Bria Of Belleville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent misappropriation of funds for two (R1 and R2) of three residents reviewed for misappropriation of funds in a sample of 3.Findings include:1.R1's admission record documents an admission date of 06/07/25 with diagnoses including: acidosis, hemorrhage of anus and rectum, paroxysmal atrial fibrillation, hypotension, cerebral infarction due to embolism of unspecified precerebral artery, altered mental status, major depressive disorder, diabetes mellitus with diabetic nephropathy, end stage renal disease, and transient cerebral ischemic attack. R1's Minimum Data Set, dated [DATE] documents a brief interview of mental status of 15 indicating cognitively intact. R1's care plan documents a focus area dated 07/11/25 of abuse: R1 is at risk for abuse and neglect related to currently being in a long term care facility with interventions listed as: alleged misappropriation of funds, will initiate additional financial monitoring dated 11/05/25 and assure 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 interview and record review the facility failed to provide appropriate services to 1 of 1 (R6) resident investigated for dementia care in a sample of 9. Findings include:R6's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R6's EMR dated 8/5/25 documents diagnose of unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.R6's MDS (Minimum Data Set) dated 11/11/25 documents a BIMS (Brief Interview for Mental Status) score of 3 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right. The MDS documents that the resident is dependent for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R6's Nurses Notes dated 10/18/25 at 6:45 PM documents Resident was involved in abuse allegation. Head…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure physical abuse did not occur for 2 of 3 residents (R1) and R3) reviewed for abuse in the sample of 7. 1-R1's Physician Order Sheet for August 2025 documents a diagnosis of nontraumatic subarachnoid hemorrhage, moderate protein calorie malnutrition, mucopurulent chronic bronchitis, weakness, major depression disorder, acute diastolic heart failure, pleurisy, anxiety disorder and spinal stenosis of the cervical region. R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making of activities of daily living. No impairments on the upper or lower extremities and independent on most tasks and does not need assistance with some tasks. R1's Initial Incident Report dated 8/21/2025 at approximately 1:35 PM, there was an altercation between (R1) and (R3). There was no injury to either resident. The two were immediately separated. The Administrator was notified. A full investigation and a final report sent when complete.…

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, interview and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner that prevents foodborne illness. This has the potential to affect all 108 residents living in the Facility. Findings include: On 5/13/25 at 8:10 AM, in the kitchen next to the oven there was a large tub containing light brown colored grains. The tub was not labeled or dated, and the scoop was lying directly on top of the grains inside. There was another large tub containing a white powdery substance that was not labeled or dated. V4, Dietary Manager (DM), stated that was sugar, and the brown grains were oats. She picked up the scoop from the oats and stated the handles always fall out into the grains. She stated she just washed both of the containers and refilled them but has not had a chance to label them. On 5/13/5 at 8:14 AM, in the walk in refrigerator there was a carton of milk and a carton of applesauce lying directly on the floor. There were two boxes of pasteurized shell eggs stored on a shelf directly above two boxes of (Nutritional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to prevent abuse in 1 of 3 residents (R31), reviewed for abuse in the sample of 38. Findings include: On 5/13/25 at 11:07 AM, R31 was observed in his room, alert to self only, pleasant and was unable to recall any details of the incident between him and R22. R31 and R22 are in rooms across the hall from one another. R31's Face Sheet, undated, documents R31 has the following diagnoses: Encephalopathy, Altered Mental Status, Slurred Speech, and a Cognitive Communication Deficit. R31's MDS (Minimum Data Set), dated 3/18/25, documents R31 has a BIMS (Brief Interview for Mental Status) score of 6, indicating R31 has severe cognitive impairment. R31's Care Plan, dated 12/23/24, documents R31 is at risk for abuse and neglect related to Encephalopathy and Cognitive Decline. R31 is at risk for complications due to occasional incontinence. He at times forgets where the bathroom is and wanders from room to room looking. R31's Progress Note, 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 interview, observation and record review, the facility failed to report an injury of unknown origin in 1 of 3 residents (R61), reviewed for abuse in the sample of 38. Findings include: On 5/13/25 at 10:49 AM, R61 was observed with multiple large and small reddish/purple colored bruises and purpura noted to her bilateral forearms and right hand. No s/s (signs or symptoms) of pain or discomfort noted. R61 speaks Spanish but is able to make her needs known with staff. R66, R61's Roommate, stated they did an x-ray yesterday because she (R61) was acting like it (shoulder) hurt and she hadn't noticed her acting like that before. R66 stated she has not seen staff being rough during care or abusive towards R61. R61's Face Sheet, undated, documents R61 has the following diagnoses: Stage 4 CKD (Chronic Kidney Disease), Dementia, HTN (Hypertension), and Dysphagia. R61's MDS (Minimum Data Set), dated 3/6/25, documents R61 has severe cognitive impairment, is dependent on staff with turning in bed and has limitations in range of motion of the bilateral upper and lower extremities. R61's…

