Azria Health Park Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, guidance from the Centers for Disease Control (CDC) and facility policy review, the facility failed to offer the recommended COVID-19 vaccine to eligible residents for 3 of 5 residents reviewed for vaccines (Resident #14, Resident #41 and Resident #50). The facility reported a census of 51 residents. Findings include:1.The Minimum Data Set (MDS) of Resident #14 dated 10/22/25 documented an admission date to the facility of 10/16/25 and a date of birth of [DATE]. It also indicated that he was not up to date with his COVID-19 vaccination.The Electronic Health Record (EHR) indicated that Resident #14 received the COVID-19 vaccination on 12/4/25 at 12:00 AM and no education was provided. The EHR lacked documentation of offering, educating or declination of vaccination prior to this time and date. The progress notes indicated that the vaccination time was actually 8:14 AM on 12/4/25.2.The MDS of Resident #41 dated 10/8/25 documented an admission date to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and policy review, the facility failed to provide a clean, comfortable and homelike environment. The facility also failed to maintain and ensure adequate supplies of the appropriate sized briefs to meet the needs of all residents who used briefs and pull-ups, and failed to ensure an adequate supply of resident care supplies and linens for two of two units. The facility identified a census of 59 residents.Findings include: Observations on the North Hall on 9/3/25 starting at 12:34 PM revealed the following: a. The window air conditioner (AC) vent in room [ROOM NUMBER] had a black substance that appeared to be mold and dirt inside the vents. The AC was on during this time. b. The window AC unit in room [ROOM NUMBER] had a black substance that appeared to be mold in the vents. The room smelled musty. c. room [ROOM NUMBER]- the bathroom floor in front of the toilet had a black non-skid strip missing and particles of old glue on the floor. The wall base was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, call light reports, resident council meeting notes, and policy review the facility failed to provide sufficient staff to meet resident needs with toileting assistance and answering call lights (within 15 minutes) for 2 of 2 units. The facility reported a census of 59 residents. Findings include:1.The Quarterly MDS assessment dated [DATE] revealed Resident #15 had diagnoses of a hip fracture, cerebrovascular accident (CVA) (Stroke), muscle weakness and a history of falls. The MDS revealed the resident had a Brief Interview for Mental Status score of 12 out of 15 indicating moderately impaired cognition. The resident had dependence on staff for transfers. The Care Plan revised 8/21/25 revealed Resident #15 had an ADL impairment related to impaired mobility and a recent surgical repair of her hip fracture. The resident had a fall with major injury on 8/21/25. The Care Plan directed staff to be sure to respond promptly to all requests for…

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

Based on observations, resident, and staff interviews, Centers for Disease Control (CDC) website data, and resident council meeting notes the leadership of the facility failed to provide adequate management of the facility. The Administrative team failed to provide adequate incontinent supplies, linen supplies and a comfortable homelike environment free of vermin. In addition, the facility failed to provide the residents with a clean kitchen. The facility identified a census of 59 residents. Findings include:Observations conducted on 9/3/25 at 12:34 PM revealed the following concerns during a walk through the North hallway; black like substances on vents of two air conditioners in two resident rooms, missing wall base in two resident rooms, minimal incontinent supplies in the North Clean Utility room (1 package XL briefs, 3 packages of wipes), room22 bathroom ceiling with spackling /heavy patches. Also, during the initial walk through the building resident mattresses were noted to been stained, a strong foul smell was noted in different areas of the building, stained linen on beds,…

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 review of Certification and Survey Provider Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), staff interview, and review of the facility QAPI (Quality Assurance Performance Improvement) plan, the facility failed to ensure an effective process to address previously identified quality deficiencies. The facility reported a census of 59 residents.Findings Include:The CASPER Report for the facility identified the facility had previously received an Infection control deficiency in 2023 and 2024. A Safe, clean, and homelike environment deficiency in 2023 and 2024. At the conclusion of the complaints survey on 09/11/2025 the facility was cited again for Infection control and Homelike environment. The Facility's QAPI Plan, revised 2/05/2025, identified a monitoring process which included multiple sources of data. The QAPI Plan failed to identify a process to address previously identified quality deficiencies.Review of the QAPI minutes since 11/27/2024 identified repeat deficiencies and deficient practices from the last standard survey, but did 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 direct observation, clinical record review, resident and staff interview, and facility policy review, the facility failed to provide incontinence care and transfers in a manner that promotes hygiene and protects residents from the spread of disease when they failed to change contaminated gloves and used another residents mechanical lift sling without sanitizing it first for 3 of 4 residents reviewed. (Resident #1, #8, and #12). In addition, the facility failed to utilize Enhanced Barrier Precautions (EBP) when providing care to a resident with an indwelling catheter (Resident #8). The facility reported a census of 59.Findings include: 1. The significant change Minimum Data Set (MDS) for Resident #8, dated 10/15/2024, documented the residents Brief Interview for Mental Status (BIMS) Score as 14, indicating intact cognition. It documented the following relevant diagnosis of indwelling catheter. It also documented the residents dependency on staff for transfers and the use of a wheelchair for mobility. 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 observation, resident and staff interviews, manufacturer instructions, and policy review the facility failed to lock brakes on a bed when staff repositioned and provided cares for 1 of 3 residents observed (Resident #12), and failed to operate a mechanical lift safely for 2 of 3 residents observed for transfers (Resident #12 and #1). The facility reported a census 59 residents. Findings include: 1.The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of left above the knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder. The MDS recorded the resident had no falls since re-entry to the facility on 3/14/25. The MDS documented the resident had dependence on staff for transfers. The Care Plan revised 1/24/25 revealed the resident had a risk for injury related to falls. The Care Plan revealed staff directives to use a mechanical lift and two staff for transfers. The care plan documented the resident had a fall out of bed 12/30/24 and diagnosed with…

