River Valley Nursing and Rehabilitation

Based on record review, observations, resident and staff interviews, and policy review the facility failed to serve at the safe temperature, and palatable. The facility reported a census of 36 residents. Findings include: A review of the Resident Council Minutes from May 2024 revealed documented complaints of food sometimes being cold. During an interview on 9/03/24 at 10:45 a.m., Resident #6 described the vegetables as overcooked and the hamburger tasted like sandpaper. He noted the food was not warm when it gets to his room on a room tray. During an observation on 9/03/24 at 1:05 p.m., a requested test tray food items temperature results: a. Mashed potatoes - 135.5 degrees Fahrenheit (F) b. Boiled carrots - 125.0 F c. Roast beef - 120.5 F When tasted, the carrots noted to be lukewarm and have a mushy consistency. The roast beef noted to be lukewarm. During an interview on 9/05/24 at 12:35 p.m., the Dietary Manager explained she expected food holding temperatures to be around 145°F. She expressed other steps may need to be put in place to keep the room trays warm. The facility…

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

Based on record review, observation, staff interview, and policy review the facility failed to assure food was properly prepared and appropriate to meet resident needs. The facility reported a census of 36 residents. Findings include: The facility menu titled Spring/Summer 2024 provided by the facility for 9/03/24 designated the following serving sizes to be given to residents with a pureed diet: a. Pot roast- #8 scoop size (4-5 ounces (oz.)) b. Gravy- 2 oz. c. Potatoes and onions- #10 scoop size (3-4 oz.) d. Carrots and celery- #16 scoop (2 ¼ oz.) e. Apple crisp- #10 scoop f. Wheat roll- #12 scoop (2 ½-3 oz.) During an observation of the puree preparation on 9/03/24 at 1:28 p.m., the Dietary Manager (DM) failed to measure the beef and placed four chunks into the blender for four residents. Beef juice was added and the DM failed to measure the resulting puree before it was poured into a serving container. A 3 oz. scoop was used to serve the meat. Five #8 scoops of carrots with added juice was then measured, blended, and the volume not measured afterward before being placed in 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, policy review, and staff interview the facility failed to prevent the potential for cross contamination due to lack of hand hygiene during preparation and plating of meals, proper storage of opened food items, uncovered garbage cans, and a lack of adequate chemical concentration in cleaning buckets. The facility reported a census of 36 residents. Findings include: During an observation of the kitchen on 9/03/24 at 10:12 a.m, the cleaning buckets were tested and lacked the appropriate chemical concentration for sanitizing surfaces. During the observation the following items were found in the freezer opened, unsealed, and undated: a. Cookie dough b. Chicken nuggets c. Ravioli d. Pizza crust e. Sausage patties f. Sausage links The dry goods pantry revealed almond extract with the lid broken off, unsealed and undated on the shelf. A continuous observation of meal preparation, and plating on 9/03/24 at 11:50 a.m., revealed: a. A garbage can found under the food prep counter with no lid, and a second can under the dish sink with no lid. b. Staff L, [NAME] wore…

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 follow accepted infection control technique and use Enhanced Barrier Precautions during wound care for 2 of 2 residents (Residents #15, and #87), and use Enhanced Barrier Precautions when emptying a urinary catheter collection bag for 1 of 1 residents (Resident #86). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], identified Resident #15 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS listed diagnoses included: multiple sclerosis, depression, and polyneuropathy. The MDS assessed Resident #15 dependent on staff to complete oral hygiene, toileting, showers, dressing, putting on and taking off footwear, personal hygiene, repositioning and transfers. The Care Plan, dated 6/6/24, identified a Focus area to address I have a need for Enhanced Barrier Precautions r/t (related to) wounds. Interventions included: 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 observation, clinical record review, policy review, and staff and resident interviews, the facility failed to ensure 1 of 7 residents reviewed for abuse remained free from physical abuse (Resident #16) when a staff member threw a box of gloves toward a resident. The facility reported a census of 36 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 4/3/24, listed diagnoses for Resident #16 included depression, chronic pain, and chronic obstructive pulmonary disease. The MDS assessed the resident dependent on staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. A Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicated intact cognition. The facility Freedom of Abuse Neglect and Exploitation Policy revised 8/2020, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. The policy stated the facility had zero tolerance for abuse of any type or manner and would address accordingly. The Care Plan, 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.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to separate a staff member from residents immediately after an an allegation of abuse involving the staff member and Resident #16. The facility reported a census of 36 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 4/3/24, listed diagnoses for Resident #16 which included depression, chronic pain, and chronic obstructive pulmonary disease. The MDS stated the resident was dependent on staff for toileting hygiene, showering, dressing, personal hygiene, and transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility Freedom of Abuse Neglect and Exploitation Policy revised 8/2020, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The policy stated the facility had zero tolerance for abuse of any type or manner and would address accordingly. The policy stated…

