Bella Terra Bloomingdale

Based on observation, interview, and record review, the facility failed to to ensure urinary catheter tubing and drainage bags were positiond in a manner to prevent infection. This applies to 3 out of 4 (R358, R96, and R95) residents reviewed for urinary catheters in a sample of 31. The findings include: 1. On 2/26/2025 at 10:40 AM, R358 was in bed and he was wearing pants. R358's urinary catheter drainage tubing came out from underneath the waistband of his pants, and then was over his pants (above the level of his bladder). R358's catheter drainage bag had been placed on top of his bed and the tubing and drainage bag contained urine. V7 (Certified Nurse Assistant/CNA) said she would provide catheter care to R358. R358's catheter tubing securement device was ripped and detached from the tubing and the tubing was not secured. After V7 completed R358's care, she again brought his catheter tubing up from his front waistband and then over his pants. R358's care plan said he required the use of a Foley catheter for acute urinary retention related to hydronephrosis and benign prostatic…

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 report a Resident fall (caused by an improper transfer) to licensed staff before assisting the Resident up from the floor, failed to transfer residents using gait belts, and failed to ensure resident tranfer status was clearly communicated. This applies to 5 out of 5 residents (R1-R5) reviewed for accidents. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including post-operative care for a lumbar L3-5 transforaminal spinal fusion surgery with complications of wound infection and dehiscence, spinal stenosis of the lumbar region with neurogenic claudication, neuropathy, abnormalities of gait and mobility, difficulty walking, and unsteadiness on feet. R1's MDS (Minimum Data Set) dated 11/30/2024 showed R1 was dependent on staff for toilet transfers. R1's hospital records dated 12/12/2024 said The patient .presents with right leg pain and numbness which…

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 showers in accordance with the facility schedule and policy for residents identified as needing assistance with showers. This applies to 5 of 5 residents (R1, R2, R3, R7, R8) reviewed for showers/baths in the sample of 8. The findings include: V1 (Administrator) and V2 (Director of Nursing) were requested to provide all shower documentation for the past 30 days for R1, R2, R3, R7, and R8. 1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses, including chronic diastolic congestive heart failure, chronic kidney disease stage 3B, dry eye syndrome, type 2 diabetes without complication, malignant neoplasm of the prostrate, other obstructive and reflux uropathy and dementia, unspecified. R1's MDS (Minimum Data Set), dated August 1, 2024, showed moderate cognitive impairment and required assistance with ADLs (Activities of Daily Living), including substantial assistance with oral hygiene,…

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 did not follow their policy for Urinary Catheter Care and failed to document the assessment of symptoms for residents with indwelling urinary catheters who developed UTIs (Urinary Tract Infections) This applies to 3 of 4 residents (R1, R2 and R8) reviewed for indwelling urinary catheter care and UTI in the sample of 8. The findings include: 1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], and discharged from the facility on October 8, 2024. R2 was admitted with multiple diagnoses: metabolic encephalopathy, unspecified psychosis, type 2 diabetes with chronic kidney disease, neuromuscular dysfunction of the bladder, unspecified dementia, pressure ulcer to the ankle, and acute and chronic respiratory failure. R2's MDS (Minimum Data Set) dated September 24, 2024, showed R2 was moderately cognitively impaired, and required assistance with ADLs (Activities of daily Living) including substantial assistance with eating, oral…

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

Based on observation, interview, and record review the facility failed to provide feeding assistance for a resident with a dysphagia diagnosis, requiring 1 to 1 feeding assistance. This applies to 1 of 4 (R1) residents reviewed for feeding assistance reviewed for safety supervision in the sample of 7. The findings include: On 10/2/2024 at 12:18PM, R1 was observed at lunch with a mechanical soft tray and thickened liquids in front of him. R1 was observed reaching for and drinking the thickened liquids on the tray. V6 Activity Director was observed sitting at the end of the lunch table R1 was eating at. On 10/2/2024 at 12:20PM, V6 said she was not qualified to feed residents. On 10/2/2024 at 12:15PM, V5 Certified Nursing Assistant (CNA) said R1 had refused lunch. V5 said she left [R1's] tray in front of him at the lunch table. On 10/2/2024 at 1:39PM, V2 Director of Nursing (DON) said resident's requiring 1:1 feeding assistance should be helped by a CNA, nurse, or speech therapy. V2 said a tray should not be left in front of a resident requiring 1:1 feeding assistance without staff…