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

Based on observations, staff interviews, and policy review, the facility failed to ensure a homelike environment and reduce clutter in the hallway for 2 or 2 units (North and South Halls). The facility reported a census of 49 residents. Findings include: Observations revealed the following: a. On 11/19/24 at 10:45 AM, the North hall had equipment parked in the hallway by the handrails including a mechanical lift, a shower chair, a stand mechanical lift, a plastic bin with drawers containing Personal Protective Equipment (PPE), carts for trash and soiled laundry, two medication carts, a treatment cart, and a wheelchair. At the same time, the North/Central hall had equipment parked along the hallway and handrails including a mechanical lift, a stand mechanical lift, and a large motorized wheelchair. At 10:55 AM, the staff on the North hall had to move to the side of the hallway in order to allow a male resident to propel his wheelchair down the hall to his room. At 12:45 PM, a wheelchair sat by the exit door in the North hall. The North hall had a stand mechanical lift, a plastic bin…

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

Based on observations, staff interviews and facility policy review the facility failed to store and serve food in a sanitary manner. The facility reported a census of 49 residents. Findings include: 1. Observation of dinner service on 11/20/24 at 5:20 PM revealed Staff C [NAME] was serving dinner in the dining room. Staff C placed tin pans in the steam table then licked her right index finger. Staff C continued with food service without washing her hands after licking her finger. At 5:45 PM in between plating resident's food, Staff C placed her right hand on her mouth, touching her lips with her finger tips and hand. Staff C continued with dinner service without washing her hands. On 11/21/24 at 1:00 PM Staff D Dietary Aide and Staff E [NAME] were in the kitchen. Staff E had a hair net up with his long hair hanging out the bottom of the hair net, resting on his shoulders. Staff D had his hair in braids and pulled back in a pony tail with the hair net only covering the hair in the pony tail. The hair net was not covering his hair his pony tail at the center of the back of his head to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility investigation file review, resident and staff interviews, and facility policy review, the facility failed to ensure all allegations of abuse including allegations of staff to resident verbal threats and rough treatment, and inappropriate touching of a resident's buttocks by Staff A were reported timely to the facility administration for three of four residents reviewed for abuse (Resident #10, #38, and #28). The incident of alleged abuse that occurred on 8/8/24 was not reported to the Department of Inspections, and Appeals and Licensing (DIAL) until 8/30/24. The allegation of abuse on 10/21/24 was not reported to DIAL until 10/23/24. The facility reported a census of 49 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had diagnoses of cerebral vascular disease (CVA) (stroke), hemiplegia, anxiety disorder, and chronic pain. The MDS recorded the resident had a Brief Interview for Mental Status (BIMS) of 13 indicating…

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.

2. A Past Calls report dated 9/20/24 to 11/19/24 revealed call light response greater than 15 minutes for the following: a. Room North (N) 10: 9/20 - 9/30/24: 16 times, with the longest response time 2 hours and 33 minutes 10/1 - 10/31/24: 35 times, with the longest response time 2 hours and 12 minutes 11/1 - 11/18/24: 5 times, with the longest response time 33 minutes The majority of call light response times greater than 15 minutes occurred on the evening (2 PM - 10 PM) and night (10 PM - 6 AM) shifts. b. Room N20 9/20 -9/30/24: 6 times with the longest response time 2 hours and 17 minutes 10/1 - 10/31/24: 42 times with the longest response time 3 hours and 3 minutes 11/1 - 11/18/24: 17 times with the longest response time 1 hour and 1 minute. The majority of call light response times greater than 15 minutes occurred on the night (10 PM - 6 AM) and evening (2 PM - 10 PM) shifts. During an interview 11/26/24 at 8:40 AM, the Regional Director of Operations reported call light response times were part of the facility's Quality Assurance Performance Improvement (QAPI) process. 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 facility record review, staff interview, and policy review, the facility failed to provide three of three sampled residents the required properly filled out forms for Medicare Liability Notices and Beneficiary Appeals within 48 hours of when skilled services ending (Resident # 26, # 204, # 205). The facility reported a census of 49 residents. Findings include: Record review of Resident #26 revealed last day of skilled coverage was dated 10/29/24. The facility issued a Notice of Medicare Non-Coverage (NOMNC) Centers for Medicare Services (CMS) Form #10123 and the form was signed before the 48 hour required window. However, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) CMS form #10055 was not present. Record review showed Resident #26 was a current resident of the facility at the time of the survey. Record review of Resident #204 revealed last day of skilled coverage was dated 06/27/24. The facility issued a NOMNC CMS Form #10123 that was signed by the power of attorney (POA) on 06/24/24, well within the 48-hour required window. However,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility policy review the facility failed to accurately complete 1 of 30 resident's (Resident #47) MDS assessment tools. The facility reported a census of 49 residents. Findings include: According to the Discharge Return Not Anticipated Minimum Data Set (MDS) assessment tool with a reference date of 8/23/24. The MDS documented Resident #47 was admitted to the facility on [DATE] from a short-term general hospital. The MDS indicated he was discharged from the facility on 8/23/24 to a short-term general hospital. The Care Plan focus area with an initiation date of 8/12/24 documented Resident #47 wished to returned to prior living arrangement at his group home. Review of a document titled Discharge Plan, Instructions and Summary dated 8/21/24 with a lock date of 9/3/24, documented Resident #47's goals of care and treatment preferences were to return to group managed facility. Resident #47 was discharged on 8/23/24 to a waiver-based housing with home health. Review of a…

