Bridgeway Senior Living

Based on observation, interview, and record review, the facility failed to maintain the kitchen walk-in cooler in safe operating condition. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 12/10/24 documents that the total census was 159 residents. On 12/10/24 at 4:15 PM, V2 (Director of Nursing) said the facility has 3 NPO (Nothing by Mouth) residents. On 12/10/24 at 10:08 AM during a kitchen tour with V23 (Dietary Manager), the walk-in cooler in the facility kitchen was noted to be 58 degrees Fahrenheit per the in unit thermometer and inside the cooler did not feel cold. On 12/11/24 at 10:32 AM during a return of kitchen tour with V23 (Dietary Manager), the walk-in cooler outside unit thermometer was showing 53 degrees Fahrenheit. V23 said he removed all of the food from the walk-in cooler on 12/10/24. V23 and surveyor then walked into walk-in cooler and surveyor 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 interview and record review, the facility failed to provide a resident and/or their family/POA (POA/Power of Attorney) in writing for the reason of transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 5 of 5 residents (R9, R25 R58, R63, and R84) reviewed for discharge in a sample of 32. The findings include: 1. R63's After Visit Summary shows that R63 was admitted to the hospital from [DATE] to 9/16/24 with the diagnosis of acute cystitis without hematuria. R63's progress notes of 9/13/24 at 9:36 PM states that resident was observed sitting in her recliner chair with head and body jerking/shaking; resident's vitals were taken, and resident noted with elevated blood pressure of 242/108. Resident was sent to the hospital/emergency room via 911. 2. R58's After Visit Summary shows that R58 was admitted to the hospital from [DATE] to 10/18/24 with the diagnosis of wound infection. R58's progress notes of 10/11/24 states that resident was seen by 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 provide in writing to the residents and/or their POA (POA/Power of Attorney) information regarding bed hold and return at the time of discharge to the hospital. This applies to 5 of 5 residents (R9, R25 R58, R63, and R84) reviewed for discharge in a sample of 32. The findings include: 1. R63's After Visit Summary shows that R63 was admitted to the hospital from [DATE] to 9/16/24 with the diagnosis of acute cystitis without hematuria. R63's progress notes of 9/13/24 at 9:36 PM states that resident was observed sitting in her recliner chair with head and body jerking/shaking; resident's vitals were taken, and resident noted with elevated blood pressure of 242/108. Resident was sent to the hospital/emergency room via 911. No bed hold documentation uploaded into the medical record. The facility was unable to provide documentation of bed hold given to the resident and/or the POA. 2. R58's After Visit Summary shows that R58 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for 5 residents (R34, R5, R151, R139, & R38) who are dependent on care for activities of daily living in a sample of 32. The findings include: 1. On 12/10/24 at 11:29 AM, R5 was observed with facial hair on her chin and around her mouth. R5 said that she was not aware that she had any facial hair on her face because she is not able to hold a mirror and the staff has never offered her one. R5 said that she had never been shaved and after touching her face and feeling the facial hair, R5 said that having the facial hair makes her feel bad and it is not a good feeling. On 12/11/24 at 11:12 AM, R5 was observed in her bed with facial hair on her chin and around her mouth. R5's EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted on [DATE] with diagnoses including MS (multiple sclerosis) and osteoarthritis. R5's 11/4/24 MDS (Minimum Data Set) section GG showed that R5…

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 6. On 12/10/24 at 11:01 AM, R109 was in her room and there were 10 Pills in a medication cup on her bedside table. R109 said that the nurse gave the medicine to her and then the nurse walked away. R109 said that she was not going to take her medications until her stomach felt better. R109 said that she had been throwing up since early morning and every time she drinks water she throws up. On 12/12/24 at 12:45 PM V2 (Director of Nursing) said that all residents need an assessment to self-medicate, and they also need an order from the physician. V2 then looks at R109 EHR (Electronic Health Record) and said that R109 did not have an order to self-medicate or an assessment. V2 said that the medications should not have been left there because the resident could throw away the medications and there is no guarantee the resident is taking the medications. V2 said she was not aware of the facility's policy on storage of medications. R109's EHR showed that she is a [AGE] year old female admitted on [DATE] with diagnoses…