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

Based on observation, interview, and record review the facility failed to follow dietary orders for a resident. This applies to 1 of 4 (R1) residents reviewed for special diets in the sample of 7. The findings include: On 10/2/2024 at 10:49AM, R1 was observed sitting up in his chair near the nursing station with thickened water in his hand taking sips. R1 was alert awake and looking around the hallway. R1 took a couple small sips of the water and asked his nurse V4 Licensed Practical Nurse (LPN) for cold water. V4 returned with cold water for the resident and handed him what appeared to be thickened water. V4 took a couple sips from the new cup. No thin liquids were observed. On 10/2/2024 at 10:49AM, V4 stated she gave [R1] thickened liquids. On 10/2/2024 at 11:11PM, V11 Speech Therapist (ST) said [R1] was evaluated by him on 9/24/2024. V11 said [R1's] hospital video swallow from the week prior (9/16/2024) did not show aspiration, however, [R1] was coughing on honey thick liquids during his evaluation of the resident at the facility. V11 said [R1] was kept on thickened liquids due…

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 the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. This applies to 1 of 4 residents (R1) reviewed for psychotropic medications. The findings include: The EMR (Electronic Medical Record) showed R1 is [AGE] years old, with diagnoses that included but not limited to unspecified focal traumatic brain injury, insomnia, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, epileptic seizures related to external causes, not intractable, without status epilepticus, encounter for gastrostomy, catatonic disorder, spondylosis with myelopathy to the cervical region, Vitamin D deficiency, Parkinsonism, quadriplegia, hypertension, and unspecified tremor. The MDS (Minimum Data Set), dated 3/12/2024, showed R1 was moderately impaired with cognition with a BIMS (Brief Interview Mental Status) score of 12/15. The neuropsychology…

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 that needs extensive assistance for activities of daily of livings (ADL's) for 1 of 9 residents (R17) reviewed for ADL's in the sample of 19. The findings include: R17's facility assessment, dated 1/12/24, shows R17 is cognitively intact (answer questions with nodding). The same assessment shows R17 is dependent with staff with ADL care, and is always incontinent of bowel and bladder functions. On 3/18/24 at 10:23 am, a strong urine odor was coming from R17. When asked if he was wet, R17 nodded- (yes). V8 (Certified Nursing Assistant- CNA) said she has not provided care with R17 since 7AM because she does not know how to care for R17. V8 stated, (R17) was supposed to be checked and changed and he is soaked now. V7 (CNA) came to the room and assisted V8 to provide incontinence care. R17's incontinent pad was heavily saturated with urine that soaked through to the bed linens. On 3/18/24 at 1 PM, V2 (Director of Nursing) said R17 is check and change, due to him being 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 provide prescription glasses to a resident to maintain vision for 1 of 1 resident (R35) reviewed for vision services in the sample of 19. The findings include: R35's resident assessment, dated 2/29/24, shows R35 has no cognitive impairments. R35's vision is adequate with glasses. A document entitled Patient Encounter, dated 9/13/23, shows, NH (nursing home) requested comprehensive exam for (R35's) eye. The same document included eye examination results with eye glasses prescription showing R35 was in need of glasses. On 3/18/24 at 9:57 AM, R35 said she has been waiting for her prescription glasses. R35 said she had her eye exam last year (September 2023) to replace her missing glasses. R35 said she needed her glasses when reading, watching TV, or to just be able to see. R35 said no one has updated her regarding her glasses. On 3/19/24 at 10:10 AM, V9 (Social Services) said he just started last month. On 2/7/24, a careplan meeting was done with R35 and her family. V9 stated Right away, (R35's) family informed…