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

Based on clinical record review, facility policy, and staff interview, the facility failed to submit a new preadmission screening and resident review (PASRR) level 1 screening as required for 1 of 20 residents screened (Resident #32). The facility reported a census of 49. Findings include: The Annual Minimum data set (MDS) for Resident #32, dated 08/02/2024, documented a brief interview for mental status score (BIMS) score of 11, indicating moderate cognitive impairment. It recorded the following relevant diagnoses: stroke, non-Alzheimer's dementia, hemiparesis, seizure disorder, depression, and psychotic disorder. The Care Plan for Resident #32, last revised 11/14/2024, documented a delusional disorder and the antipsychotic and antidepressant therapy currently used by the resident to manage symptoms. The Medication Administration Record (MAR), dated 11/2024, documented use of Olanzapine, an antipsychotic, every day in the month. It further documented the use of Venlafaxine, a selective Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) used to treat depression, every day in 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, staff interview, and facility policy review, the facility failed to track and document behaviors for residents taking psychiatric medication for 3 of 3 residents screened (Resident #32, #11, and #24). The facility reported a census of 49. Findings include: 1. The Annual Minimum data set (MDS) for Resident #32, dated 08/02/2024, documented a brief interview for mental status score (BIMS) score of 11, indicating moderate cognitive impairment. It recorded the following relevant diagnoses: stroke, non-Alzheimer's dementia, hemiparesis, seizure disorder, depression, and psychotic disorder. The Care Plan for Resident #32, last revised 11/14/2024, documented the resident had alterations in mood and behavioral symptoms and was receiving antipsychotic and antidepressant therapy to manage symptoms. It directed staff to attempt non-drug approaches to redirect behavior as appropriate, but did not document what behaviors the resident had nor what non-drug approaches should be used. Review of the Medication Administration Record (MAR), dated 11/2024, documented…

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, observation, staff interview and manufacturer's instructions, the facility failed to administer insulin flexpen to ensure the proper amount of insulin administered for one resident observed who received insulin during medication pass (Resident #28). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a diagnosis of Diabetes Mellitus, and had received insulin injections seven of the seven days during the lookback period. The Medication administration record (MAR) dated 11/01/24 through 11/30/24 revealed insulin Lispro subcutaneous solution 8 units injected subcutaneously three times a day. During an observation on 11/20/24 at 01:14 PM, Staff P, Licensed Practical Nurse (LPN), prepared to administer the Lispro pen-injector to Resident #28. She was observed taking the medication out of the box, checking the MAR, and then administering the medication to Resident #28. She was not observed 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, environmental tour, resident, staff and laundry personnel interviews, the facility failed to provide clean, available linen draw-pads for resident care and failed to keep a clean, safe, and comfortable homelike environment. The facility reported a census of 48 residents. Findings include: On 2/28/24 at 10:50 am, Staff E, Certified Nursing Assistant (CNA) stated the facility did not have enough facility linen in the mornings. He stated if the night shift used a lot of linen (i.e. wash clothes, draw pads, etc.), the morning staff had to wait until the laundry was washed, restocked and available. He stated linen would not be available until 10:30 am one to two times per week. Observation on 2/28/24 at 10:57 am revealed the South nursing hall linen supply closet revealed no draw pads were stocked. Staff F, Certified Medication Aide (CMA) toured the supply closet and confirmed no draw pads were available. On 2/28/24 at 11:00 am, Staff A, CNA stated there wasn't enough linen (pads, chucks,…

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, staff interviews, and facility policy and procedure review, the facility failed to give medications as directed per the physicians orders during medication pass for (Resident #13), and failed to draw labs as ordered for (Resident #7) failed to follow physician orders for 3 of 3 residents reviewed (Resident #16, #19, and #20). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #13 with diagnosis for which included hypertension, ulcerative colitis, chrones disease, diabetes mellitus, arthritis and restless leg syndrome. The resident had a Brief Interview for Mental Status (BIMS) score of 13 for which indicated no impaired cognition, and required dependence with activities of daily living. The Clinical Physicians Orders on the Point Click Care Program dated 2/2/23, instructed to take Rivaroxaban (Xarelto)(medication to treat and prevent blood clots) oral tablet 20 milligrams by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, the facility failed to maintain accurate resident records for 4 of 4 residents reviewed, (Resident #7, #16, #19 and #20). The facility census was 48 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 with diagnosis for which included anemia, atrial fibrillation and aphasia. The resident had short and long term memory impairments and modified decision making abilities and required assistance with activities of daily living. The MDS also documented the use of anticoagulant in the last 7 days. The Progress Notes dated 1/2/24 at 5:41 p.m., documented resident is on Coumadin and will required INR checks on Wednesday. Labs needed CBC (complete blood test)(used to look at over all health), CMP (comprehensive metabolic panel)(test that measures 14 different substances in the blood), Lipid (blood test that can measure the amount of cholesterol and triglycerides in your blood), A1C (a blood test that measures your average…