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

Based on interview, observation and record review, the facility failed to investigate an injury of unknown origin in 1 of 3 residents (R61), reviewed for abuse in the sample of 38. Findings include: On 5/13/25 at 10:49 AM, R61 was observed with multiple large and small reddish/purple colored bruises and purpura noted to her bilateral forearms and right hand. No s/s (signs or symptoms) of pain or discomfort noted. R61 speaks Spanish but is able to make her needs known with staff. R66, R61's Roommate, stated they did an x-ray yesterday because she (R61) was acting like it (shoulder) hurt and she hadn't noticed her acting like that before. R66 stated she has not seen staff being rough during care or abusive towards R61. R61's Face Sheet, undated, documents R61 has the following diagnoses: Stage 4 CKD (Chronic Kidney Disease), Dementia, HTN (Hypertension), and Dysphagia. R61's MDS (Minimum Data Set), dated 3/6/25, documents R61 has severe cognitive impairment, is dependent on staff with turning in bed and has limitations in range of motion of the bilateral upper and lower extremities.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise and updated care plans with progressive interventions following falls for 1 of 6 (R57) residents investigated for accidents in a sample of 38. Findings include: R47's EMR (Electronic Medical Record) undated documented that the resident was admitted to the facility on [DATE]. R47's EMR dated 9/13/18 documents a diagnosis of repeated falls. R47's EMR dated 12/15/18 documents a diagnosis of hemiplegia, unspecified affecting left nondominant side. R47's EMR dated 12/10/20 documents a diagnosis of difficulty in walking, not elsewhere classified. R47's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 5 out of 15. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires substantial/maximal assistance for sit to lying and sit to stand. The MDS document that the resident requires partial/moderate assistance for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to communicate and collaborate with the outpatient dialysis center and monitor the dialysis access site for 1 of 3 residents (R318) reviewed for hemodialysis in the sample of 38. Findings include: R318's Face Sheet documents R318 was admitted to the facility on [DATE] with diagnoses including end stage renal disease. R318's Minimum Data Set (MDS) dated [DATE] documented R318 was cognitively intact, dependent with mobility and received dialysis. R318's Care Plan initiated 5/15/25 documents R318 has impaired renal function related to end stage renal disease. R318's Physician Order dated 4/30/25 documents check for thrill (vibration or buzzing sensation felt when palpating the skin over a hemodialysis fistula or graft) and bruit (whooshing sound heard when listening to an arteriovenous fistula, a surgical connection between an artery and a vein used for hemodialysis) every day and night shift. R318's Treatment Administration Record (TAR) for May 2025 does…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide food that accommodates food allergies for 1 of 2 residents (R95) reviewed for food and nutrition services in the sample of 38. Findings include: R95's Face Sheet documents R95 was admitted to the facility on [DATE]. R95's Minimum Data Set (MDS) dated [DATE] documented R95 was cognitively intact. R95's Physician Order dated 4/16/25 documents R95 is on a regular diet. R95's Allergy Report created 4/24/24 documents R95 has a cinnamon allergy. R95's Diet Card from Breakfast documents R95 has an allergy to cinnamon and lists dislike as Allergic to Cinnamon (in bold, capitalized print). The Facility's Menu for 5/13/25 documented raisin toast would be served for breakfast. On 5/13/25 at 8:48 AM, V7, Dietary Aid, was plating food from the steam table, then handing the plates to Certified Nursing Assistants (CNAs). He stated the CNAs look at the resident's meal tickets and tell us what to serve on the plate. On 5/13/25 at 8:50 AM, V5, CNA,…