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 treat pressure injuries by not ensuring pressure relieving devices/ interventions were in place for a resident with a pressure injury. This applies to 1 of 6 residents (R63) reviewed for pressure injuries in a sample of 19. The findings include: 1. R63's Care Plan, date 11/13/23, states (R63) has a Stage 3 pressure ulcer (injury) to her sacrum related to Dehydration, Disease Process, history of ulcers and immobility. The interventions include: Apply gel chair cushion to wheelchair and check air mattress is functioning properly every shift and PRN (as needed). R63's Progress Notes, dated 11/13/23, state, The patient has a pressure injury. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels and all bony prominences. All prevention measures were discussed with the staff at the time of the visit. The resident is incontinent of bowel and bladder. Use appropriate moisture barrier…

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 fall interventions were in place for a resident with a history of falls. This applies to 1 of 19 residents (R7) reviewed for safety in the sample of 19. The findings include: R7's face sheet shows she is a [AGE] year old female, with diagnoses including spinal stenosis, weakness, history of falling, osteoporosis, history of left femur fracture, and abnormalities of gait and mobility. R7's current care plan, dated through March 2024, documents she is a high risk for falls related to generalized weakness, cognitively impaired, and poor safety awareness R7's interventions include a low bed, red star sign located outside of her room and please make sure that my call light is within reach. On 3/18/24 at 9:44 AM, a red star was on located outside of R7's room. She was lying in a low bed. She said she had some falls. Her call light cord was wrapped under the right upper side of the metal bed frame. This surveyor asked, Where's your call…

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 fortified supplements for a resident with significant weight loss. This applies to 1 of 8 residents (R47) reviewed for weight loss in the sample of 19. The findings include: R47's Physician Order Sheets dated through March 2024, shows orders for house supplement three times a day, fortified cereal with breakfast, fortified pudding with lunch, and fortified pudding with dinner. R47's Dietary Progress note, dated 2/15/24, documents she is a [AGE] year old female with diagnoses including Parkinson's, dementia, depression, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R47's current weight of 104.6 lb (pounds), BMI (Body Mass Index) classified as underweight for height and age. R47 with 13.8 pound weight loss in one month and 25.8 lb since 9/1/23 .POA (Power of Attorney) notified and nursing of significant weight loss. Started on appetite stimulant on 2/9/24, resident continue to note 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 observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times) There were 32 opportunities with 3 errors resulting in a 9.32% error rate. This applies to 2 of 4 residents (R66, R7) observed in the medication pass. The findings include: 1. On 3/18/24 at 10:40 AM, V4 (Registered Nurse-RN) was preparing R66's morning medications. R66's medications included gabapentin 100 mg three times a day (milligrams) and sertraline 100 mg twice a day. R66's Medication Administration Record, dated March 2024, shows orders to administer at 9:00 AM, gabepentin 100 mg three times a day for neuropathy pain, and Sertraline 100 mg every morning and at bedtime for mood stabilization. 2. On 3/18/24 at 10:48 AM, V4 was preparing R7's morning medications. R7's medications included metoprolol 50 mg. R7's Medication Administration Record, dated March 2024, shows orders to administer at 9:00 AM, metoprolol 25 mg twice at day for hypertension. On 3/19/24 at 11:24 AM, V5 (Licensed Practical Nurse/LPN) said medications should be given at the scheduled…