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, resident and staff interview along with facility policy and procedure the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 out of 5 resident reviewed. (Resident #6 and #17). The facility identified a census of 48 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #6, with an assessment reference dated 1/25/24, documented diagnosis for which included Renal insufficiency, renal failure, diabetes mellitus, cerebrovascular accident, anxiety and depression. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems, has adequate hearing and is able to make self understood and has the ability to understand others. The MDS document that the resident required total assistance with the toilet, personal hygiene, and is always incontinent of bowel and bladder and received a diuretic in the last 7 days. The Plan of Care with a…

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

Based on observations, resident and staff interview, clinical record review and policy review the facility failed to provide appropriate incontinence care by failing to ensure all stool was removed from the resident's skin for 1 of 1 resident reviewed (Resident #8) and failed to assist a resident with incontinency (Resident #6) and failed to assist a resident with supervision at meals (Resident #15). The facility reported a census of 48 residents. Findings include: 1. On 2/28/24 at 11:07 AM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, provided peri-care to Resident #8 following a incontinent bowel movement. Staff B cleaned the resident's intergluteal cleft and the posterior portion of his scrotum. A round area of stool remained on Resident #8's left hamstring after Staff B helped the resident dress. At 11:20 am, Staff B stated she was not certain she cleaned the resident's skin completely and noted the stool on his hamstring upon rechecking his skin. Staff B cleaned the resident's skin and helped him dress. The Quarterly MDS for Resident #8 dated 1/31/24 identified…

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, staff and resident interview at the time of the investigation, the facility failed to promptly identify and intervene for two residents that were at risk for pressure ulcers for 2 of 2 residents reviewed. (Resident #1 and #2). The facility identified a census of 48 residents. Findings include: 1. A Quarterly Minimum Data Set (MDS) completed for Resident #1 with an Assessment Reference Date (ARD) of 12/8/23, documented diagnosis for which included peripheral vascular disease, diabetes mellitus, non-Alzheimer dementia and depression. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others and does not resist cares. The resident required partial to substantial assistance from staff for dressing, toilet use and personal hygiene and dependent with transfers. The MDS also documented a wheelchair as prior…

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, staff interviews, and facility policy review, the facility failed to ensure a door was alarmed in the basement for which one (1) resident who was seen getting onto the elevator with staff supervision and went down to the basement (Resident #16) and failed to supervise two (2) residents who were not suppose to be in left in rooms unsupervised (Resident #15 and #16) and also failed to keep medication carts locked at all times on two (2) incidents. The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 documented diagnosis for which included hypertension, non-Alzheimer dementia and low back pain. The MDS documented the resident with a Brief Interview for Mental Status (BIMS) score of 9 for which indicated moderately impaired decision making abilities, adequate hearing and has the ability to be understood and understand others, no wandering observed, a walker used for mobility and independent with…

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

Based on record review, staff interview and facility policy the facility failed to have 1 of 3 residents seen at least once every 60 days by the physician. (Resident #6) The facility census was 48 residents. Finding include: 1. The Quarterly Minimum Data Set (MDS) for Resident #6, with an assessment reference dated 1/25/24, documented diagnosis for which included Renal insufficiency, renal failure, diabetes mellitus, cerebrovascular accident, anxiety and depression. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 13, for which indicated no impairments with decision making or memory problems, has adequate hearing and is able to make self understood and has the ability to understand others, needs total dependence on toilet and personal hygiene and is always incontinent of bowel and bladder and receives a diuretic in the last 7 days. The Clinical Record for Resident #6 documented that the Advanced Registered Nurse Practitioner seen the patient on these dates: *11/2/2023 *11/16/23 *12/7/23 *12/14/23 *2/1/24 *2/15/24 *2/19/24 *3/5/24 The clinical…