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 appropriately prime an insulin pen prior to administration for 1 of 1 insulin injections observed (Resident #13) and follow physician orders after a hospitalization for 1 of 2 residents reviewed (Resident #17). The facility reported a census of 36 residents. Findings include: During a medication pass on 9/04/24 at 6:58 a.m, Staff D, Licensed Practical Nurse (LPN) completed an accucheck on Resident #13 and determined the resident needed the base dose and an additional 12 units of sliding scale insulin. She preformed hand hygiene and opened the Lantus pen. She attached the safety needle to the end of the pen and then dialed the pen to 50 units. She then took the Glargine pen and put the safety needle on the end. She dialed the pen to 12 units. Staff D then entered the resident's room, explained the procedure to the resident, cleansed the area, and administered both insulin injections. During an interview on 9/04/24 at 10:19 a.m., 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 observation, record review and staff interview the facility failed to provide baths for 2 out of 3 residents reviewed (Resident #6 and #32 ). The facility reported a census of 36 residents. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] for Resident #32 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating cognition intact. It further indicated diagnoses including: quadriplegia (inability to voluntarily move all limbs of the body from the neck down), depression and anxiety. The MDS assessed Resident #32 dependent on staff for transfers, bathing, dressing and personal hygiene. The Care Plan, initiate date of 7/15/24, revised on 9/4/24 included a Focus area to address I require assistance with ADL's (Activities of Daily Living) r/t (related to) Limited Mobility, Limited ROM (Range of Motion) and being paraplegic. Interventions included: BATHING/SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated, and The resident is totally dependent…

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, resident, family and staff interview, the facility failed to carry out interventions for 2 of 2 residents reviewed (Resident #17 and Resident #33). Resident #17 had a lab result return with a high white blood cell count and did not intervene for two days, and Resident #33 identified with 2+ pitting edema. The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #17 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 14 out of 15. The MDS listed diagnoses included: type 2 diabetes mellitus with diabetic polyneuropathy, coronary artery disease and seizure disorder. The MDS identified Resident #17 as requiring partial/moderate staff assistance with oral hygiene, toileting, and repositioning and was dependent on staff for assistance with showers, dressing, personal hygiene. A review of the lab report dated as collected 8/30/24 at 9:45 PM revealed order for a CBC (complete blood count),…

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, resident and staff interview, the facility failed to complete dressing changes as ordered for a re-opening pressure ulcer for 1 of 1 residents (Resident #15) reviewed. The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], identified Resident #15 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The MDS listed diagnoses included: multiple sclerosis, depression, and polyneuropathy. The MDS assessed Resident #15 dependent on staff to complete oral hygiene, toileting, showers, dressing, putting on and taking off footwear, personal hygiene, repositioning and transfers. The Care Plan, dated 8/7/24, included a Focus area to address I have a stage 4 pressure area to my coccyx/left buttock. Interventions included: Administer treatments as ordered and monitor for effectiveness. A Progress Note, dated 8/7/24 at 8:16 a.m., communicated New order received from hospice and clarified to coccyx…

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 and staff interview the facility failed to provide range of motion for 1 of 1 residents reviewed to maintain current level of range of motion to all extremities (Resident #32). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #32 indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Listed diagnoses included: quadriplegia (inability to voluntarily move all limbs of the body from the neck down), depression and anxiety. The MDS indicated Resident #32 dependent on staff for transfers, bathing, dressing and personal hygiene. The Care Plan, initiated on 7/15/24, included a Focus area to address I require assistance with ADL's (Activities of Daily Living) related to limited mobility, limited range of motion and being paraplegic. Interventions included: The resident is non ambulatory and utilizes a broda chair and needs dependent assistance by staff to move around…