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, interview and record review, the facility allowed its staff to use cell phones in the resident areas, resulting in an un-homelike environment for 5 of 5 residents (R1, R2, R3, R4, and R5) reviewed for resident rights in the sample of 9. Findings include: On 1/24/25 at 9:35 AM V6, LPN (Licensed Practical Nurse) was observed at the nurse's station on her cell phone. On 1/24/25 at 9:40 AM V5, LPN, was observed at the nurse's station on her cell phone. On 1/24/25 at 2:42 PM V7, Agency RN (Registered Nurse), was observed on his cell phone at the 400/500 nurse's station. On 1/28/25 at 11:07 AM V12, CNA (Certified Nursing Assistant) was observed leaning on the nurse's desk between 100/200 hall on his cell phone. On 1/28/25 at 11:27 AM V12, CNA, was observed sitting on a bench by the dining room on her cell phone. On 1/29/25 at 4:10 AM, V18, CNA, was observed on the 200 hallway, lying in a reclining wheelchair, covered up, on her cell phone. On 1/24/25 at 9:30 AM, R3 stated the staff are always on their cell phones when they should be taking care of them. On 1/24/25 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, interview, and record review, the facility failed to provide palatable food at an acceptable temperature for 4 of 5 residents (R1, R2, R3, and R5) reviewed for food provided at a preferred temperature in the sample of 9. Findings include: 1. On 1/28/25 at 8:43 AM, hall tray temperatures were taken with the following noted: on the 100 hall the potatoes temped at 105 degrees Fahrenheit, and the grits temped at 141 degrees Fahrenheit. On the 500 hall, the 500 hall tray potatoes temped at 120.7 degrees Fahrenheit, and the eggs temped at 92.6 degrees Fahrenheit. On 1/29/25 at 4:18 AM, R1 stated the food is always cold when she gets it in her room. 2. On 1/24/25 at 9:45 AM, R2 was observed in her room with her breakfast tray on her bedside table untouched. R2 stated the food is terrible, that is why she didn't eat it this morning. R2 stated, sometimes you can get a cheeseburger but it's cold like the rest of the food and if she gets a grilled cheese, it's cold and burnt. 3. On 1/24/25 at 9:30 AM, R3 stated the food is the worst on earth, cold, unidentifiable,…

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, interview, and record review, the facility failed to provide nourishing snacks between meals or at bedtime for 4 of 5 residents (R1, R2, R3, and R5) reviewed for snacks in the sample of 9. Findings include: 1. On 1/29/25 at 4:20 AM, V19, LPN (Licensed Practical Nurse) stated they always have snacks available for the residents. V19 stated they were passed out to the residents last night around 8:00 PM, pointing to 2 trays on the shelf at the nurse's station, and stated this is what's left. There were bags of marshmallows and an applesauce left on the trays. V19 stated the residents get what they want off of the tray and leave what they don't. V19 stated there are usually marshmallows, fudge rounds and applesauce available. On 1/28/25 at 8:35 AM, the breakfast trays were taken to the 100 hall to be passed out by staff. On 1/28/25 at 11:17 AM, R1 stated if the facility brings snacks, they are usually left at the nurse's station. R1 stated the facility still did not offer snacks and if it wasn't for her roommate who is able to go to the nurse's station and get them…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers and incontinent care to 3 of 5 residents (R1, R2, and R5) reviewed for care provided to dependent residents in the sample of 9. Findings include: 1. On 1/24/25 at 12:50 PM, R1 was observed and stated she does not receive showers because she has a port in her chest and staff does not want to get it wet and they will not cover it. R4 stated she occasionally gets a bed bath but not often and she thinks her last bed bath was last week. R4 stated that staff rarely washes her hair. On 1/29/25 at 4:18 AM, R1 was observed in bed lying on her left side, with a slight feces' odor noted. R1 stated she thinks she pooped. R1 stated she hasn't been changed since she was put to bed last night (1/28/25), unsure of time. R1 stated they won't change her until they get her up around 5:00 AM. On 1/29/25 at 4:50 AM, R1 was observed with V21, CNA (Certified Nursing Assistant), in bed. V21 stated R1 uses her call light and will tell her when 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the Facility failed to notify the resident representative of a change of condition for 1 of 3 residents (R2) reviewed for change of condition in the sample of 6. Findings include: R2's Physician Order Sheet (POS) for October 2024 documents a diagnosis of amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, hypertension, depression, chronic pain and encounter for screening for COVID-19. R2's Facesheet documents R2 has four emergency contacts documented as the following family members, V9, V10, V11 who was also listed as emergency contact #2, and V12. R2's MDS dated [DATE] documents R2 is cognitively intact for decision making of activities of daily living. She uses a motorized wheelchair and is always incontinent of bowel and bladder. R2's Care Plan dated 11/21/2022 documents R2 was at risk for respiratory infection related to COVID-19. R2 was also documented for potential for difficulty in breathing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician and resident representative of a change in condition for 1 of 3 residents (R2) reviewed for change of condition in a sample of 6. Findings include: R2's admission Record, with a print date of 08/27/24, documented R2 has diagnoses of but not limited to Chronic Respiratory failure with hypoxia, chronic pulmonary embolism, and non-pressure chronic ulcer of right calf limited to breakdown of skin. R2's Minimum Data Set (MDS), dated [DATE], documented R2 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15. R2's Physician's Order, dated 10/02/23, documented Oxygen at 2 Liters (L) via nasal cannula at bedtime (HS) for sleep apnea. R2's Progress Notes, dated 07/27/2024 at 08:04 AM, documented Nurses Notes Resident is shaking and very warm to touch. Resident is short of breath, oxygen (O2) saturation (sat) on room air is 85%. Place oxygen to 1 liter and O2 sat is 90%. Place oxygen to 2 Liters…