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, along with the facility policy, the facility staff failed to answer resident call lights in a timely manner (no longer than 15 minutes) for 3 of 3 residents reviewed . (Resident #2, #14 and #15). The facility identified a census of 48 residents. Findings include: 1. A Minimum Data Set (MDS) assessment form dated 2/22/24 documented Resident #2 had diagnosis that included orthostatic hypotension, neurogenic bladder, . The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no impaired decision making abilities. The assessment documented the resident as dependent on two (2) staff members with bed mobility, toilet use and personal hygiene and total assistance of one person physical assist with bathing. During an interview on 1/19/22 at 2:44 p.m., Resident #2 stated that it will take the staff over an hour an a half to answer the call light. During an interview on 2/10/22 at 10:00 a.m., Staff C, Certified Nurses Aide (CNA) confirmed and verified that it will take over 15 minutes 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 observations, staff interview, clinical record review and policy review the facility failed to provide appropriate catheter care to prevent urinary tract infections for 1 of 1 residents reviewed (Resident #8) and failed to provide hand hygiene supplies to prevent cross contamination for 3 of 3 residents (#8, #9, and #10). The facility reported a census of 48 residents. Findings include: On 2/28/24 at 11:07 AM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, provided peri-care to Resident #8 following a incontinent bowel movement. Staff B cleaned the resident's intergluteal cleft and the posterior portion of his scrotum. A round area of stool remained on Resident #8's left hamstring after Staff B helped the resident dress. (677) On 2/28/24 at 11:15 am, Staff B helped the resident get dressed and raised the urinary catheter collection bag above the resident's bladder and allowed the urine in the catheter tubing to flow back toward the resident's bladder. She guided the collection bag through the left leg opening of the resident's shorts and released 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 policy review, document review, and staff interview the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility reported a census of 49 residents. Findings include: Review of document with effective date of 9/1/18 titled, Abuse, Neglect, and Exploitation Prohibition and Prevention Program Policy revealed. a. All prospective employees undergo a background-screening process in accordance with Human Resource policies and procedures and applicable law. Review of background check for Staff C revealed the background check was completed 3/2/11. Review of an untitled document with staff phone number and hire dates provided by the facility revealed a hire date for Staff C of 8/7/23. On 11/15/23 at 2:24 PM Staff D stated Staff C had been hired at least 3 times in the past. Staff D stated the facility's expectation was that the background check would have been resubmitted and received prior to rehiring Staff C. On 11/15/23 at 2:54 PM the Administrator stated staff would have resident direct care training…

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 policy review, observation, document review, and staff interview the facility failed to make nursing staff information readily available in a readable format to residents and visitors at any given time. The facility failed to post the nurse staffing data. The facility reported a census of 49 residents. Findings include: An observation on 11/15/23 at 2:30 PM revealed nursing staff information posted outside of the DON's office on a bulletin board had staffing from 11/9/23 posted. Review of an untitled document on 11/15/23 with nursing staff information revealed nursing staff information for the date of 11/9/23. On 11/15/23 at 2:54 PM the Administrator stated the facility's expectation was that the nursing staff information would be posted readily available to residents at any given time. The Administrator stated he had designated a staff to post the information but was not being completed as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interviews the facility failed to complete Monthly Medication Regimen Review (MRR) by a licensed pharmacist for 4 of 5 residents reviewed (#14, #18, #31, & #37). The facility reported a census of 49. Findings include: 1. Review of a facility binder titled, Pharmacy Monthly Regimen Review revealed it was completed by a licensed pharmacist for the months of February, March, May, June, and July 2023, but not reviewed by the pharmacist for the months April, September, & October. During an interview 11/15/23 at 4:33 PM Staff H revealed that MRR's could not be proven that they were completed and sent to the Primary Care Physician (PCP). Staff H further revealed her expectation is for MRR's to be completed and sent to the physician for review every month. Review of a facility provided policy titled, Medication Regimen Reviews with a revision date of May 2019 documented: 1. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending…

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, 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 18 of 49 residents reviewed. The facility reported a census of 49 residents. Findings include: Review of an undated document titled Consistency List revealed 4 residents required a pureed diet, 2 residents requested pureed meat diet, and 12 residents required a mechanical soft diet. On 11/13/23 at 4:15 PM Staff I, Cook, stated the serving size scoop for the pureed sandwich would be either a green #12 or blue #16. Staff I stated he would use the blue #16. Staff I stated he did not know what the serving size was for beets because the week one menu was in the dietary managers office. Staff I stated he did not know how many mechanical soft diets were ordered. An observation of the supper meal service on 11/13/23 at 5:10 PM revealed Staff I used a blue handled scoop #16 for pureed sandwich and a red handled scoop #24 for pureed beets. Review of document titled…

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 document review and staff interview the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager. The facility reported a census of 49 residents. Findings include: Request for documentation from Staff L of qualifications for dietary manager revealed no certification or documentation. On 11/15/23 at 3:00 PM Staff A, Senior [NAME] President of Clinical Services, stated the dietary manager is not certified as a dietary manager and does not have a certificate. Staff A stated the facility does not have a policy on employment of a dietary manager. On 11/15/23 at 11:05 AM the Administrator stated the facility's expectation was that the facility would employ a full time dietitian or a certified dietary manager. The Administrator stated the facility did not employ either at that time.

Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling foods that were open with open dates, did not maintain chemical solution at the correct concentration in a low temperature dish machine, ensure kitchen staff wear hair restraints appropriately, and did not practice appropriate hand hygiene by touching food and contaminated objects. The facility reported a census of 49 residents. Findings include: An observation of supper meal service on 11/13/23 at 5:10 PM revealed Staff I completed hand hygiene prior to meal service. Staff I then picked up a grilled cheese sandwich with his bare right hand and placed the sandwich on a plate. Staff I then used a scoop with his right hand to serve soup into a bowl with left hand holding the bowl. Staff I then used tongs in his right hand to serve beets into a bowl held in left hand. Staff I then picked up the next sandwich with his right hand and placed it on the next plate. This service continued without hand hygiene through the entire meal service. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing catheter cares, enteral tube feedings, wound care and personal care for residents, and failed to review the infection control policy annually with appropriate staff. The facility reported a census of 49 residents. Findings include: 1. On 11/13/23 at 1:40 PM an observation revealed Staff O, CNA standing in front of the administrators office door with a COVID test in hand. Staff O was not wearing a mask. Staff O was discussing symptoms and the COVID test with the used COVID test in hand without a mask. Staff O walked back down to the DON's office with the test in hand. DON present in office with Staff O while not wearing a mask. Staff O applied her mask prior to leaving the facility. A resident was present in DON's office while Staff O was present. Staff O walked down 2 resident halls with residents present in the hallways and rooms to obtain the COVID-19…