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 interview, the facility failed to follow the Care Plan and utilize a mechanical lift for 1 of 3 residents reviewed for mechanical lift transfers(Resident #16). The facility reported a census of 36 residents. Findings: 1. The Minimum Data Set(MDS) assessment tool, dated 4/3/24, listed diagnoses for Resident #16 included depression, chronic pain, and chronic obstructive pulmonary disease. The MDS assessed the resident dependent on staff for toileting hygiene, showering, dressing, personal hygiene, and transferring and listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Lifting and Transferring Residents, dated 10/31/23, directed staff to transfer a resident based on the resident's assessment. The Care Plan, dated 4/10/24, included a Focus area to address The resident requires assistance with ADL's (Activities of Daily Living) r/t (related to) Fatigue, Impaired balance, Limited Mobility. The Interventions listed included The resident is totally…

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 and resident interviews, the facility failed to ensure the physician provided orders for a resident's immediate care and needs for 1 of 3 residents reviewed for a change in condition (Resident #33). The facility reported a census of 36 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 5/8/24, listed diagnoses for Resident #33 included multiple sclerosis, muscle weakness, and difficulty walking. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Physician Services, revised 10/2023, stated the physician would develop, implement and monitor an effective and appropriate treatment plan to meet the resident's needs and achieve realistic goals. Physician's Progress Notes reflected the resident's current clinical and functional status, condition change(s) since the previous visit, and response to his/her plan of care, medication regimen, treatments, therapy, discharge plans, disposition and other factors relating to the…

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

Based on clinical record review, staff and resident interviews, and policy review the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and Care Plan for 1 of 1 resident reviewed (Resident #6). The facility reported a census of 36 residents. Findings include: The facility posting titled Aspire of Pleasant Valley Mealtimes indicated meals times: Breakfast at 8 AM, Lunch at 12 PM, and Supper at 6 PM. The Care Plan revised 4/12/22 for Resident #6 documented the resident received dialysis M, W, F (Monday, Wednesday and Friday). During an interview on 9/03/24 at 10:45 a.m, Resident #6 stated he was missed altogether for supper last night (9/2/24). He reported he goes to dialysis Monday, Wednesday, and Friday and often doesn't get food afterwards. He gets back between 4-5 PM and eats in his room. He explained he needs assistance with eating so staff are supposed to help after they finish assisting in the dining room. They will leave the tray out at the nurses…

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

Based on clinical record review, staff interview, and policy review that facility failed to provide pneumococcal and influenza immunizations as required for 2 out of 5 residents reviewed (Resident #10, Resident #19 ). The facility reported a census of 36 residents. Findings include: The facility immunization record for Resident #10 indicated the last pneumococcal vaccine was administered on 8/27/22. There was no record of the vaccine being offered or declined since that time. The facility immunization record for Resident #19 indicated the last influenza vaccine was administered on 10/07/22. There was no record of the vaccine being offered or declined since that time. During an interview on 9/04/24 at 3:18 PM the MDS (Minimum Data Set) Coordinator explained she sends and collects permission forms for all the vaccines at the same time. She confirmed that she did not have a form for Resident #10. She acknowledged they do not know if the resident refused the vaccine or was not offered one. She also confirmed she could not find a declination or acceptance form for the influenza vaccine…

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

Based on record review, staff interviews, and facility policy review, the facility failed to document monthly Infection Surveillance for the months of September, October and November 2023, after the previous Infection Preventionist left the position in August 2023. The facility reported a census of 25 residents. Findings Include: 1. A review of the Infection Surveillance Data revealed no data collected for the months of September, October and November 2023. In an interview on 11/20/23 at 9:06 AM, the former Infection Preventionist (IP) reported she resigned in August 2023 and had not collected any data for monthly Infection Surveillance. She had returned to the facility to assist with completion of Minimum Data Sets (MDS), however, she did not assist with Infection Prevention. In an interview on 11/20/23 at 9:23 AM, the Director of Nursing (DON) reported collection of Infection Surveillance data had been a problem after the former IP left and she had not received any training on Infection Surveillance since starting in October 2023. A review of the facility policy titled: Infection…