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 maintain temperature logs, properly store and label food items, and discard potentially spoiled food items. This applies to 5 residents (R153, R5, R16, R8, and R109) reviewed for personal food storage in a sample of 32 residents. The Findings include: 1. On 12/10/24 at 10:45 AM 153's personal refrigerator did not have a temperature log on it and there was no thermometer in the refrigerator. Inside of the refrigerator were 4 supplement drinks, 1 yogurt, several cups of jello, water and puddings. 2. On 12/10/24 at 11:29 AM, R5's personal refrigerator did not have a temperature log on it and there were 10 Peanut Butter and Jelly sandwiches in it, 3 cups of ice cream that was in a liquid form, 2 cups of sherbet that had also turned into a liquid form and the sherbert had separated, 1 of the sherbert cups was open without a lid and half full. 3. On 12/10/24 at 01:09 PM, R8's personal refrigerator was observed without having a temperature log and did not have a thermometer in it. In the freezer was ice cream and in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control practices. This applies to all 159 residents residing in the facility. The findings include: 1. On December 10, 2024, at 11:30 AM, R161's room did not have any EBP (Enhanced Barrier Precautions) signage or isolation bin with PPE (Personal Protective Equipment) outside of her room. On December 11, 2024, at 12:25 PM, V10 (Wound Care Coordinator/RN-Registered Nurse) and V31 (CNA/Certified Nurse Assistant) went to R161's room and only applied gloves before starting wound care treatment. At 12:31 PM, V10 and V31 touched R161's urinary catheter bag and placed it onto the bed. At 12:33 PM, V31 lowered R161's bed and the urinary catheter bag was resting on the ground. At 1:57 PM, V10 entered R161's room with only gloves on and began moving the urinary catheter bag and placed onto the bed. On December 12, 2024, at 9:29 AM, V10 and V11 (LPN/Licensed Practical Nurse) went to R161's room to provide wound care and only had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide care with dignity to 1 resident (R139) reviewed for resident rights in a sample of 32. The findings include: On 12/10/24 at 12:19 PM, V9 (Nurse) was observed standing over R139 while feeding her. V9 was observed telling R139 eat, eat. in a demeaning tone. R139 is an [AGE] year old female admitted to the facility on [DATE] with diagnoses including hemiplegia, spinal stenosis, contracture of muscle, muscular degeneration, & vascular dementia. R139's 10/22/24 MDS (Minimum Data Set) section C showed that R139's mental cognition is severely impaired. R139's 10/22/24 MDS section GG showed that R139 needs substantial/maximal assistance for eating. On 12/12/24 12:32 PM V2 (Director of Nursing) said that staff should not be standing over R139 when feeding her, they should be sitting down next to her, so they are at the same level for dignity. The facility's Resident Rights Statement dated December 2023 showed that all residents have a…

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

Based on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 1of 1 residents (R63) reviewed for accommodation of needs in a sample of 32. The findings include: On 12/10/24 at 11:48 AM, R63 was sitting in recliner chair in her room. R63's call light was attached to her bed by the side rail. R63's bed was by the window, while R63 was sitting closer to door. When asked about her call light, R63 said, I cannot reach it from here, I do use it and it irritates me when it does not follow me across the room. I do need it; I can use it. Surveyor pushed R63's call light at 11:51 AM, V7 (Minimum Data Set/MDS Coordinator) came to R63's room. V7 said the call light should be close to the residents and within their reach all the time so they can us it when they need assistance. R63's MDS of 10/8/24 shows that R63's cognition is moderately impaired; R63 is dependent on staff for toileting hygiene and partial/moderate assistance with personal hygiene. R63's care plan (initiated 12/27/22) shows that R63 is at risk for…

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

Based on interview and record review, the facility failed to invite a resident to the care plan meetings. This applies to 1 of 1 resident (R146) reviewed for care plan meetings in a sample of 32. The findings include: On December 10, 2024 at 11:01 AM, R146 said he wished somebody would tell him what he needed to do to go home. R146 said he was not told what the goals were or what he needed to do to be discharged home. R146 said he had never heard of a care plan meeting and had never been invited to one. R146 said he made his own goals up. On December 12, 2024 at 11:31 AM, V20 (Social Services Director) said R146 does not attend his meetings because he had never chosen to. V20 said she did not have documentation or progress notes to show she had invited R146 to the care plan meetings. V20 said R146's family was never there and had never scheduled to come to the meetings. V20 said she did not have documentation, including progress notes, to show the facility staff had invited the family to the care plan meetings. R146's Care Plan Meeting Attendance forms dated November 12, 2024,…