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 policy review, document review, and staff interview the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property and procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property when 3 employees reviewed did not have current training for Dependent Adult Abuse. The facility reported a census of 49 residents. Findings include: Review of document with effective date of 9/1/18 titled, Abuse, Neglect, and Exploitation Prohibition and Prevention Program Policy revealed: a. The facility maintains an abuse-prevention training program for all new hires and existing staff that is consistent with their expected roles. b. Resident rights and abuse-prevention training is conducted during orientation and at least annually for all employees. Request for documentation of Dependent Adult Abuse training from the Administrator for Staff E, Staff F, and Staff G revealed no documentation or certificate for Staff E…

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 policy review, document review, and staff interview the facility failed to ensure continued competence of nurse aides by failing to provide the required in-service training at a minimum of 12 hours per year for 5 of 5 employees reviewed. The facility reported a census of 49 residents. Findings include: Review of the last 12 months of nursing aide in-service revealed 2.5 hours completed for the month of January 2023 and 1 hour for the month of August 2023. Review of document revised 8/22 titled In-Service Training, Nurse Aide revealed annual in-services are no less than 12 hours per employment year. On 11/15/23 at 2:19 PM the Administrator stated the facility's expectation was nursing aides would have completed at least 12 hours of in-service training a year. The Administrator stated the in-service training documents provided were all that could be found for the last year of in-services.

Based on observation, staff interview, and policy review the facility failed to complete activities of daily living on a resident requiring assistance with gown change and hygiene. The facility further failed to provide privacy to a resident requiring enteral feeding for 2 of 8 residents reviewed (Residents #21 & #32). Findings include: 1. Record review of the Minimum Data Set (MDS) for Resident #21, dated 9/3/23 revealed diagnoses of cysticercosis (a parasitic tissue infection caused by larval cysts of the tapeworm), dysphagia, thrombocytopenia, and gastrostomy status. During an observation 11/14/23 at 12:15 PM Staff B Licensed Practical Nurse (LPN) entered Resident #21's room and announced to Resident #21 who she was and what she was doing. Staff B then did not check placement of Resident #21's gastrostomy tube before completing water flushes and enteral feeding. During this observation it was noted that Staff B did not have the door shut with Resident #21's shirt up exposing the abdomen. Halfway through this observation Staff P (LPN - Unit Manager) was in Resident #21's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews and the facility policy review, the facility failed to keep a clean, safe, and comfortable homelike environment. The facility reported a census of 49 residents. Findings include: 1. An observation during the facility's environmental tour on 11/13/23 from 1:50 PM to 2:30 PM revealed the following concerns: a. The primary wall in room [ROOM NUMBER] South had an area of spackle that was unpainted. b. The wall in room [ROOM NUMBER] South had peeled paint above the bed's headboard. c. The wall in room [ROOM NUMBER] South had unpainted spackle above the bed's headboard. There was also a large puddle of water on the floor in the center of the room slightly closer to the entry door. d. The door magnet used to hold the door open in room [ROOM NUMBER] South was misaligned and had to be manually adjusted to function properly. e. The wall across from the South unit nurses' station had a dried, brown liquid stain that resembled splashed beverage. On 11/20/23 at 9:30 AM, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview the facility failed to notify the Long-Term Care Ombudsman of a transfer to the hospital for 2 of 3 residents reviewed (Resident #24, and #34). The facility reported a census of 49 residents. Findings include: 1. Review of Resident #24's Electronic Health Record (EHR) revealed that Resident #24 was hospitalized from [DATE] through 6/2/23. 2. Review of Resident #34's EHR revealed that Resident #34 was hospitalized from [DATE] through 4/13/23. Review of the facility policy for notifying the Long-Term Care Ombudsman revealed there was no policy. During an Interview 11/15/23 at 10:54 AM with Staff A and the Administrator revealed the facility had no ombudsman notification for these hospitalizations. Staff A and the Administrator revealed their expectation is for notification of the ombudsman when a Resident is sent to the hospital.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents reviewed (Residents #24, #34). The facility reported a census of 49 residents. Findings Include: 1. Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a most recent admit date from an acute hospital stay dated 4/13/23. Review of Resident #24's Electronic Health Record (EHR) revealed that Resident #24 was hospitalized from [DATE] through 4/13/23. 2. Review of Resident #34's MDS dated [DATE] revealed a most recent admit date from an acute hospital stay dated 6/2/23. Review of Resident #34's EHR revealed that Resident #34 was hospitalized from [DATE] through 6/2/23. During an Interview 11/15/23 at 10:54 AM with Staff A and the Administrator revealed the facility did not have bed hold notifications for these hospitalizations. Staff A and the Administrator revealed their expectation is for a bed hold to be completed when a Resident is sent to the hospital.…

