Accura Healthcare of Pleasantville, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility abuse investigation, staff interviews and policy review, the facility failed to provide a thorough investigation into 2 of 2 allegations of misappropriation of resident's (Resident #30 and Resident #9) funds. The facility reported a census of 45 residents. Findings include: Review of Resident #30's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment and diagnoses of hypertension, Non-Alzheimer's Dementia, Anxiety Disorder, Schizophrenia, and speech disturbances. Review of Resident #30's Electronic Health Record (EHR) indicated on 4/3/25 Resident #30's height measured 64 (5' 4) and weighed 183.2 pounds on 5/5/25. Review of Resident #9's MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment and diagnoses of Renal insufficiency, Hemiplegia, Cerebrovascular Accident, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and policy review, the facility failed to accurately complete a resident's Minimum Data Set (MDS) assessment by not coding Hospice services and diagnosis of Dementia for 1 of 19 Residents reviewed in the sample (Residents #26). The facility reported a census of 45 residents. Findings include: Review of Resident #26's Census Report revealed Resident #26's admission to the facility on 9/4/24 and hospice level of care on 11/8/24. Review of Resident #26's Hospice admission Plan dated 11/8/24 revealed admission to Hospice services with a diagnosis. of Dementia. Review of Resident #26 Significant Change MDS dated [DATE], revealed BIMS of 00, indicating severe cognitive impairment. The MDS section for special treatments, procedures, and programs indicated Hospice Level of care and active diagnoses including; Atrial Fibrillation, Heart Failure, Hypertension, Stage 4 Chronic Kidney disease, Diabetes Mellitus, Macular Degeneration, and Depression. Review of Resident #26's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to develop a comprehensive care plan for 2 of 19 residents reviewed for care plans (Resident #26 and #37). The facility reported a census of 45 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had diagnosis of diabetes. The MDS revealed the resident had no skin issues. The Care Plan revised on 10/30/24 revealed the resident had a potential for pressure ulcer development related to decreased mobility and incontinence. The Care Plan lacked information about a sore on top of the resident's head or information that pertained to a history of skin cancer or a chronic skin condition. The Progress Notes revealed: a. On 10/9/24 at 12:33 PM (admission summary) included documentation as follows; resident admitted to the facility. Skin normal. b. On 1/9/25 at 9:16 PM and 3/20/25 at 7:24 PM, a dietary note documented the resident had a history of skin cancer. c. On 3/20/25 at 1:18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, the facility failed to ensure care conferences held at least quarterly for one of one residents reviewed for care conferences (Resident #33) and failed to document follow up on the concerns addressed. The facility reported a census of 45 residents. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had diagnosis of depression. The MDS recorded the resident had a Brief Interview for Mental Status score of 15 indicating intact cognition. The MDS indicated having family or a close friend involved in discussions about his care as very important. The electronic health record (EHR) revealed a Care Conference Meeting /Attendance note dated 10/24/24. Two family members attended, and as well as the resident. The EHR and paper chart lacked documentation of the care conferences held between 11/2024 - 4/30/25. In an interview 4/28/25 at 1:15 PM, the resident reported he had gone to a care conference meeting in the past…

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, resident and staff interviews, the facility failed to complete an assessment and provide an intervention for 3 of 3 residents (Resident #12, #26 and #37). Resident #12 acquired a puncture wound to his right lower calf from a broken wheelchair and the nurse failed to make an assessment 12 or more hours after a CNA reported the incident. The facility failed to monitor Resident #26 after obtaining a burn. The facility reported a census of 47 residents Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #12 revealed a diagnoses of heart failure, renal insufficiency, diabetes mellitus, identified limited range of motion to both lower extremities and inability to walk 10 feet. The MDS failed to identify the use of a wheelchair as a mobility device. The MDS identified a risk for developing pressure ulcers or injuries of the skin and identified two venous/arterial ulcers present on the lower legs which required an application of nonsurgical…

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, observations, staff interviews, and policy review the facility staff failed to change gloves when performed cares and then touched other objects for one of four residents sampled for cares (Resident #18). The facility staff also failed to disinfect a mechanical lift after use for one of three residents observed for transfers. The facility reported a census of 45 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had diagnoses of cerebrovascular accident (CVA)(stroke), hemiplegia (paralysis on one side of the body) and neurogenic bladder (loss of bladder control). The MDS recorded the resident had an indwelling catheter. The MDS documented the resident required partial to moderate assistance for toileting hygiene and substantial to maximum assistance for lower body dressing. The Care Plan revised 2/17/25 revealed the resident required Assistance with activities of Daily Living (ADL's) related to cerebral infarction and…