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 interview the facility failed to protect residents' clothing from loss for 4 of 16 residents (R7, R10, R15, R16) reviewed for homelike environment in the sample of 16. Findings include: 1. R7's Minimum Data Set, MDS, dated [DATE] documented that R7 is cognitively intact. On 8/6/24 at 9:20 AM R7 stated that she recently bought several new clothing items online and that they are all missing. R7 stated that she is missing two pairs of blue jeans and four brand new shirts. R7 stated she reported it to the CNAs (Certified Nursing Assistants) a few weeks ago and that they replied it is laundry's job to make sure her clothes are labeled. R7 stated that she then reported it to the laundry staff and that they said it is the CNAs responsibility to label the clothes. R7 stated that no other facility staff have come to talk to her about her missing clothes. R7 stated that it has had her upset because she spent a lot of her money on new clothes. 2. R10's MDS, dated [DATE], documented that R10 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain steam table holding temperatures before and during meal service and to maintain food at the proper temperatures while preparing and serving meal trays to residents. This has the potential to affect all 121 residents residing at the facility. Findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order, dated 1/27/24, documents Regular diet, Regular texture, Regular Liquids consistency. On 5/28/24 at 10:55 AM, R1 stated I eat in my room and the food is always cold. 2. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE]. R7's MDS, dated [DATE], documents R7 has a moderate cognitive impairment. R7's Physician Order, dated 12/21/22, documents Regular diet, Regular texture, Regular Liquids consistency. Super cereal at breakfast. On 5/28/24 at 9:45 AM, R7 stated The food is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to assess, monitor, and treat pressure ulcers for 2 of 4 (R3, R6) residents reviewed for pressure ulcers in the sample of 9. Findings include: 1. R3's Face sheet, undated, documents an original admission date of 5/19/24. Diagnosis includes osteoarthritis of knee, moderate protein-calorie malnutrition, unspecified anemia, essential primary hypertension, chronic embolism and thrombosis of other specified deep vein of left lower extremity, atelectasis, ileus, unspecified, other cholelithiasis without obstruction, other specified disorders of bone density and structure, unspecified multiple injuries, subsequent encounter. R3's Minimum Data Set, MDS, dated [DATE], section C, BIMS (Brief Interview of Mental Status) score is left blank, memory ok, independent in making decisions regarding tasks of daily life and shows no evidence of acute change in mental status from the resident's baseline. MDS dated [DATE], section GG, shows she needs 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 interview, observation, and record review, the facility failed to provide timely and complete incontinent care for 2 of 3 residents (R1, R7) reviewed for incontinence care in the sample of 9. The findings include: 1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnosis of Multiple Sclerosis, Morbid obesity, Dysarthria/Anarthria, Paraplegia, Hypothyroidism, Neuralgia/Neuritis, Ataxia, Major depressive disorder, Anxiety disorder, Anemia, Neuromuscular dysfunction of bladder, and Radiculopathy cervical region. R1's Care Plan, dated 4/21/24, documents R1 requires assist with daily care needs related to Multiple Sclerosis, paraplegia, neuroglia/neurotics. Utilizes 1/2 siderails x two to self-reposition and bed mobility. Interventions: Assist with Activities of Daily Living (ADLs), Encourage/ Assist with turning and repositioning every two hours and as needed, full body mechanical lift with two assist for transfers, monitor for changes with daily care abilities 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 observation, interviews, and record review the facility failed to serve meals at regular times in a manner that meets the resident's needs and per posted scheduled mealtimes. This has the potential to affect all 117 residents living in the facility. Findings include: The Facility's posted mealtimes are breakfast at 7:30 AM, lunch at 12:00 PM and dinner at 5:30 PM. On 5/14/24 at 10:15 AM facility staff were observed passing breakfast trays on the 400-hall. On 5/14/24 at 1:18 PM facility staff were observed passing lunch trays on the 400-hall. On 5/15/24 at 10:03 AM facility staff were observed passing breakfast trays on the 200-hall. On 5/15/24 at 1:20 PM facility staff were observed passing lunch trays on the 200-hall. On 5/14/24 at 9:55 AM R19 stated Breakfast has been late every morning for the past couple of weeks. Supper sometimes comes after 7 PM. On 5/14/24 at 10:22 AM V13, Certified Nurse Assistant, CNA, stated breakfast has been late every morning for a while now. On 5/14/24 at 10:24 AM V14, CNA/Restorative Aide stated that the residents have been complaining 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, interview, and record review, the facility failed to make sure mechanical lift transfers were provided in a safe manner and care plan interventions were followed to prevent falls for 4 of 4 residents (R65, R78, R90, R91) reviewed for transfers and falls in a sample of 44. Findings include: 1. R78's Face Sheet, print date of 05/15/24, documented R78 has diagnoses of but not limited to amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and Hypertension (HTN). R78's Minimum Data Set (MDS), dated [DATE], documented R78 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she is dependent on staff for bed mobility, dressing, and transferring. R78's Care Plan, with an admission date of 03/17/23, documented R78 requires assistance with all ADLs (Activities of Daily Living) related to impaired mobility and Dx (diagnoses) of Amyotrophic lateral sclerosis (ALS). Interventions include but are 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.