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 separate COVID-19 positive and COVID-19 negative residents to prevent the transmission of COVID-19 when the residents shared the same room, and failed to ensure staff wear PPE (Personal Protective Equipment) when entering a COVID-19 positive room. This applies to 6 of 27 residents (R1, R2, R8- R11) reviewed for COVID-19 infection. The findings include: 1. R2's face sheet (11/7/23) showed the following diagnoses of COVID-19, Type 2 Diabetes Mellitus, and unspecified systolic congestive heart failure. R2's MDS (Minimum Data Set), dated 9/28/23, shows R2's cognition is intact. R2 tested positive for COVID-19 on 10/30/23. On 11/7/23 at 12:06 PM, R2's room door had a contact and droplet sign and a PPE (Protective Personal Equipment) bin with surgical masks, N95 masks, face shields, and gowns outside the room. R2 was in bed and her call light was on. V6 (Certified Nurse Assistant/CNA) entered the room without full PPE; she had a mask covering…

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 assess, supervise, and implement safety measures for a resident who voiced homicidal and suicidal threats for 1 of 1 resident (R2) reviewed for safety and supervison in the sample of 6. The findings include: R2's Face Sheet shows she admitted to the facility on [DATE], with diagnoses of: dementia, anxiety, and depression, and discharged from the facility on 10/19/23. R2's Medication Administration Record shows since admission, she was refusing to take her ordered medication of: Mirtazapine (anti-depressant), buspirone (anti-anxiety), sertraline (anti-depressant) and divalproex (bi-polar). R2's Nursing Notes, dated 10/17/23 at 8:23 PM, shows, This writer was informed by assigned nurse aide that the patient that she was taking care of hit her with the tv remote control, hitting her on her left lower jaw DON (Director of Nursing)/ADON (Assistant Director of Nursing) made aware On 11/1/23 at 10:00 AM, R1 said he was walking down the hallway and heard…

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 a resident was administered the correct medication for 1 of 4 residents (R1) reviewed for medication administration in the sample of 5. The findings include: On 11/1/23 at 10:00 AM, R1 said the other day, he received a yellow capsule around lunch time that was given to him by V6 (Licensed Practical Nurse). R1 said he usually takes hydralazine (pink tablet) around lunch time. R1 said he brought the medication back to V6, and told her it was not his. On 11/1/23 at 10:42 AM, V6 said she prepared R1 and R6's medication at the same time, since they both were in the dining room for lunch. V6 said she prepared a hydralazine (pink tablet) for R1 and a gabapentin (yellow capsule) for R6. V6 said she set R1's medication on the table next to him, and when she was walking to give R6 his medication, R1 came up to her and said the medication given to him was not his. V6 said she accidentally gave R1 R6's medication. On 11/1/23 at 11:30 AM, V2 (Director of Nursing) said nurses should always verify who the resident is before giving…

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 sufficient staff to meet the care needs of the residents. This failure has the potential to affect all 100 residents in the facility. The findings include: The Resident Census and Conditions of Residents form dated April 24, 2023, showed the facility census as 100 residents. 1. R21's Order Summary Report dated 4/25/23 shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, aphasia, gastrostomy status, dysphagia, contracture, and major depressive disorder. R21's MDS dated [DATE] shows R21 requires total assistance for bed mobility, toilet use, and personal hygiene. R21 is always incontinent of bowel and bladder. R21's Care Plan initiated on 7/2/21 shows R21 is at risk of oral/dental health problems related to poor oral hygiene. Inability to care for self, needs assistance with oral hygiene. On 4/24/23 at 9:58 AM, R21 was lying in bed. R21 was nonverbal. There was saliva coming out of R21's left side of…