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

Based on employee roster review, education transcript review and staff interviews, the facility staff failed to complete a minimum of 12 hours of regular in-service education for 3 of 4 Certified Nursing Assistants (CNAs) sampled who had worked at the facility greater than 1 year (Staff G, Staff M, and Staff N). The facility identified a census of 45. Findings include: 1. A CNA-CMA Roster revealed Staff G, CNA, had a hire date 5/20/21, Staff M, CNA, had a hire date of 10/9/23 and Staff N, CNA, had a hire date 7/6/22. The Relias Education Transcripts reviewed 5/2024 - 4/2025 revealed the education and number of hours completed for the following: Staff G =8.95 hours completed Staff M = 1.0 hours completed Staff N = 0 hours completed During interview on 5/6/25 at 11:30 AM, the Director of Nursing reported mandatory staff in-services held monthly and education courses set up on Relias for staff to complete. The DON reported staff needed to complete at least 12 hours of education each year. During an interview on 5/7/25 at 11:10 AM, the Administrator reported the staff who worked nights…

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

Based on observation and staff interview the facility staff failed to maintain a locked and secured treatment cart for one of two med carts reviewed. The facility identified a census of 45 residents. Findings include An observation 9.22.24 at 12:47 p.m. revealed a treatment cart positioned along the wall in the nurse's station area beside the resident's paper chart rack unlocked and unattended accessible to all residents in the front of the building. During an interview 9.25.24 at 1:20 p.m. the Administrator indicated the facility referred to areas of the building as the front and the back with the back also known as the Chronic Confusion Dementing Illness (CCDI) unit. Additionally, she confirmed 30 residents resided in the front portion of the building. During an interview 9.23.24 at 1:35 p.m. Staff C, Certified Nursing Assistant (CNA) confirmed she observed unlocked, unattended med carts with the drawers left open including the narcotic drawer for any staff, visitors or residents to access. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA confirmed she frequently observed…

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 interviews, and staff interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility reported a census of 45 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #9 had a Brief Interview for Mental Status (BIMS) of 9 which indicated moderate cognitive impairment. MDS also documented maximal assistance with dressing and moderate assistance with toileting. On 9/24/24 at 7:20 AM Resident #9 stated she had fallen at night when she had the injury to her head and was on the floor yelling for help for a long time before anyone came into the room. Resident #9 stated that she could not reach her call light. Resident #9 stated she received stitches as a result of the accident. Resident #9 stated she tried to clean up the blood but kept on bleeding. Resident #9 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 observations, clinical record review, resident interviews, staff interviews, Resident [NAME] of Rights, and policy review the facility failed to provide personal care to a resident that was incontinent, provide medication when a resident requested, allow a resident to make his own decision, and properly serve residents on appropriate flatware. Concerns were found for 4 of 6 residents reviewed for dignity (Resident #4, 10, 20, and 22). The facility reported a census of 45 residents. Finding include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 15, which indicated no cognitive impairment. On 9/23/24 at 3:48 PM Resident #10 stated Staff G, Licensed Practical Nurse (LPN) was the nurse 9/20/24 overnight to 9/21/24. Resident #10 stated Staff G brought her in medications on that overnight around 2:30 AM Resident #10 stated there were 2 pills in the medication cup and she asked Staff G if Tylenol was in the medication cup.…