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, staff interviews, and policy review, the facility failed to implement a comprehensive care plan for 3 of 3 residents reviewed (Residents #1, #4, & #25). The facility reported a census of 49 residents. Findings include: 1. On 11/13/23 at 1:54 PM, a post-it note was observed on Resident #4's dresser directing staff to weigh the resident daily before breakfast. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. It also indicated the resident required extensive, one-person assistance with all Activities of Daily Living (ADLs) except eating. The Electronic Health Record (EHR) included diagnoses of Morbid Obesity, Chronic Atrial Fibrillation (irregular heart rhythm), Chronic Kidney Disease (CKD), urine retention, and Congestive Heart Failure (CHF). The EHR Weight and Vitals section revealed multiple days with no documented weight. 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 observation, clinical record review, policy review, and staff interview, the facility failed to provide staff assistance for activities of daily living by not offering an opportunity to complete oral hygiene for 1 of 4 residents reviewed (Residents #29). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #29 entered the facility on 12/1/22. MDS documented diagnoses of Non-Alzheimer's Dementia, Anemia, Unsteadiness on feet, and History of falling. The MDS further revealed that Resident #29 needed partial/moderate staff assistance with oral hygiene. During an observation of Resident #29 room on 11/13/23 at 01:38 PM revealed no oral hygiene supplies in the private bathroom. During a subsequent observation of Resident #29 room on 11/14/23 at 12:30 PM, no oral hygiene supplies were present in the private bathroom. During an interview with the Director of Nursing (DON) on 11/14/23 at 2:58 PM, stated her expectations were for the 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 document review, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not providing medical services related to inadequate dental health and by not following physicians orders for 2 of 2 residents reviewed (Resident #34 & Resident #4). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #34 dated 9/4/23 revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. During an observation on 11/13/23 at 1:50 PM with Resident #34 revealed the Resident was missing teeth and had broken teeth. During an interview 11/13/23 at 1:50 PM with Resident #34 revealed he has been trying to get into a dentist for 6 months and hasn't been yet. Review of a facility provided document titled Patient History, from an outside dental clinic revealed Resident #34 had seen a dental provider 3/21/22 for pulp vitality tests, limited oral…

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 staff interview, and policy review, the facility failed to provide restorative services to prevent decline in range of motion and mobility for 2 of 2 resident (Resident #1 & #25). The facility reported a census of 49. Findings include: 1. On 11/14/23 at 8:30 AM, Resident #25 stated she was not receiving restorative therapy. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. It included diagnoses of Coronary Artery Disease (CAD), Heart Failure, Diabetes Mellitus, and End-Stage Renal Disease (ESRD). It also indicated the resident was dependent with repositioning, transferring, and showering/bathing and required maximal assistance with personal hygiene and dressing. The Physician Orders directed Physical and Occupational Therapy to evaluate and treat the resident. The Care Plan did not include restorative therapy as a focus or intervention. 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 observation, staff interview, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not applying initials to formula bottles. The facility further failed to verify the gastrostomy tube (feeding tube) was functioning properly before beginning a feeding for 3 of 3 residents reviewed (Resident #21, #45, and #47). The facility reported a census of 49 residents. Findings include: 1. Record review of the Minimum Data Set (MDS) for Resident #21, dated 9/3/23 revealed diagnoses of cysticercosis (a parasitic tissue infection caused by larval cysts of the tapeworm), dysphagia, thrombocytopenia, and gastrostomy status. During an observation 11/14/23 at 12:15 PM Staff B Licensed Practical Nurse (LPN) entered Resident #21's room and announced to Resident #21 who she was and what she was doing. Staff B then did not check placement of Resident #21's gastrostomy tube before completing water flushes and enteral feeding. During an interview 11/14/23…

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 complete pre and post dialysis assessments for 1 of 1 resident reviewed for dialysis treatment (#25). The facility reported a census of 49 residents. Findings include: On 11/14/23 at 11:54 AM, Resident #25 stated she receives hemodialysis every Monday, Wednesday, and Friday and the facility staff does not always take her vital signs before she leaves and never checks her vital signs or dialysis port when she returns. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had a BIMS score of 14 out of 15, indicating intact cognition. It included diagnoses of Coronary Artery Disease (CAD), Heart Failure, Diabetes Mellitus, and End-Stage Renal Disease (ESRD). It also indicated she was receiving dialysis. The Electronic Health Record (EHR) included an order dated 10/12/23 directing staff to complete vital signs, weight, and an evaluation before and after dialysis. It also directed staff to obtain 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 observation, record review, staff interview, and policy review, the facility failed to respond to residents' call light within 15 minutes for 2 residents reviewed (Residents #14 & #28). The facility reported a census of 49. Findings included 1. On 11/13/23 at 3:19 PM, Resident #14 stated her resident call bell system did not function properly. The resident pressed and activated her call light system. A red light was noted on the resident's wall outlet. At 3:40 PM, an observation of the call light monitor screen at the South nurses' station revealed the resident's call bell notification didn't register as would be indicated by the listing of the resident's room number. A staff member entered the resident's room at 3:40 PM when the surveyor exited. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. It included diagnoses of hypertension, Diabetes Mellitus, Parkinson's Disease, anxiety…