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

Based on observation, interview, and record review, the facility failed to sanitize and store dish ware to prevent cross contamination. This failure has the potential to affect all 100 residents in the facility. The findings include: The Resident Census and Conditions of Residents form dated April 24, 2023, showed the facility census as 100 residents. On April 24, 2023, at 9:30 AM, V14 (Kitchen Aide) unloaded a tray of clean dishware from the dishwasher. V14 was not wearing gloves. V14 immediately walked over to the sink, rinsed off a tray of dirty pans, and loaded the tray off dirty pans into the dishwasher. While the tray of pans was in the dishwasher, V14 unloaded dirty dishes from a cart by the sink. V14 wore no gloves. Without washing his hands or wearing gloves, V14 then emptied the clean pans from the dishwasher. On April 24, 2023, at 9:34 AM, a large metal scoop was lying in a container of dried oatmeal. On April 24, 2023, at 9:35 AM, V14 (Kitchen Aide) placed a tray of dirty dishes into the dishwasher. V14 wore no gloves. Once the dishwasher stopped, V14 emptied 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) assistance for residents' requiring extensive assistance for seven of 22 residents (R21, R50, R26, R90, R8, R37, R356) reviewed for ADL assistance in the sample of 22. The findings include: 1. R21's Order Summary Report dated 4/25/23 shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, aphasia, gastrostomy status, dysphagia, contracture, and major depressive disorder. R21's MDS (Minimum Data Set) dated 2/9/23 shows R21 requires total assistance for bed mobility, toilet use, and personal hygiene. R21 is always incontinent of bowel and bladder. R21's Care Plan initiated on 7/2/21 shows R21 is at risk of oral/dental health problems related to poor oral hygiene. Inability to care for self, needs assistance with oral hygiene. Interventions initiated on 12/16/21 include R21 will be provided mouth care as per ADL (Activities of Daily Living) personal hygiene and provided…

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 medications requiring refrigeration were stored in a refrigerator with a working thermometer. This applies to 4 of 4 (R46, R44, R84, R41) residents reviewed for pharmacy services in the sample of 22. The findings include: On 4/26/2023 at 10:15AM, the medication room on the old town unit was observed with V22 (Registered Nurse/RN). The medium-sized medication refrigerator sitting on the floor labeled B had no thermometer inside of it. The small medication storage refrigerator above refrigerator B had a thermometer inside of it, reading 58 degrees. On 4/26/2023 at 10:15AM, V22 said she did not see a thermometer inside of the refrigerator. V22 said the night nurse checks the refrigerator temperatures and documents them on the temperature log. On 4/26/2023 at 10:17AM, V3 (Assistant Director of Nursing/ADON) said he did not see a thermometer in the lower medication refrigerator labeled B. V3 said there should be a thermometer in the refrigerator. V3 said the night nurse should be checking the refrigerator…

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 recipes when preparing pureed foods to ensure food palatability and nutritive value for 5 of 5 residents (R17, R64, R73, R74, R202) reviewed for pureed diets in the sample of 22. The findings include: The facility's pureed diet list dated April 24, 2023, showed R17, R64, R73, R74, and R202 received pureed diets. The facility's lunch menu dated April 24, 2023, showed pot roast, buttered egg noodles, green peas, dinner rolls, and chocolate brownies were to be served for lunch. On April 24, 2023, at 9:55 AM, V13 (Cook) was preparing to pureed foods lunch. V13 stated she was preparing purees for eleven residents. The facility's pureed peas recipe printed April 24, 2023, showed peas and powdered thickener were to be pureed together to make pureed peas. The recipe showed no documentation of water being added to the mixture to make the puree. On April 24, 2023, at 10:00 AM, V13 (Cook) added 11, 4-ounce scoops of cooked peas to the food processor and began to puree the peas. V13 stopped the food processor 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 change gloves and perform hand hygiene during incontinence care for two of 22 residents (R50, R21) reviewed for infection control in the sample of 22. The findings include: 1. R21's Order Summary Report dated 4/25/23 shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, aphasia, gastrotomy status, dysphagia, major depressive disorder, and left knee contracture. R21's MDS (Minimum Data Set) dated 2/9/23 shows R21 is always incontinent of bowel and bladder. On 4/24/23 at 11:37 AM, V4 (Certified Nursing Assistant/CNA) performed incontinence care to R21. V4 unfastened R21's incontinence brief. There was dark stool noted to R21's front peri area.V4 wiped R21's front peri area, touched R21's pillows, and R21's body to help her roll to her side. V4 began wiping the stool from R21's buttocks. R21's nurse came into her room to place a dressing onto R21's abdomen. V4 touched R21's body to lay her back on her back so…