Based on observation, interview, and record review the facility failed to remove expired stock medications from the front hall medication room and from 2 medication carts. This failure has the potential to affect 54 residents. Findings include: On 5/13/24 at 1:20 PM, the 200 hall medication cart was inspected and the cart contained the following expired bottles of medications: 1 bottle of Bisacodyl stool softener tablets with an expiration date of 1/24, 1 bottle of Geri Dryl allergy relief tablets with an expiration date of 2/24, 1 bottle of Acidophilus probiotic capsules with an expiration date of 3/23, 1 bottle of lutein 20mg capsules with an expiration date of 3/24, 1 bottle of sodium bicarbonate tablets with an expiration date of 11/23, 1 bottle of sodium chloride tablets with an expiration date of 1/24, 1 bottle of Coenzyme Q-10 100 mg tablets with an expiration date of 3/24, 1 bottle of Optimum iron 65 mg tablets with an expiration date of 1/24, and 1 bottle of multivitamins with an expiration date 3/24. On 5/13/24 at 1:35 PM, the 100-hall medication cart was inspected, 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 interview, and record review, the facility failed to ensure residents are offered and receive if wanted the pneumococcal vaccination in accordance with Center for Disease Control and Prevention (CDC) recommendation for 5 of 6 residents (R6, R9, R48, R82 and R91) reviewed for pneumonia vaccinations in the sample of 44. Findings include: 1.R6's Face Sheet, dated 5/15/24, documented R6 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis and chronic obstructive pulmonary disease. R6's electronic medical record (EMR) does not document any pneumonia vaccination administration nor a history of any pneumonia vaccinations. 2.R9's Face Sheet, dated 5/15/24, documented R9 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, type two diabetes, chronic kidney disease with dialysis, peripheral vascular disease, and atherosclerotic heart disease. R9's EMR does not document any pneumonia vaccination administration nor a history of any pneumonia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to ensure 2 residents (R58, R99) reviewed for Activities of Daily Living (ADLs), were assisted with their needs, in the sample of 44. Findings include: 1. R58's Minimum Data Set (MDS) dated [DATE] documents R58 is severely cognitively impaired and is always incontinent of bowel and bladder. It further documents R58 requires total assistance with incontinent care. R58's Care Plan dated 7/10/2023 documents R58 requires assistance with all Activities of Daily Living (ADLs). It further documents, Keep clean and dry after incontinent episodes. On 5/14/24 at 9:00 AM, V15, Certified Nursing Assistant (CNA) was observed providing incontinent care for R58. At this time V15 stated, The other lady left at 6 (AM) I know she hasn't done changes since last night. I know this because (R99, R58's roommate) told me. At this time, R99 stated she know's R58 was last checked on/provided incontinent care at 11 PM the prior night (5/13/2024) by (V15). R99 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, interview and record review, the Facility failed to ensure treatments prescribed daily by a physician were completed for four consecutive days for 1 of 24 residents (R9) reviewed for Quality of Care in the sample of 44. Findings include: R9's Face sheet dated 5/15/2024 documents R9 has diagnoses of Type Two Diabetes, Peripheral Vascular Disease, Acquired absence of the Right Great toe, and non-pressure chronic ulcer of the left ankle. R9's Minimum Data Set, dated [DATE] documents R9 is cognitively intact. R9's Care Plan dated 3/8/2024 documents, (R9) had reopened his DFU (Diabetic Foot Ulcer) to his right great toe as well as, Treatment as ordered to right great toe. R9's Care Plan further documents R9 is on an antibiotic for the wound infections in R9's right greater toe and left ankle. R9's Treatment Administration Record (TAR) dated 5/11/2024 documents, Apply betadine to left medial ankle then apply calcium alginate and cover with a dry dressing daily to promote wound healing. R9's TAR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinent care in a timely manner and to do complete incontinent care for 3 of 5 residents (R58, R78, R91) reviewed for incontinent care in a sample of 44. 1. R78's Face Sheet, print date of 05/15/24, documented R78 has diagnoses of but not limited to amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and Hypertension (HTN). R78's Minimum Data Set (MDS), dated [DATE], documented R78 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she is dependent on staff for bed mobility, dressing, transferring, and she is always incontinent of bowel and bladder. R78's Care Plan, with an admission date of 03/17/23, documented R78 is incontinent of bowel and bladder, she will be kept clean, dry, and odor free through stay in the facility, check R78 frequently to see if she is clean and dry. It further documented R78 is at risk for skin…