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 obtain residents' blood glucose levels appropriately and failed to follow physician order for administering insulin. This applies to 2 of 2 residents (R100 and R121) reviewed for blood glucose monitoring and insulin. The findings include: 1. On 12/10/24 at 10:38 AM, V6 (Agency Registered Nurse/RN) checked R100's blood glucose level. R100's glucose level was 221. V6 said that R100 gets insulin per sliding scale. At 10:49 AM, V6 returned to R100's room and administered 4 units of insulin Aspart to R100's left upper arm. R100 said he had breakfast around 8:00 AM. The lunch trays were passed at 12:18 PM. Review of R120's Electronic Medical Record (EMR) shows the following diagnoses of chronic kidney disease, disorder of kidney and ureter and Type 2 diabetes mellitus without complication. R100 has a physician order for accucheck four times a day, Insulin Aspart injection solution 100 unit/ml, inject as per sliding scale. On 12/11/24 at 9:13 AM, V6 (Agency RN) said she took R100's 11 AM blood glucose level yesterday…

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 implement a physician's order. This applies to 1 resident (R77) reviewed for quality of care in a sample of 32. The findings include: On 12/10/24 at 12:39 PM R77 was in her room eating her lunch. The diet slip on her tray showed No Straws. At 12:54 PM V14 CNA (Certified Nurse's Assistant) brought a cup of water with a straw in the cup and placed it on R77's table and removed her lunch tray. On 12/12/24 at 01:09 PM V15 (CNA) said that she put a straw on R77's lunch tray and was bringing the tray to R77's room when V13 SLP (Speech Language Pathologist) took R77's tray from V15 and brought it into R77 room herself. On 12/12/24 at 01:15 PM V13 said that she did a bedside swallow study on R77 at that time, and she used the straw. V13 said that her evaluation determined that R77 is still not to use straws. V13 said that R77 last evaluation was in June of 2023, and it was determined that she was not to use straws, was to be on mechanical soft…

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 restorative services to a resident as recommended per ADL (Activities of Daily Living) Restorative Assessment. This applies to 1 resident (R128) reviewed for restorative services in a sample of 32. The findings include: R128's Face Sheet shows he is a [AGE] year old male with a history of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, dysphagia following cerebral infarction, and repeated falls. R128's MDS (Minimum Data Set) dated 10/15/24 shows he has impairments on one side of both upper and lower extremities, and he uses a wheelchair for mobility. On 12/10/24 at 11:38 AM, R128 was interviewed by surveyor while sitting in his bed. R128 is unable to speak due to history of stroke and aphasia, but he was able to respond to yes or no questions by moving his head up and down and side to side. R128 said the facility staff did offer him a communication board, but he did…

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 properly position resident's indwelling catheter bag/drainage bag during wound care dressing change and incontinent care. This applies to 3 of 3 residents (R5, R84 and R155) reviewed for indwelling catheters and incontinent care in a sample of 32. The findings include: 1. On 12/11/24 at 8:37 AM, R84 was observed sitting in her motorized wheelchair going down the hallway. R84's indwelling catheter drainage bag was hanging on the arm rest of the motorized wheelchair above the bladder line. There was back flow of urine noted. On 12/12/24 at 10:30 AM, V10 (Wound Care Nurse) and V11 (Licensed Practical Nurse/LPN) completed wound care for R84. V10 informed R84 of her dressing change; at 10:34 AM, V11 approached R84's left side of the bed and unhooked her catheter drainage bag from the side of the bed, lifted it up and placed it on the bed, back flow of urine was noted in the tubing. V11 moved to right side of the bed and turned R84 on her right…