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, policy review, and staff interviews the facility failed to implement gradual dose reductions (GDR) instead continued psychotropic medications without review and failed to ensure as needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for 1 of 5 residents reviewed (Resident #34). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #34 dated 9/24/23 documented a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS further documented diagnosis of anxiety, depression, and schizophrenia. Review of the Electronic Healthcare Record (EHR) page title Physician Orders revealed Resident #34 had active orders for Ativan/Lorazepam 0.5 mg oral tablet as necessary (PRN) give one tablet every 6 hours for anxiety/restlessness. Review of a facility provided document titled, Noted to Attending Physician/Prescriber with a Medication Regimen Review date of 8/10/23 documented: CMS regulations require that all PRN psychotropic…

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

Based on observation, staff interview, and facility policy review the facility failed to keep all medications in a locked medication cart, inaccessible to unauthorized staff and residents. The facility reported a census of 49 residents. Findings include: A continuous observation on 11/13/23 from 04:49 PM to 04:52 PM near the nurses station on North Hall revealed a medication cart left unattended while medications were stored on top of the cart, a total of 5 pre-filled insulin pens/syringes. Four residents had passed by the cart. In an interview with Staff R, Regional Director of Operations on 11/13/23 at 04: 53 PM she stated her expectation was for the staff to lock medications in the medication cart if staff stepped away from the cart. A facility provided policy titled Administering Medications revised on 4/2019 documented the medication cart had to be closed and locked when out of sight of the medication nurse or aide and no medications were to be kept on top of the medication cart.

Based on observation, record review, resident interview, staff interview, and policy review the facility failed to provide needed assistance in making appointments for dental services for 1 of 1 residents (Resident #34). The facility reported a census of 49 residents. Findings include: Review of the Minimum Data Set (MDS) for Resident #34 dated 9/4/23 revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition. During an observation on 11/13/23 at 1:50 PM, Resident #34 noted to be missing teeth and had broken teeth. During an interview 11/13/23 at 1:50 PM Resident #34 revealed he had been trying to get into a dentist for 6 months and hasn't been yet. Review of a facility provided document titled Patient History, from an outside dental clinic, revealed Resident #34 had seen a dental provider 3/21/22 for pulp vitality tests, limited oral evaluation, x-ray, and 3 teeth being extracted. This document further revealed that Resident #34 was seen by this clinic 12/2/22 for pulp vitality tests, limited oral evaluation, and x-ray. This document further detailed…

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 interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 8 residents reviewed (Residents #6, #32, and #34) The facility reported a census of 49 residents. Findings include: An observation of supper meal service on 11/13/23 at 5:10 PM revealed the temperature of the pureed grilled cheese sandwich was 119 degrees Fahrenheit and the temperature of the pureed beets were 119 degrees Fahrenheit. Review of a document dated 2001 titled Food Preparation and Service revealed mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation or they reheat to 165 degrees Fahrenheit for at least 15 seconds. On 11/13/23 at 4:15 PM Staff I, Cook, stated he never checks the temperatures on the pureed food prior to serving. On 11/15/23 at 11:05 AM the Administrator stated the facility's expectation was that the temperatures of pureed and mechanical soft food would be served at…

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

Based on staff interviews and facility policy review the facility failed to produce Quality Assurance Performance Improvement (QAPI) documentation that demonstrated the implementation and effectiveness of a comprehensive QAPI program that addressed the full range of services the facility provided. The facility reported a census of 49 residents. Findings include: In an interview on 11/20/23 at 02:28 PM the Administrator and Staff R, Regional Director of Operations, revealed they were aware that the QAPI program needed improvement and due to high turnover of the administrators in the previous year, they lacked consistency of the QAPI program. A review of the facility provided policy titled Quality Assurance and Performance Improvement (QAPI) Program revised 2/2020 documented: 1. This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components 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 have an Infection Preventionist in attendance during the facilities quarterly meetings from December 2022 to November 2023 for 2 out of 4 quarters. The facility reported a census of 49 residents. Findings include: Record review of the facilities last 12 months of Quality Assessment and Assurance (QAA) committee meeting agenda/minutes revealed an Infection Preventionist was not in attendance during the facilities quarterly meetings for Quarter 1 & Quarter 2 of 2023 (from February through June). A review of the facility provided policy titled Quality Assurance and Performance Improvement (QAPI) Program revised 2/2020 documented the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and makes adjustments to the plan. In an interview on 11/20/23 at 02:28 PM the Administrator and Staff R, Regional Director of Operations, revealed they were aware that QAA meetings lacked consistency of required attendees.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure the resident call system functioned properly for 1 of 1 resident (Resident #14). The facility reported a census of 49. Findings included On 11/13/23 at 3:19 PM, Resident #14 stated her resident call bell system did not function properly. The resident pressed and activated her call light system. A red light was noted on the resident's wall outlet. At 3:40 PM, an observation of the call light monitor screen at the South nurses' station revealed the resident's call bell notification didn't register as would be indicated by the listing of the resident's room number. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. It included diagnoses of hypertension, Diabetes Mellitus, Parkinson's Disease, anxiety disorder, depression, Bipolar disorder, Schizophrenia, and drug induced tremors. It revealed the resident 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.