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, resident interview, staff interview and facility policy review the facility failed to bath 3 of 4 residents according to their individual schedules and bathing requests. (Resident #2, #4 and #5 ) The facility also failed to provide appropriate perineal cares for 1 of 3 residents reviewed. (Res #10) Findings include: 1. A Minimum Data Set Assessment (MDS) form dated 9.12.24 indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (severely cognitively impaired), with no delirium, behaviors or rejection of cares and required partial to moderate assistance of staff with bathing. A Care Plan indicated the resident with a Focus are of an activities of daily living (ADL's) self-care performance deficit related to (r/t) confusion and incontinence. The Interventions/Tasks included the following: a. Bathing/showering with assistance of one (1) staff member two(2) times a week and as needed (PRN). (revised 2.20.24) According to the facilities Shower form (not dated) identified the resident's bath days as Monday 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 electronic health records (EHR) review, personnel file review, observations, resident interview, staff interview, and policy review the facility failed to provide complete and accurately documented electronic health records for 2 of 5 residents (Residents #10, and #20) reviewed. The facility reported a census of 45 residents. Findings include: 1. Review of Resident #20's MDS dated [DATE] revealed an admission date of 9/16/24 from another nursing home. Review of Resident #20's Care Plan with a revision date of 9/17/24 revealed that Resident #20 is at risk for skin breakdown related to incontinence. During continuous observation 9/24/24 from 12:10 PM to 2:53 PM Resident #20 was getting up from the lunch table and was observed to have a large wet area to the back of the Residents pants. Staff H, Certified Nurse Assistant (CNA) was observed to have her hand on the wet spot on Resident #20's back when the transfer occurred. Resident #20 was transferred with an assist of one with a gait belt by Staff H CNA 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 clinical record review, staff email and policy review the facility failed to represent an accurate picture of the resident's status during the observation period of the Minimum Data Set (MDS) by not completing an accurate assessment of resident behaviors for 1 of 3 residents reviewed. (Resident #1) The facility also failed to properly code their 802 Matrix related to restraints for 6 of 6 residents reviewed. The facility reported a census of 45 residents. Findings include: 1. An Incident Report form dated 8.13.24 at 9:45 p.m. included the following documentation: The MDS Coordinator and Director of Nursing (DON) heard yelling down the hall and responded. They found Resident #1 had shoved Resident #2 up against the wall which resulted in a fall. A Minimum Data Set assessment dated 8.18.23 indicated Resident #1 had no signs of delirium, mood or physical, verbal behavioral symptoms directed towards others or other verbal symptoms not directed towards others. 2. Review of a Resident Matrix form printed 9.22.24 by the facility staff identified 6 of 45 residents with restraints.…

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 the facility failed to implement Care Plans (CP) for 3 of 3 residents (Resident #2, #4 and #5) reviewed. The facility reported a census of 45 residents. Findings include: 1. A Quarterly Minimum Data Set Assessment (MDS) form dated 9.12.24 indicated Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 (severely cognitively impaired), with no delirium, behaviors or rejection of cares and required partial to moderate assistance of staff with bathing. A Care Plan indicated the resident with a Focus area of an activities of daily living (ADL's) self-care performance deficit related to (r/t) confusion and incontinence, with revision date 2/20/24. The Interventions/Tasks included the following: a. Bathing/showering with assistance of one (1) staff member two(2) times a week and as needed (PRN). (revised 2.20.24) According to the facilities Shower form (not dated) identified the resident's bath days as Monday and Thursday. According to the resident's Shower Skin Check Report forms the resident…

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

Based on observation, clinical record review and staff interview the facility staff failed to properly set up and administer medications in accordance with Professional Standards of Practice for 3 residents reviewed. (Resident #10, #1 and #21). The facility identified a census of 45 residents. Findings include: 1. During an observation 9.24.24 at 12:10 p.m. as the medication carts had been assessed with the Clinical Nurse Specialist, Staff B, Licensed Practical Nurse (LPN) approached the medication cart, opened the top drawer and removed two (2) clear plastic medication cups, one that contained a clear red liquid identified by Staff B as liquid protein and the other plastic med cup stacked under the previous said med cup contained Baclofen and Gabapentin non of which were labeled as to the resident's name and actual medication present. Staff B indicated Resident #10 refused to take her medications before she ate lunch so she placed them in the top drawer which had been the norm for the resident. The Clinical Nurse Specialist confirmed this observation. During an interview 9.23.24 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 observation, clinical record review, staff interview and facility policy review the facility failed to follow physician orders for 1 of 3 residents reviewed. (Resident #18) The facility identified a census of 45 residents. Findings include: Review of the Medication Administration Record (MAR) form dated 9/1/24 to 9/30/24 for Resident #18 indicated the resident's medication list included the following medications documented as administered on 9.1.24: a. Memantine HCL (hydrochloric acid) 10 mg. (for Alzheimer's disease) b. Mirtazapine 7.5 mg. (Depression) During an observation of the front medication carts on 9.24.24 at 12:10 p.m. with the Clinical Nurse Specialist cards Memantine HCL 10 mg and Mirtazapine 7.5 mg had been present in the medication card for Resident #18 scheduled 9.1.24. The other medication scheduled at the same time Olanzapine 7.5 mg had been absent. During an interview at the same time, the Clinical Nurse Specialist confirmed staff documented all 3 medications as administered and she agreed with the observation. An observation 9.24.24 at 11:55 a.m. revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview the facility failed to provide restorative services to the residents as a means to maintain their highest level of functioning. (Resident #5) The facility identified a census of 45 residents. Findings include: The Quarterly Minimum Data (MDS) dated [DATE] documented that Resident#5 had required moderate assistance with toileting hygiene, and upper body dressing. During an interview 9.24.24 at 2:25 p.m. Resident #5 indicated staff failed to perform range of motion (ROM) exercises and she preferred to exercise as her goal had been to return home. During an interview 9.23.24 at 1:35 p.m. Staff C, Certified Nursing Assistant (CNA) confirmed the facility failed to provide restorative services for the residents. During an interview 9.23.24 at 2:06 p.m. Staff E, CNA confirmed the facility failed to provide restorative services for the residents. According to an email 9.26.24 at 1:28 p.m. the Clinical Nurse Specialist indicated the facility lacked a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility activity calendars, resident interview, staff interview and facility assessment the facility failed to employ a Activities Director (AD). The residents activity choices did not reflect a well round choice that catered to the residents interests for their physical, mental and psychosocial wellbeing. The facility reported a census of 41 residents. Findings include: The Facility Assessment updated 1/15/24 documented under category of psycho/social/spiritual support the facility to provide opportunities for social activities, life enrichment, individual small group and community. Support community integration if resident desires. Activities and religious services to meet the needs of the residents. Facility positions to include a full time Activities Director. The Assessment documented under resources needed to provide competent support and care for the residents every day included the following; Activities Director, volunteers, and religious groups. Services listed in the Facility Assessment…