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 the Quality Assessment and Assurance committee met quarterly with the required members. This failure has effects all the residents in the facility. The findings include: The Facility Data Sheet dated 6/20/24 showed there were 163 residents residing in the facility. On 7/1/24 at 10:00 AM, V3 (DON - Director of Nursing) provided a monthly QA (Quality Assurance) Committee sign-in sheet dated 4/23/24. This form showed the meeting was attended by Restorative, MDS Coordinator, Infection Control Preventionist, Business Office Manager, Admissions, Laundry/Housekeeping, Human Resources, ADON, and DON. The Administrator and Medical Director were not in attendance. (There were no monthly sign-in sheets for May or June 2024). The last QAPI (Quality Assurance and Performance Improvement) sign-in sheet was 12/23/23. The Administrator, Medical Director, and other required staff were present for this meeting. (There was no QAPI sign in sheet since 12/23/23 provided). On 7/1/24 at 2:11 PM, V13 (Social Services Director) said she…

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

Based on observations, interview, and record review the facility failed to ensure the resident hallway was safe, sanitary and comfortable for 7 residents (R12, R13, R14, R15, R16, R17, R18) reviewed for safe, sanitary, comfortable environment in the sample of 18. The findings include: The facility census report dated 6/19/24 showed R12, R13, R14, R15, R16, R17, and R18 resident in the rooms affected. On 6/20/24 at 10:25 AM, near the B-wing nurses' station and the beginning of the 2401-2408 hallway there were ceiling tiles missing and water steadily dripping. The carpet in a 5 foot radius of this area was saturated and caused a sloshing sound when the surveyor attempted to walk past the area. There was a large, gray, round, wheeled trash can under the missing tiles, but water was still dripping onto the carpet and surrounding area. There were 4 pink, personal care basins at the base of the trash can and two towels, with a light brown discoloration, spread out on the floor. The missing tiles exposed pluming and the air ducts. The water appeared to be steadily dripping from the duct…

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 incontinence care to a resident dependent on staff for ADLs (Activities of Daily Living). This applies to 1 of 4 residents (R4) reviewed for ADLs. The findings include: On February 29, 2024, at 11:22 AM, R4's bedding had a stain visible on the flat sheet underneath him. R4 said he had not been changed since the night before and was wet. R4 then said the staff said they could change him after lunch. R4 said the staff usually change him when they can and have the time, and he felt they probably did not have the time this morning. R4 said he was dependent on staff for everything. On February 29, 2024 at 11:41 AM, V7 (CNA) said she had not rounded on R4 because she was waiting for the wound nurse to change him. V7 said she normally changed him two times a day. V7 said she was going to clean him after she passed the lunch trays. At 12:28 PM, V7 (CNA/Certified Nurse Assistant) came to R4's room to provide incontinence care. V7 turned R4 to his right side and the sheet under R4 was made visible, showing a 2.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. R11 is 80 years-old with multiple medical diagnoses which include dementia, needs assistance with personal care, generalized muscle weakness, and abnormalities of gait and mobility. R11's Minimum Data Set (MDS) dated [DATE] shows that R1 is total dependent on staff for toileting and hygiene. On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen which showed the different drying stages of the urine in the linen. R1's wound dressing to his sacral area was wet with urine. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM On January 24, 2024, at 2:58 PM, V3 (Assistant Director of Nursing/ADON) stated that the residents are to be checked and changed for incontinence every 2 hours and as needed to prevent skin breakdown, urinary tract infection, and promote comfort. Based on observation,…

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 peri-care in a manner that would prevent urinary tract infection. In addition, the facility failed to ensure that an indwelling urinary catheter bag is not touching the floor. This applies to 5 of the 7 residents (R14, R38, R114, R160, R163) reviewed for peri-care and indwelling urinary care in the sample of 34. The findings include: 1. Face sheet shows that R14 is an [AGE] year-old who has multiple medical diagnoses which include Parkinson's disease, muscle weakness, and urinary tract infection (UTI). On January 22, 2024, at 11:13 AM, V16 (Certified Nursing Assistant/CNA) assisted R14 to the toilet who voided. After R14 voided, V16 assisted R14 to get up and cleaned R14's back perineum. Then V16 pulled the incontinence brief up and assisted R14 back to the bedroom without cleaning her frontal perineum. 2. Face sheet shows that R160 is 85 years-old with multiple medical diagnoses which include need assistance for personal care,…