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 personnel file review, facility policy review, and staff interview the facility failed to ensure Cardiopulmonary Resuscitation (CPR) certified staff scheduled 24/7 for 4 of 15 days in [DATE]. The facility reported a census of 25 residents. Findings Include: A review of staff CPR certifications revealed Staff G, Registered Nurse (RN) CPR certification expired on [DATE]. During an interview on [DATE] at 3:00 PM, the Regional Administrator stated Staff G updated her CPR certification on [DATE]. A review of the [DATE] through [DATE] schedules revealed Staff G worked the following days with an expired CPR certification: a. [DATE] b. [DATE] c. [DATE] d. [DATE] During an interview on [DATE] at 4:26 PM, the Director of Nursing (DON) stated the facility has residents who have a full code status. She stated she would expect at least one CPR certified staff to be scheduled at all times. An undated facility policy, titled Cardiopulmonary Resuscitation included the statement Note: Licensed Nurses will maintain…

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

Based on facility assessment review, observations, and staff interviews the facility failed to employee a sufficient amount of staff to meet residents needs. The facility reported a census of 25 residents. Findings Include: A review of the Facility Assessment, updated on 5/18/23, revealed the facility needed an average of 4 to 6 Certified Nursing Assistants (CNA) per day to care for the residents' needs. An observation on 11/14/23 at 11:45 AM, revealed the facility had one CNA on duty. During an interview on 11/14/23 at 12:00 PM, Staff B, Licensed Practical Nurse (LPN) stated there is one CNA today, and the Director of Nursing (DON) is assisting the CNA as needed. Staff B stated she is unaware of how often there is only one CNA at the facility. Staff B stated there have been two instances when she has been the only staff in the building from 6:30 AM until 7:50 AM. Staff B stated this occurred on 10/17/23, and on 11/3/23. Staff B stated the CNA scheduled at 6:00 AM had called off and there was not a replacement available. During an interview on 11/14/23 at Staff H, CNA stated she…

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

Based on observations, record review and staff interviews, the facility failed to follow proper food preparation techniques during a meal service. The facility reported a census of 25 residents. Findings Include: During an observation of the noon meal on 11/14/23 starting at 12:00 PM, the Dietary Manager (DM) donned gloves and began to plate meals with the following noted: a. At 12:09 PM, the DM removed a bun from a bag and touched handles of ladles and counter attached to steam table. b. At 12:11 PM, the DM did not change gloves, plated 2 meals, removed 2 buns from plastic bag and touched surface of counter attached to steam table. c. At 12:12 PM, the DM did not change gloves, plated 2 meals, removed 2 buns from plastic bag and touched counter attached to steam table. d. At 12:13 PM, the DM did not change gloves, plated 2 meals, removed 2 buns from plastic bag and touched counter beside steam table. e. At 12:14 PM, the DM removed gloves and placed on top of counter in front of microwave oven. She washed her hands and donned new gloves. f. At 12:15 PM, the DM plated 2 more plates,…

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 4. The (MDS) Assessment Tool, dated 10/1/23, listed diagnoses for Resident #14 included multiple sclerosis, depression, and polyneuropathy (malfunction of nerves throughout the body). The MDS assessed the resident dependent on staff for all care related to toileting. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Care Plan, dated 7/27/23, revealed a Focus Area related to a Stage 4 coccyx pressure ulcer. A review of Physician Orders revealed a 11/3/23 order to change the wound vacuum, wash wound, and apply duoderm two times weekly. During an observation on 11/20/23 at 11:32 AM, Staff B, LPN completed wound care. During cares Staff B observed to not complete hand hygiene in between glove changes during the following tasks transitions: a. At 11:37 AM, Staff B donned gloves, applied wound cleanser to 4 X 4 in a basin and opened the wound vac. b. At 11:39 AM, Staff B doffed gloves. c. At 11:39 AM, without completing hand hygiene or donning new gloves, Staff B cut foam 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 clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to treat residents with dignity during services related to incontinence care for 2 of 4 residents (Residents #9, and #14). The facility reported a census of 25 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated 10/17/23, listed diagnosis for Resident #9 included Parkinson's Disease, schizophrenia, and type 2 diabetes. The MDS assessed the resident dependent on staff for all care related to toileting. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 4 out of 15, indicating severely impacted cognition. The Care Plan, dated 4/25/22, addressed a Focus Area of bladder incontinence, and bowel incontinence. Interventions included checking the resident every two hours and assisting with toileting as needed, and clean the peri-area after each episode of incontinence. During an interview on 11/13/23 at 2:56 PM, Staff E, Certified Nursing Assistant (CNA) stated on 11/6/23 she and Staff F, CNA were asked 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 3. The MDS Assessment Tool, dated 10/7/23, listed diagnoses for Resident #17 included history of a stroke affecting the left side, neurogenic bladder, and type 2 diabetes mellitus. The MDS assessed the resident dependent on staff for all care related to toileting and as always incontinent. The MDS listed the resident's BIMS score as 8 out of 15, indicating moderately impaired cognition. The Care Plan, dated 10/13/23, addressed a Focus Area of bladder incontinence due to history of a stroke. Interventions included checking the resident every two hours and as required for incontinence. During an observation on 11/13/23 at 11:40 AM, Staff A, CNA and Staff D, CNA assisted the resident in getting up and ready for the day. A strong odor of urine noted to be present in the room. At 11:45 AM, Staff A removed the blankets off of the resident. The resident's clothing, incontinence bed pad, and bed sheet was wet. The sheet had a large wet area, with a brown ring along the edges. The incontinence brief appeared heavily…