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 interviews, staff interviews and facility policy the facility failed to provide dignity with dining for residents in the main dining room used by up to 20 residents at 3 of 3 meals observed. The facility reported a census of 41 residents. Findings include: Observation on 06/03/24 at 08:57 AM of the breakfast meal in the main dining room, Certified Nursing Assistant (CNA) Staff D was at the table with residents needing feeding assistance. Staff D stood and walked around the table, gave one gentleman a bite, saying a bite for you, proceeded to give the next gentleman a bite stating, a bite for you, walked around the table and spoon fed another resident saying a bite for you. Picked up resident cup standing over the resident said, take a drink, to the next resident, take a drink and walked around the table feeding five different residents in the same manner, standing over the resident and walking around the table spoon feeding and holding cups for the residents needing assistance.…

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 interviews, staff interviews and facility policy the facility failed to offer a home like environment for resident dining experience in the common dining area where up to 20 residents have daily meals for three of three meal observations. The facility reported a census of 41. Findings include: Observation on 06/04/24 at 12:15 to 12:54 PM of dining for lunch meal, Resident #22 at the table with other yelling profanity, get your asses out, God dam repeatedly and other words of profanity in addition made loud singing noises then yelling out again profanity throughout the entire meal. Resident #22 Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview for Mental Status, (BIMS) score for cognition could not be completed and coded behavior present, fluctuates, changes in severity. Diagnoses included non-traumatic brain dysfunction and Alzheimer's disease. In an interview on 6/4/23 at 1:33 PM the Administrator queried about dining expectation and yelling resident. 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 facility activity calendars, resident interview, staff interview and facility assessment the facility failed to provide a program to include resident activities catered for resident interests for resident's physical, mental and psychosocial wellbeing. The facility reported a census of 41. Findings include: A Document reviewed, April 2024 reflected the facility activity calendar which included the following; a. 8 days without activities b. 7 days with Bingo as the only activity (every Tuesday & Friday) c. 2 days with Shopping as the only activity for those days d. 1 entry for resident council as the only activity for that day e. 2 entries for movie as the only activity for those days f. 1 entry for Church as the only activity for that day g. 2 days with manicures as the only activity listed h. 5 entries for crafts, but the only activity documented for those days i. 3 entries for color/puzzle packet, the only activity available for those days j. One day listed as a monthly birthday party, with nothing…

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, dietary documents, staff interview, resident interview and policy review, the facility failed to prepare appropriate portions for six (6) residents who received pureed meals, and nine (9) residents who received mechanical soft diets. The facility failed to serve appropriate portions for multiple residents who received tater tots. The facility failed to post menus or offer residents alternative options. The facility reported a census of 41 residents. Findings include: 1. On 6/05/24 at 11:25 AM, Staff F, [NAME] was observed placing seven (7) serving portions of ham loaf into a blender to prepare nine (9) mechanical soft diets. He placed the contents into a measuring cup and verbalized three (3) cups of prepared mechanical soft ham loaf. The prepared amount was observed to be two (2) cups. Staff F referred to the dietary conversion chart and stated it lacked a column for 9 servings, so he used the 8 servings column and indicated a #10 (3 1/4 ounce) serving scoop was required. At 11:37 AM,…