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, interview and record review, the facility failed to administer medications according to the physician order for 1 of 4 residents (R54) reviewed for medication administration in the sample of 44. Findings include: On 5/14/24 at 8:45 AM, V5, Licensed Practical Nurse (LPN), was seen giving the following medications to R54: Fish Oil 1200 MG (milligram) ordered, only had 1000 MG in the cart and V5 gave that 1000 MG dose. V5 stated He's going to get 1000 MG because that's what I have. V5 was to give R54 Folic Acid 800 MG, V5 placed two 1000 MCG (microgram) pills in a medicine cup, when questioned on the proper dose, V5 stated That's microgram and not milligram. We usually have 400 MG tablets, but we don't have it in the cart. V5 went to the medication room and obtained the 400 MG tablets, went back to R54 and took out the previous two Folic Acid pills from the medication cup and replaced them with the 400 MG tablets. When questioned if she was going to give R54 the two 1000 MCG pills to R54, V5 stated Yes Sir, I was. V5 was giving R54 his Symbicort Inhaler 2 puffs as…

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

Based on interview and record review the facility failed to provide appetizing/palliative meals for 2 of 24 residents (R57, R99) reviewed for Dietary Services in the sample of 44. Findings include: 1. R99's Face Sheet dated 5/15/2024 documents R99 has a diagnosis of Moderate Protein-Calorie Malnutrition. On 5/13/24 at 12:57 PM R99 stated, I had my daughter bring in food. It's (facility food) so disgusting. I wouldn't feed it to my dogs. It's so nasty. 2. R57's Face Sheet dated 5/15/2024 documents R57 has a diagnosis of Moderate Protein-Calorie Malnutrition. R57's Care Plan dated 2/15/2024 documents R57 is at risk for altered nutrition/hydration status and weight fluctuation. It further documents a goal of maintaining adequate food intake to prevent weight changes. R57's Progress Note dated 2/29/2024 documents, Patient refused to take morning and noon dose of Keflex (antibiotic) because he didn't eat breakfast and lunch here because it's not appetizing. R57's Monthly Weight Report dated 5/15/2024 documents R57 was 137 pounds in January 2024 and was 128 pounds in February 2024. R57'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 observation, interview, and record review, the facility failed to perform hand hygiene and cleanse multi-use resident equipment to prevent the spread of infection for 4 of 6 residents (R32, R49, R78 and R91) reviewed for infection control in the sample of 44. Findings include: 1. R78's Face Sheet, print date 05/15/24, documented R78 has diagnoses of but not limited to amyotrophic lateral sclerosis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and Hypertension (HTN). R78's Minimum Data Set (MDS), dated [DATE], documented R78 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she is dependent on staff for bed mobility, dressing, transferring, and she is always incontinent of bowel and bladder. R78's Care Plan, admission date of 03/17/23, documented R78 is incontinent of bowel and bladder, she will be kept clean, dry, and odor free through stay in the facility, check R78 frequently to see if she is clean and dry. It further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review staff failed to administer several significant medications for 1 of 1 resident (R4) during a scheduled medication pass. Findings include: R4's undated Face Sheet documents pertinent medical diagnosis as Metabolic Encephalopathy, Bipolar Disorder, Unspecified Protein Calorie Malnutrition, Cognitive Communication Deficit and Sensorineural hearing loss, bilaterally. R4's Physician Order Summary report undated documents orders for the following medications: Amlodipine 5 mg daily for Primary Essential Hypertension, Ouetiapine Furamate 25 mg twice a day related to Encephalopathy, Seroquel 200 mg at bedtime related to Bipolar Disorder and Venlafaxine Extended Release 37.5 mg twice a day for Depression. R4's Care Plan dated 4/16/24 documents Care Areas for psychotropic and Hypertension medications. The Interventions included Take the medication(s) as ordered. R4's Minimum Data Set (MDS) dated [DATE] do not document any cognitive impairment. R4's Electronic Medication Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor the administration of medications as ordered by the physician for 5 of 5 residents (R1, R2, R9, R10, R11) reviewed for medications in a sample of 11. This resulted in residents receiving medications that were not prescribed for them or a delay in receiving prescribed medications. The findings include: 1. R1's Face Sheet undated documents R1's medical diagnosis as Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Encephalopathy, Unspecified, Cognitive Communication Deficit. R1's Physician Order Summary (POS) undated documents R1's medications as Remeron 15 mg (milligrams) at bedtime for weight loss related to depression; Levetiracetam 750 mg BID (twice of day) for seizures; Lisinopril 10 mg Daily for hypertension; Coreg 0.25 mg BID for hypertension; Lacosamide 100 mg BID for seizures and Clopidogrel 75 mg Daily related to cerebral infarction. R1's Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the Facility failed to ensure food was palatable, attractive and at a safe and appetizing temperature for 7 residents (R1, R3, R4, R5, R6, R7, and R8) reviewed for food in the sample of 40. Finding include: On 3/19/2024 at 8:09 AM, V2, Director of Nursing, stated Yes, I am aware of residents having food complaints. I have had complaints that the food is not warm enough. I have told residents that if the food is not warm enough staff can always warm it up for them. They are also complaining about portion sizes of the food. We have had turn around in the kitchen. Different staff coming and going I think this has been affecting the kitchen as well. The food complaints are up and down. On 3/19/2024 at 8:55 AM, in the main dining room was a large steam table. Hall trays for R4, R5, R6 and R7 were being prepared and placed on top of the steam table. On 3/19/2024 at 9:01 AM, the R4, R5, R6 and R7's hall trays were sitting on top of the steam table. There was a plate on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a communication system was working for all residents. This system relays directly to a staff member or to a centralized work area for 30 of 31 residents (R1, R8, R11, R12, R13,R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39 and R40) reviewed for working communication systems in the sample of 40. Findings include: On 3/19/2024 at 7:54 AM, Tour of the facility was conducted. During the tour handheld bells were observed on patient tables on the 100 and 200 hallways. On 3/19/2024 at 8:09 AM, V2, Director of Nursing (DON), stated some of the call lights in the building are not working and we have given residents hand bells for them to ring until the call lights are fixed. I am not sure how long the call lights have not been working but I am sure we placed a bid, and it was accepted. Hopefully, it will be fixed soon. R1's Minimum Data Set (MDS) dated ,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error did not occur for 1 of 5 residents (R5) reviewed for medication administration in the sample of 7. Findings include: On 1/30/24 at 12:55 PM, R5 was observed in the hallway pleasantly confused and unable to provide any details of his medications. On 1/31/24 at 11:45 AM, V11, Licensed Practical Nurse, stated that he was the nurse that had the medication error involving R5. V11 stated that he had given R5 his medications and he took them, then he gave R7 her medications and she agreed to take them, so he (V11) walked away. V11 continued to state that he did not stay with R7 while she took her medication and R7 gave her medication to R5 and R5 took the medication. V11 stated that R5 did not have any adverse effects. V11 stated that he was to stay with the resident until they take their medications. On 1/31/24 at 11:50 AM, V3, Assistant Director of Nurses, stated that there was a medication error involving R5, R7 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 observation, interview, and record review, the facility failed to provide a clean, comfortable, safe and homelike environment for 2 of 5 residents (R4, R5) reviewed for physical environment in the sample of 5. Findings include: 1. On 1/10/24 at 2:47 PM, R4 who was alert to person, place and time stated housekeeping does not do a good job. She stated they only come in to mop and take out her trash about once a week. On 1/10/24 at 2:50 PM, R5 who was alert to person, place and time stated housekeeping is short-handed and does not take out the trash on weekends. She stated sometimes they do not come in on weekdays either, but it generally happens more often on weekends. 2. On 1/10/24 at 1:15 PM, in the 300 hallway there was a bag of linens sitting on the floor outside od a room. On 1/10/24 at 1:17 PM, the 500 hallway was lined with a cart containing an ice chest, a bedside table, a chair, a clean linen cart, a meal cart with discarded trays, a nightstand, two wheelchairs, two specialty chairs and two…