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 document a thorough assessment of a resident being transferred to the hospital for one of three residents reviewed (Resident #6). The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #6 as cognitively impaired with a BIMS (Brief Interview for Mental Status) of 6 out of 15 and had the following diagnoses: Metabolic Encephalopathy (an alteration in consciousness caused due to brain dysfunction), Renal Insufficiency (kidney failure) and Obstructive Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). The MDS also identified Resident #6 had impairments to both arms and legs and required staff assistance with most activities of daily living. The MDS also identified Resident #6 received 51% or more of his diet from tube feedings. A review of the facility Progress Notes…

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, clinical record review, staff interviews, and facility policy review, the facility failed to ensure catheter tubing and catheter bag are positioned in a manner to prevent possible infection for 1 of 4 residents (Resident #21). The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated, 10/29/23, listed diagnosis for Resident #21 included Alzheimer ' s disease, depression, and generalized weakness. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 1 out of 15, indicating severely impaired cognition. A review of the clinical record revealed a 10/17/23 Physician Order for a Foley catheter. The Care Plan, dated 10/23/23, included a focus area for an indwelling catheter. The plan included an intervention to check the tubing for kinks each shift. An observation on 11/13/23 at 2:00 PM, revealed Resident #21 sitting in a geriatric chair in the common area outside of the dining room. The resident's catheter tubing looped down towards the floor, and then back up to the bag positioned…

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, resident and staff interviews, the facility failed to serve food that was warm and palatable for three of twenty four residents reviewed (Residents #3, #5 and #10). The facility reported a census of 25 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had the following diagnoses: Type 2 Diabetes Mellitus, Coronary Artery Disease and Anxiety Disorder. The MDS documented Resident #3 with impairments to both sides of arms and legs and required staff assistance with most activities of daily living. In an interview on 11/13/23 at 9:51 AM, Resident #3 reported the food here is nasty. He will ask for it to be cooked a certain way, i.e.: eggs. He likes his eggs over-easy and they serve it to him overcooked or scrambled. They do this most of the time. He eats in his room and most of the time his food is cold. In an observation 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 clinical record review, observations, resident and staff interviews, the facility failed to give one of one residents reviewed foods of his personal choice (Resident #3). The facility reported a census of 25 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had the following diagnoses: Type 2 Diabetes Mellitus, Coronary Artery Disease and Anxiety Disorder. The MDS also identified Resident #3 had impairments to both sides of arms and legs and required staff assistance with most activities of daily living. In an interview on 11/13/23 at 9:51 AM, Resident #3 reported the food here is nasty. He will ask for it to be cooked a certain way, i.e.: eggs. He likes his eggs over-easy and they serve it to him overcooked. They do this most of the time. He eats in his room and most of the time his food is cold. In an observation and interview on 11/14/23 at 8:18 AM, the resident served…

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 interviews, the facility failed to provide one of one residents reviewed who required assistance with his meal (Resident #5). The facility reported a census of 25 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] identified Resident #5 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and had the following diagnoses: Acute Kidney Failure requiring dialysis, Paraplegia (paralysis of one half of the body) and Multiple Sclerosis. The MDS also identified the resident had impairments to both sides of both arms and legs and required staff assistance with most activities of daily living. In an interview on 11/14/23 at 8:20 AM, Resident #5 reported he was served cold scrambled eggs, cold bacon and it was overcooked, could crack a tooth on it. He was served a packet of jelly, however, no one offered to open it up and put it on the bread for him. Resident #5 reported he only has one good hand, and this happens…

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.