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 policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 41. Findings include: On 6/05/24 at 11:15 AM, Staff F, Cook, checked the temperature of the lunch menu items. The Ham Loaf temperature was recorded at 139.5° Fahrenheit (F). The lettuce temperature was recorded at 40.8° F. During food service, Staff F served lettuce at room temperature from the serving bowl on the counter. On 6/5/24 at 1:20 PM, Staff F checked the temperature of the remaining lunch menu items. The Ham Loaf temperature was recorded at 129.5° F. On 6/07/24 at 12:21 PM, the Administrator stated staff should follow the facility policy regarding food service temperatures. A policy titled Food Temperatures dated 2021 indicated temperatures should be taken periodically to assure hot foods stay above 135° F and cold foods stay below 41° F during the holding and plating process and until food leaves the service area.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by failing to properly contain hair in the food preparation area and failing to prevent cross-contamination during food service. The facility reported a census of 41 residents. Findings include: On 6/05/24 at 11:15 AM, Staff F, [NAME] was observed in the food preparation area with an uncovered mustache and goatee. His head cap also failed to contain all of his hair. At 11:25 AM, Staff F sliced tomatoes with bare hands and placed the tomatoes in the serving dishes. Staff F also retrieved a serving scoop from a supply drawer and laid it face-down on the counter used to store food preparation equipment. At 11:50 AM, Staff F filled a dressing dispenser and the nozzle tip touched the ungloved palm of his hand. At 12:40 PM, Staff F placed lettuce from a bowl onto a resident's plate. He put the lettuce back into the main bowl then reached back in the main bowl and placed the lettuce back onto the resident's plate. At 1:10 PM, Staff F used bare hands placed buttered bread…

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, provider interview and staff interview, the facility failed to provide timely notification of resident evacuation from the facility for 1 of 3 residents reviewed (Resident#94). The facility reported a census of 41 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #94 dated 1/18/24 indicated a planned discharge assessment, with return anticipated. A Progress Note dated 1/18/24 7:43 PM documented, facility had to initiate an emergency evacuation this morning at approximately 4:30 AM., transferred to another facility at 9:10 AM. Emergency contact/family was notified at approximately 2:50 PM of the evacuation and transfer. On 6/3/24 at 2:30 PM Hospice staff I reported when she assisted with relocation of Resident#94 there was frustrations with lack of communication to the residents emergency contact. On 06/10/24 at 1:30 PM the Administrator, acknowledged notification expectation is to be timely. No policy was received.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, responsible party interview and staff interviews the facility failed to ensure quarterly interdisciplinary team meeting with inclusion of the resident and/or resident representative to discuss resident changing goals, for care plan review and /or revisions for 1 of 2 (Resident #17) residents reviewed. The facility reported a census of 41 residents. Findings included: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition moderately impaired. The MDS revealed diagnoses of non-traumatic brain dysfunction, dementia, renal diseases, depression and chronic pain. The Care plan initiated 1/29/24 included interventions to keep resident and my family up to date on any health conditions, instruct me and family on rationale for continued nursing home placement, encourage ongoing family involvement, discuss with the resident/family any concerns, fears, issues regarding…

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

Based on interviews, observations and record review, the facility failed to follow professional standards during medication administration for 1 out of 4 residents (Resident #11) reviewed. The facility reported a census of 41. Findings include: The Quarterly Minimum Data Set (MDS) documented that Resident #11 had diagnoses including heart disease, diabetes, anemia, asthma, respiratory failure, anxiety, depression, and kidney disease. Medication Administration Record (MAR) for resident #11 revealed the following: a.Trelegy, 1 puff inhale orally one time a day directed to rinse mouth with water and expectorate after use (used for long term respiratory failure.) Start date 1/6/24 b.Thiamine HCl Oral Tablet 50 milligram, give 1 tablet by mouth one time a day (used to strengthen immune system, and improve the body's ability to withstand stressful conditions). Start date 11/14/23 c.Humulin R Insulin, regular, Inject 5 units subcutaneously three times a day (used to decreased blood sugar levels). Start date 9/1/23 Observation on 6/5/24 at 8:20 AM Staff A, Certified Medication Aide (CMA)…