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, interview, and record review, the facility failed to adhere to infection control practices and policies related to staff donning and the utilization of appropriate PPE (Personal Protective Equipment) while caring for residents, failed to perform hand hygiene before and after resident care, and failed to disinfect shared medical equipment taken out of an isolation room for 2 (R1, R3) of 3 residents reviewed for infection control in the sample of 3. The findings are: On 10/2/23 at 10:40 AM, R3 had a Contact isolation sign posted on the outside of his door, and a plastic cart for PPE outside the door, however, the cart was empty with no PPE seen in the cart. On 10/2/23 at 10:45 AM, V4, Certified Nursing Assistant, (CNA), stated, If a resident is on isolation, there will be a plastic cart in front of the door with PPE supplies in it. There should also be a sign on the door. On 10/2/23 at 10:48 AM, R1 had a contact isolation sign posted on the outside of his door, a PPE cart was sitting outside the door with only one gown and a box of surgical masks, with no gloves…

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, interview, and record review the facility failed to ensure food was stored food in a manner which prevents potential contamination and food borne illness. This has the potential to affect all 113 residents living in the facility. Findings include: On 4/18/2023 at 8:02 AM, staff were inside the walk-in refrigerator and were pulling out products and setting them on the metal counter in the kitchen. There was a large industrial container of beans, with no date or label, a large metal pan of a white gravy substance with no cover and no date or label, and large clear container of a soup-like substance with no date and no label. On 4/18/2023 at 8:03 AM, in the kitchen walk in refrigerator there was a large industrial clear container containing individualized storage bags with cereal-looking substance inside. These items were not dated or labeled. On the second shelf of the metal cart inside the refrigerator was a box of yogurt and next to the yogurt was a package of sausage. On 4/18/2023 at 8:05 AM, V3, Dietary Manager stated, I am not sure why that is not labeled…