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 as ordered by the physician. There were 31 medication opportunities with 4 errors, resulting in an 12.9% medication error rate. This applies to 4 of 6 residents (R8, R13, R36, R39) reviewed for medication administration in the sample of 34. The findings include: 1. On January 22, 2024, at 4:57 PM, V19 (Nurse) administered Ferrous Sulfate (Fe SO4) Elixir medication to R39. V19 poured the medication in the medicine cup and stated that she will administer the medication to R39. V19 also said that the order is to give 6.8 milliliter (ml) of the Fe SO4 Elixir. Upon inspection, it was noted that there was 7.5 ml of the Ferrous Sulfate in the medicine cup. V19 then re-check how much medication was in the cup, she poured some of the Ferrous Sulfate in the garbage can. It was noted that there was only 5ml of medication in the cup. The order is for 6.8 ml. R89's Medication Administration Record (MAR) dated January 2024, shows Ferrous Sulfate (Fe SO4) Elixir 220 milligram (mg)/5 ml. 2. On January…

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 label and date medications after opening to determine expiration dates. In addition, facility also failed to refrigerate an insulin that is unopened. This applies to 6 of 6 residents (R14, R15, R22, R31, R47, R151) reviewed for medication storage. The findings include: On [DATE], at 2:55 PM, the A-Unit Team 1 cart was observed with V27 (Nurse), and the following was noted: 1. R14's Arnuity Ellipta (fluticasone furoate inhalation powder) 100 mcg (micrograms) and Fluticasone Propionate and Salmeterol 250/50 mcg opened and not dated. 2. R47's Fluticasone Furoate 100 mcg/25 mcg opened and not dated. The Recommended Minimum Medication Storage Parameters based on manufacturer's guidance of the Fluticasone Furoate shows Date product when opened and discard in 6 weeks after opening the foil tray or when the counter reads 0. Whichever comes first. 3. R151's Breo Ellipta 200/25 opened and not dated. 4. R31's Breo Ellipta 200/25 open and not dated.…

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

Based on observation, interview and record review, the facility failed to provide fortified foods as ordered by the physician. This applies to 5 of 5 (R27, R33, R137, R146, R152) residents reviewed for dining in the sample of 34. The findings include: On January 22, 2024, at 9:20 AM, during initial tour of the kitchen, V7 (Cook) stated that she is preparing barbecue pulled pork, carrots and mashed potato for the lunch meal service. On January 22, 2024, starting at 11:13 AM, V7 was platting the meal for the lunch service. V7 was noted to serve the mashed potatoes she had prepared for the meal to the residents that showed fortified mashed potato on the diet card. R27, R33, R137, R146, R152 received regular mashed potatoes instead of fortified potatoes. When asked, V7 stated that she used hot water and chicken base powder and a little butter to prepare the mashed potato. Recipe for Fortified Mashed Potatoes listed ingredients as Potato, Mashed Instant (complete); 2% milk; milk (nonfat dry); sour cream; margarine; iodized salt. On January 22, 2024, at 11:50 PM, V6 (Food Service Manager)…

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 follow standard infection control processes in regards to hand hygiene and gloving during provisions of peri-care and medication administration. In addition, the facility failed to ensure that items were not stored under the medication room sink. This applies to 4 of the 34 residents (R13, R14, R38, R160) reviewed for infection control in the sample of 34. The findings include: 1. On January 22, 2024, at 5:10 PM, V17 (Nurse) administered medications to R13. During the preparation of medications, V17 was wearing gloves. V17 popped each medication from the bingo card medication container to her gloved hands, then V17 would put the medications in the medicine cup. V17 opened the drawers of the medication cart to gather the additional items she needed for R13. When V17 completed the preparation of R13's medications, V17 proceeded to administer the medications to R13 including the Dorzolamide HCL and Timolol Maleate eye drops while wearing the same gloves and without hand hygiene. 2. On January 22, 2024, at 11:13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to place residents' indwelling catheter urinary drainage bags into a privacy bag. This applies to 2 of 5 residents (R51, R114) reviewed for dignity. The findings include: 1. R51's EMR (Electronic Medical Record) showed R51 was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, dementia, and benign prostatic hyperplasia. R51's MDS (Minimum Data Set) dated November 21, 2023, showed R51 had moderately impaired cognition. On January 23, 2024, at 9:39 AM, R51's indwelling urinary catheter bag was hanging on the side of the bed facing the door and was visible from the hallway. R51's drainage bag was not in a privacy bag. 2. R114's EMR showed R114 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy acute benign prostatic hyperplasia, and kidney failure. R114's MDS dated [DATE], showed R114 was cognitively intact. On January 22, 2024, at 10:04 AM, R114's indwelling…

