:23 AM with Resident #7 revealed staff at the facility are nice to her for the most part. She stated some staff can sometimes be short and not so nice, but she doesn't want to get anyone in trouble. She then proceeded to explain a Certified Nurse Aide (CNA) is no longer allowed to work with her because they do not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interviews, family interviews, staff interview and facility policy review the facility failed to ensure residents were provided with routine toileting assistance throughout the day to avoid being incontinent for 4 of 4 residents reviewed (Resident #7, #15, #9 and #10). The facility reported a census of 67 residents. Findings include: 1. Record review of Resident #7's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status score of 15 out of 15 indicating no cognitive impairments. The MDS also documented she is dependent on staff to assist her with transferring to the toilet and from her bed to her chair. Resident #7's active diagnosis include cancer, paraplegia, and diabetes. During an interview on 12/11/23 at 11:23 AM Resident #7 stated she is incontinent and only gets her underwear changed about twice a day and has to sit in her urine for a long time waiting for them to change her. She also stated she is ok with being changed twice a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, family interview, staff interview, and facility policy review, the facility failed to notify family after an incident for 1 of 3 residents. Resident #9 sustained an injury to her leg when her motorized wheel chair ran into the bed frame and staff failed to call the family after the incident. The facility reported a census of 68 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #9 had a BIMS score of 15 out of 15 indicating intact cognitive ability. The MDS documented she used a motorized wheel chair, was frequently incontinent of urine and always continent of bowel. The Care Plan updated on 7/18/23, documented Resident #9 required staff assistance for activities of daily living, required the help of 2 staff for transfers, and used an electric wheelchair for mobility. The Care Plan also documented the resident required the assistance of 2 staff for toileting and repositioning. An addition was made to the Care Plan on 11/14/23 that showed…

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 clinical record review, family interview, staff interviews and facility policy review the facility failed to provide timely and complete assessments for 1 of 3 residents reviewed. Resident #9 sustained an injury on her leg after she ran her electric wheel chair into the bed and her leg got wedged under the bed frame. The facility failed to assess for safe use of an electric wheel chair and failed to provide ongoing monitoring and documentation of the cellulitis of the leg that ensued after the accident. The facility reported a census of 68 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive ability. The MDS documented she used a motorized wheel chair, was frequently incontinent of urine and always continent of bowel. The Care Plan updated on 7/18/23, documented Resident #9 required staff assistance for activities of daily living and required the help of 2 staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review the facility failed to ensure 1 of 3 residents (Resident #4) was provided adequate nursing supervision to prevent him from exiting the building. The facility reported a census of 67 residents. Findings include: According to the admission Minimum Data Set (MDS) assessment tool dated 8/1/23, documented Resident #4 Brief Interview of Mental Status (BIMS) score of 0 out of 15 indicating severe cognitive impairment. The MDS documented she required supervision with one-person physical assistance for bed mobility, transfer, locomotion, dressing, eating, toilet use and personal hygiene. The MDS documented he utilized a cane for mobility and did not use a wander/elopement alarm. The following diagnoses were documented for Resident #4: stage 3 kidney disease, dementia with behavior disturbances. The Care Plan focus area with an initiation date of 7/26/23 documented Resident #4 required staff assistance for activities of daily living. 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 clinical record review, resident interviews and staff interviews the facility failed to ensure that staff responded to call lights in a timely manner for 2 of 3 residents reviewed. Resident's #15 and #9 stated that during the evening and overnight hours, at times it took over an hour for staff to respond to the call lights and they became incontinent because they had to wait so long. The facility reported a census of 68 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive ability. The Care Plan dated 11/25/23, documented Resident #15 was admitted to the facility to receive occupational and physical therapy with goals to transition back to home, was unable to ambulate independently and utilized a wheel chair for mobility. The Care Plan documented he had a urinary catheter and required 2 staff for assistance in toileting and for transfers. It documented he had…

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.