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 and staff interviews the facility failed to complete a discharge summary for 2 of 2 residents (#43, and #94 ) reviewed. The facility reported a census of 41 residents. Findings include: 1. On 6/05/24 at 10:45 AM, Resident #43's the Electronic Health Record (EHR) was reviewed for a patient-initiated discharge. The EHR revealed Resident #43 was admitted to the facility on [DATE] for skilled services. The discharge Minimum Data Set (MDS) dated [DATE] indicated Resident #43 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated moderately impaired cognition. It also revealed he was independent in all Activities of Daily Living (ADLs) but required only supervision for bathing. The EHR included diagnoses of Major Depressive disorder and alcohol-induced dementia with anxiety. The EHR progress notes lacked discharge documentation. On 6/05/24, the Director of Nursing (DON) stated Resident #43's care was managed by the Program of All-inclusive Care for the Elderly…

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, family interview, staff interview and facility policy the facility failed to provide appropriate intervention and catheter care to minimize or prevent complications from the occurrence of urinary tract infections for 1 of 3 residents reviewed (Residents #2). The facility reported a census of 41 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident#2 had an indwelling catheter. Diagnoses included seizure disorders, cerebral infarction, intellectual disability, renal disease and neurogenic bladder. The MDS documented that the resident required maximum assistance for personal hygiene, and dressing. The Care plan for Resident #2 revised 3/12/24 documented, the resident had a suprapubic catheter with the goal to be freed from catheter related trauma. Observation on 06/03/24 at 1:44 PM Resident #2 sat in a chair in her room, observed the catheter bag on the floor. Observation on 06/04/24 at 1:17 PM Resident #2 sat in a wheel…

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

Based on interviews, record review, facility policy review, and Centers for Disease Control information the facility failed to follow proper infection control practices to migate the risk for the spread of infectious disease. The facility reported a resident census of 24. Findings include: On 2/1/24 at 1:00 p.m. Staff E, Certified Nurse Aide (CNA), stated he recalled the weekend of September 23 and 24. That morning he had been tested for COVID and was positive. Staff E stated he contacted the Director of Nursing (DON) and informed her he was positive for COVID, but asymptomatic. Staff E stated he was allowed to continue to work and required the use of a mask. Staff E stated he was the only aide working on the North and South halls those mornings. Staff E stated working alone happens on occasion. According to daily assignment sheets and verified by staff time records, on Saturday 9/23/23 and Sunday 9/24/23, the facility only had one aide (Staff E) and one nurse assigned for 29 residents on the North and South halls during the hours of 6:08 a.m. to 9:00 a.m. on Saturday and 6:07 a.m.…

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

Based on record review and staff interviews, the facility failed to provide sufficient staffing to ensure residents receive care and services to maintain their optimal health and well being. Facility reported census was 24 residents. Findings include: According to daily assignment sheets and verified by staff time records, on Saturday 9/23/23 and Sunday 9/24/23, the facility only had one aide and one nurse assigned for 29 residents on the North and South halls during the hours of 6:08 a.m. to 9:00 a.m. on Saturday and 6:07 a.m. to 9:42 a.m. on Sunday. In an interview on 2/1/24 at 1:00 p.m. Staff E, Certified Nurse Aide, stated he recalled the weekend of September 23 and 24. That morning he had been tested for COVID and was positive. Staff E stated he contacted the Director of Nursing (DON) and informed her he was positive for COVID, but asymptomatic. Staff E stated he was allowed to continue to work and required the use of a mask. Staff E stated he was the only aide working on the North and South halls those mornings. Staff E stated working alone happens on occasion. During those…

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 and staff interviews, the facility failed to ensure residents are appropriately assessed and provided interventions to maintain their optimal health, and well being for 1 of 3 residents reviewed. (Resident #7) The facility reported census was 24. Findings include: According to a Quarterly Minimum Data Set (MDS) with a reference date of 1/4/24, Resident #7 had a Brief Mental Status (BIMS) score of 9 indicating an moderately impaired cognitive status. Resident #7 required extensive assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #7 was coded as always continent of bowel and bladder. Resident #7's diagnosis included diabetes mellitus. In an interview on 2/7/24 at 9:35 a.m. the Director of Nursing (DON) stated that on 1/2/24 she was involved with the admitting assessment of Resident #7. During the assessment Resident #7 was found to have an elevated heart rate of 163 beats per minute. The DON stated she was concerned, but did not know Resident #7's baseline so she asked Staff Z, Licensed Practical Nurse, 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.