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 include a plan of care for pain management in the Comprehensive Care Plan for residents experiencing pain. This applies to 2 residents (R102 and R132) reviewed for care planning in the sample of 34. 1. R132's face sheet showed R132 has resided in the facility since January 2023 and has diagnoses that include but are not limited to rheumatoid arthritis, Parkinson disease, and myasthenia gravis. R132's comprehensive care plan was reviewed and there was no plan identified or interventions for pain management found in R132's comprehensive care plan. On January 22, 2024, at 10:02, R132 stated she has pain in both knees that makes it very difficult for her to stand. R132 stated there is a prescription for lidocaine pain patches to be placed on each knee daily. On January 24, 2024, at 11:01 AM, V2 (Director of Nursing) stated the comprehensive care plan for R132 should include a plan and interventions for pain management. 2. R102's face sheet documents 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 observation, interview, and record review, the facility failed to obtain prescriber's orders for holding a dose of insulin and for a formulary exchange of insulin; and failed to assess for medication self -administration and provide a secure bedside storage for self administered medications. This applies to 3 of 3 (R8, R22, R83) residents reviewed for medication administration and medication storage in a sample of 34. 1.R8's EMR (Electronic Medical Record) showed R8 admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, unspecified, type 2 diabetes mellitus with hyperglycemia, unspecified diastolic congestive heart failure, and cerebral infarction unspecified. R8's MDS (Minimum Data Set) dated January 2, 2024, showed R8 with severe cognitive impairment, and required partial assistance from staff for bed mobility, transfer, toileting and lower body dressing, putting on and taking off shoes, moderate assistance for bathing and set up…

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 wound care as ordered by physician and failed to ensure that a resident with a sacral pressure injury was kept clean and dry to promote wound healing per plan of care. This applies to 1 of 8 residents (R11) reviewed for pressure ulcer in the sample of 34. The findings include: R11 is 80 years-old with multiple medical diagnoses which include unstageable pressure ulcer in the sacral region, dementia, generalized weakness, and need assistance with personal care. On January 22, 2024, at 11:47 AM, V13 (Certified Nursing Assistant/CNA) was providing care to R11. There was a pervasive urine odor in the bedroom. R11's linen sheet was heavily saturated with urine, there were layers of brown ring stain in the linen. R1's wound dressing to his sacral area was wet. The label date of the dressing change was faded and illegible. The surrounding skin of the wound was macerated. V13 stated that the last time she changed R11's incontinence brief was at 7:00 AM. On January 24, 2024, at 10:58 AM, V22 (Wound Care Nurse)…

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 assess and provide interventions for R150's left hand contracture. This applies to 1 of 5 (R150) residents reviewed for range of motion and positioning in a sample of 34. R150's EMR (Electronic Medical Record) showed R150 was admitted to the facility on [DATE], with multiple diagnoses including spastic hemiplegia affecting left non dominant side, weakness, spinal stenosis lumber region, chronic viral hepatitis, vascular dementia, osteoarthritis of left, and contracture of muscle left forearm. R150's MDS (Minimum Data Set) dated October 17, 2023, showed R150 with moderate cognitive impairment and impairment of upper extremity range of motion on one side, and substantial assistance from staff for bathing, dressing, bed mobility, dependent on staff for transfer and assistance with eating. R150's care plan ADL (Activity of Daily Living) dated July 10, 2023, identifies limited ROM (Range of Motion), but does not include an intervention 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 observation, interview, and record review the facility failed to ensure effective treatment and interventions for a resident's pain. The facility also failed to provide pain relief patches for one resident per physician orders. This applies to 2 of 6 residents (R102 and R132) reviewed for pain in the sample of 34. Findings include: 1. R102's face sheet documents a [AGE] year old female admitted to the facility last on May 19, 2022, with diagnoses that include Fracture of one rib, Fracture of shaft of Femur, Dementia, Anxiety, Depressive Disorder, History of falling, and Schizoaffective disorder. On January 22, 2024, at 10:41 AM, R102 stated she was scared and in pain. R102 stated her neck, legs, back and head hurt. R102 stated her pain level was an 8 out of 10. R102 stated she had pain medication about an hour ago and the nurse said she would give her more pain medication after 12:00 PM. R102 stated, I can't bear the pain. On January 22, 2024, at 10:47 AM, R102 told V4 (LPN/Licensed Practical Nurse) her…