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 interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infections. This has the potential to affect all 113 residents living in the facility. Findings include: The facility's Infection Surveillance Monthly Report dated March 2023 documents the resident name, infection onset, infection, signs and symptoms, status, and the pharmacy order. The report does not document if a culture was done, the type of bacteria present, or isolation status. The facility's Infection Surveillance Monthly Report dated April 2023 documents the resident name, infection onset, infection, signs and symptoms, status, and the pharmacy order. The report does not document if a culture was done, the type of bacteria present, or isolation status. The facility's Antibiotic Tracking binder was not up-to-date and did not have all the cultures for infections present in the facility. On 04/20/23 at 9:00 AM, V28, Infection Control Preventionist was unable to explain the way that the facility tracks 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 observation, interview and record review, the facility failed to provide an adequate amount of linen for the residents for (R6, R9, R32, R48, R93) reviewed for homelike environment in the sample of 48. Findings include: 1. On 4/18/23 at 3:03 PM, R32 stated I live on the 500-hall, and I am not sure if staff do not have enough supplies, or they are not doing laundry, but the staff are always running out of washcloths and towels during the night shift. They have to use pillowcases to clean me up and trust me they are not cleaning me that well. Do you want to be cleaned with a pillowcase and then they are washing those pillowcases and people are putting their heads down on them. It's gross if you think about it. R32's Minimum Data Set (MDS), dated [DATE], documents R32 is cognitively intact. 2. On 4/19/23 at 10:43 AM, during the Group Meeting with residents, R93 stated there is not enough linen. R93's MDS, dated [DATE], documents R93 is cognitively intact. 3. On 4/19/23 at 10:43 AM, during the Group…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve palatable meals and follow the menu for 8 of 9 residents (R6, R9, R14, R48, R58, R69, R90, R93) reviewed for food in the sample of 47. Findings include: 1. On 4/19/23 at 10:43 AM, during the Group Meeting, R90, stated she was served burnt bacon this morning, they don't give food substitutions, the food is cold, they ran out of white milk so they were served chocolate milk for their cereal, and they run out of food so they can't get more. R90's Minimum Data Set (MDS), dated [DATE], documents R90 is cognitively intact. 2. On 4/19/23 at 10:43 AM, during the Group Meeting, R69 stated he was served burnt bacon this morning, they don't give food substitutions, the kitchen ran out of white milk so they were served chocolate milk for their cereal, the food is cold, and they run out of food so they can't get more. R69's MDS, dated [DATE], documents R69 is cognitively intact. 3. On 4/19/23 at 10:43 AM, during the resident council meeting, R93…

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 interview and record review the facility failed to ensure that the antibiotics prescribed are effective in treating residents' infections for 4 of 4 residents (R41, R72, R82, R317) reviewed for antibiotic stewardship in the sample of 48. Findings include: The facility's Infection Surveillance Monthly Report dated March 2023 documents the resident name, infection onset, infection, signs and symptoms, status, and the pharmacy order. The report does not document if a culture was done, the type of bacteria present, or isolation. The report documents that R41 and R72 had urinary tract infections and started on antibiotics. The facility's Infection Surveillance Monthly Report dated April 2023 documents the resident name, infection onset, infection, signs and symptoms, status, and the pharmacy order. The report does not document if a culture was done, the type of bacteria present, or isolation. The report documents that R84 and R317 had urinary tract infections and started on antibiotics. 1. R41's Physician Order dated 03/25/23 documents Cephalexin Oral Capsule 250 MG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide supervision and allowed a resident to have access to food items which could cause potential choking hazards for one of one resident (R95) reviewed for supervision to prevent accidents in the sample of 48. Findings Include: R95's undated face sheet, documents R95 has diagnoses of Hemiplegia and Hemiparesis and Dysphagia Oropharyngeal Phase. R95's Minimum Data Set, dated [DATE] documents R95 is cognitively intact. R95's Physician Order Sheet (POS) dated 3/15/23 documents R95 is to receive nothing by mouth (NPO) diet, NPO texture, NPO consistency. R95's Care Plans dated 1/14/23 and 4/19/23 both document (R95) is NPO and receives all nutrition and medication through his gastrostomy tube (g-tube). The Care Plan documents R95 will occasionally refuse to follow his NPO status and will take and eat his roommate's food. R95's intervention is reminding the resident on the importance of following his NPO status. R95's Nurses Note date 1/24/23…

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.