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 serve foods at safe and palatable temperatures at the lunch meal service. This applies to all 170 residents that received foods prepared at the facility kitchen. The findings include: On 02/17/23 at 9:25AM, V2 (Director of Nursing) stated that the facility census on 02/16/23 was 172 residents with two residents on NPO (nothing by mouth) status. During course of the survey and during Resident Council Meeting on 02/15/23, multiple residents voiced that the food served at meals was cold and unpalatable. On 02/16/23 at around 11:00 AM, V1(Administrator) was informed that the food temperatures will be monitored at tray line service for the lunch meal. On 02/16/23 at 11:27 AM, the facility kitchen was visited prior to the scheduled meal service at 11:30 AM. The meal temperature logs for the lunch meal service for 02/16/23 showed no entry of temperatures for the items to be served for the lunch meal. Further review of the temperature logs for previous days, showed that on Tuesday (02/14/23) temperatures were logged…

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

Based on observations, interview and record review, the facility failed to serve portion sizes to the residents on Regular consistency diets. This applies to 5 of 5 residents (R23, R36, R86, R163, R164) observed for dining in the sample of 40. The findings include: Facility Menu for the lunch meal Wednesday (Week 2) included stewed chicken over rice. Facility diet spreadsheet for the meal showed Stewed chicken over rice 2 each plus #8 dip rice. Facility scoop equivalent portion chart showed that #8 scoop=3.75 fluid oz/ounces or 1/2 cup. On 02/15/23 at 11:44 AM, lunch meal tray line was observed in the facility kitchen. V5 (Cook) was using a #8 scoop and served 1 scoop of stewed chicken with vegetables mixed with rice to the residents with Regular diets. V5 stated that he prepared the rice and chicken [boneless] stew item by mixing it together. R23, R36, R86, R163 and R164 were observed to receive one #8 scoop of stewed chicken and rice mixture. On 02/15/23 at 11:49 AM, V6 (Consultant Dietitian) stated that the regular diets should have received the rice and chicken items served…

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

Based on observation, interview and record review, the facility failed to serve mechanical soft consistency ham for breakfast, garlic bread and vegetable mechanical soft options for lunch and failed to serve pureed consistency chicken and stew for the lunch meal. This apples to 8 of 8 residents (R2, R28, R43, R93, R107, R108, R119, R130) observed for dining in the sample of 40. The findings include: Facility Diet Roster by texture printed on 2/14/23 included that R2, R28, R43, R108 were on Mechanical Soft consistency diets and R93, R107, R119 and R130 were on Pureed consistency diets. 1. On 02/14/23 at around 12:00 PM, at lunch meal tray line in the facility kitchen, V4 (Dietary Manager) stated that the residents on mechanical soft diet get mashed potato instead of garlic bread. On 02/14/23 at 12:17 PM, during dining observation in the Unit E dining room, R2, R28, R43, R108 diet cards showed mechanical soft diet and these residents received garlic bread. These residents also received mixed vegetables with lima beans that appeared hard and dry. R2, R28, R43 and R108 were all noted to…

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

Based on observation, interview and record review the facility failed to get residents out of bed. This applies to 3 residents (R7, R57, and R170) reviewed for choices in a sample of 40. 1. On 2/14/23 at 10:55 am, R7 was lying in bed wearing a hospital gown. R7 stated she is regularly left in bed but would like to be gotten up. On 2/15/23 at 11:03 am, R7 was gowned and lying-in bed. R7 Stated she was not gotten up the previous day and would still like to be gotten up. On 2/15/23 at 3:25 pm, R7 was gowned and lying in bed. R7 stated she had still not been gotten out of bed and wanted to get up. On 2/15/23 at 11:35 am, V15 CNA (Certified Nursing Assistant) was informed by the resident that she wanted to get out of bed into a Geri-chair. On 2/15/23 at 3:32 pm, V15 sated she had not gotten R7 out of bed. R7's Face Sheet showed a diagnosis of multiple sclerosis. R7's most recent MDS (Minimum Data Set) showed she requires total staff dependence for transfers. R7's February 2023 physician orders show to transfer resident to Geri-chair for thirty minutes every day and evening shift. 2. 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 resident rooms were sanitary and homelike. This applies to residents (R7, R52) reviewed for environment in the sample of 40. 1. On 2/15/23 at 11:03 am, extensive dry wall damage and large brown discolorations with ceiling damage noted in R7's bedroom. A large yellow bucket was under the damaged ceiling area. R7 stated the ceiling leaks every time it rains and maintenance poked a hole in the ceiling and put the bucket under the leak. R7 stated she should not have to live in a room like this. On 2/16/23 at 9:50 am, V16 CNA (Certified Nursing Assistant) stated the water damaged ceiling has been there for four months. V16 stated they spray painted it a month ago and put the bucket under the leak. V16 noticed the damaged drywall two weeks ago when they moved the other bed out. R7's Face Sheet showed she is a [AGE] year old female with a history of multiple sclerosis. R7 requires staff assistance with activities of daily living per her…

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 promote a safe environment by ensuring oxygen tanks were stored securely and by not keeping hazardous chemicals at the bedside. This applies to 2 of 5 residents (R40, R44) reviewed for accidents and hazards in a sample of 40. Findings include: 1. R40 is a [AGE] year-old female with moderate cognitive impairment as per Minimum Data Set (MDS) dated [DATE]. On 2/15/23 at 9:30 AM, R40 was observed in her bed and a metal oxygen tank was unsecured at the bedside. On 2/15/23 at 9:35 AM, the surveyor observed V9 (Agency Registered Nurse) stated that Oxygen tanks should have been secured with a stand. The facility presented the Oxygen use and Storage Policy dated 1/1/2015 document: The oxygen tank must be secured in a tank holder or wheelchair. At no time will a tank be left unattended outside proper housing. 2. R44 is a [AGE] year-old female with moderate cognitive impairment as per Minimum Data Set (MDS) dated [DATE]. On 2/14/23 at 12:07 PM, an…

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

Based on observation, interview, and record review, the facility failed to ensure the head of the bed was elevated for a resident receiving a tube feeding. This applies to one resident (R115) reviewed gastric tube feeding in a sample of 40. Findings include: On February 14, 2023, at 11:09 AM, R115 was observed lying in bed with head of the bed elevated at 20-degrees. R115 was observed to be breathing noisily. V13 (MDS Coordinator) stated that the head of the resident's bed should be higher. On February 15, 2023, at 8:50 AM, R115 was observed lying in bed, head of bed was elevated at 20-degrees with the tube feeding running. V14 (RN-Registered Nurse) stated R115's head of bed was too low and needed to be higher. V14 stated that if head of bed is too low there is potential for aspiration pneumonia. R115's Face Sheet showed the gastric feeding tube is due to diagnosis of dysphagia. R115's most recent Minimum Data Set showed R115 has severe cognitive impairment and is totally dependent on one staff with eating. R115's February 2023 Physician Order Sheet showed an order for Osmolite 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide PICC (Peripherally Inserted Central Catheter) line care by not changing the dirty PICC line dressing for 13 days. This applies to 1 of 1 resident reviewed (R154) for IV (intravenous) services in a sample of 40. Findings include: R154's Face Sheet showed he is a [AGE] year-old male and his most recent Minimum Data Set showed his is cognition intact. On 2/14/23 at 10:20 AM, R154 was observed with a right upper arm PICC line with a dirty and wrinkled dressing dated 2/1/23 (13 days earlier). On 2/14/23 at 10:20 AM, R154 stated, They didn't change my dressing for quite a while; I think it's been almost two weeks since they changed it. R154's Physician Order Sheet showed that R154 is receiving IV antibiotics with Ceftriaxone 2-gram daily for his wound infection. On 2/15/23 at 11:00 AM, V2 (Director of Nursing - DON) stated, PICC line dressings should be changed every seven days or as needed. He can get an infection if his dressing 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.