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 screen and offer COVID-19 vaccines/boosters to 4 of 5 residents (R18, R27, R47, R84) reviewed for immunizations in the sample of 22. The findings include: 1. R18's admission Record showed R18 was admitted to the facility on [DATE]. R18's Immunization Record printed April 25, 2023, showed R18 received her last COVID booster vaccine on May 20, 2022. R18's record showed no documentation that R18 was screened for or offered a COVID-19 booster while in the facility. 2. R27's admission Record showed R27 was admitted to the facility on [DATE]. R27's Immunization Record printed April 25, 2023, showed R27 received her last COVID vaccine on August 18, 2021. R27's record showed R27 was not screened for or offered a COVID-19 booster until April 25, 2023. 3. R47's admission Record showed R47 was admitted to the facility on [DATE]. R47's Immunization Record printed April 25, 2023, showed R47 received her last COVID vaccine on May 8, 2021. R47's record showed R47 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 22 (R63, R76) residents reviewed for dignity in the sample of 22. The findings include: 1. R63 is a [AGE] year-old female resident who resides at the facility. R63's Minimum Data Set (MDS) section C shows R63 with a BIMS score of 15, cognitively intact. On 4/24/2023 at 11:21 AM, R63 said on 4/22/2023 from approximately 5:30 PM until 8:45 PM she was left in her stool and urine while sitting up in her chair. R63 said she asked staff to change her, but staff were too busy to get to her in a timely manner. R63 said when she was finally changed, R63 had urine and feces on her shirt and her shirt needed to be changed. R63 said she was upset by having to wait to get her brief changed and didn't like being left in feces and urine. On 4/25/2023 at 1:54PM, V17 (Certified Nursing Assistant/CNA) said residents should be toileted or changed every two hours. V17 said if a resident is soiled…

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 and clarify a resident's advance directives. This applies to 1 of 22 (R9) reviewed for advanced directives in the sample of 22. The findings include: R9's admission Record form shows R9 being admitted to the facility on [DATE]. On 4/25/2023 at 12:43 PM, R9's code status was not listed in the facility's computer charting system. On 4/25/2023 at 1:52 PM, V19 (Director of Social Services) said a resident's advance directives and power of attorney should be addressed upon admission by nursing or social services. On 4/25/2023 R9's Order Summary Report dated 4/25/2023 did not show an active code status order. On 4/26/2023 at 1:44 PM, V16 (Registered Nurse/RN) said R9's code status was not listed in the computer. V16 said there was no POLST form for R9 scanned into the computer. On 4/26/2023 at 9:00 AM, V1 (Administrator) said R9's code status was not clarified with R9's family until the evening of 4/25/2023. V1 said a resident's code…

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, record reviewed, the facility failed to provide a resident with privacy by not closing the window curtain during cares for 1 of 22 residents (R71) reviewed for privacy in the sample of 22. The findings include: R71's Order Summary Report shows he was admitted to the facility on [DATE] with diagnoses including Gilbert Syndrome, unspecified intellectual disabilities, malignant neoplasm of thyroid gland, depression, pressure injuries, dementia, osteomyelitis, and anxiety disorder. On 4/24/23 at 1:41 PM, V7 (Wound Care Nurse) provided wound care for R71 with the assistance of V8 (Certified Nursing Assistant/CNA). R71 was lying on his left side. R71's buttocks was exposed to his window. There was a white truck outside of R71's window. There was a gentleman sitting in his white truck outside of R71's window. R71's buttocks was visible through the window. On 4/25/23 at 11:32 AM, V6 (CNA) said curtains in residents' room should be closed to provided privacy for the residents. 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 cleanse a resident's perineal area in a manner to prevent urinary tract infections for one of ten residents (R60) reviewed for urinary tract infections in the sample of 22. The findings include: R60's Order Summary Report dated 4/25/23 shows R60 was admitted to the facility on [DATE] with diagnoses including heart disease, major depressive disorder, macular degeneration, chronic kidney disease, dementia, excoriation disorder, and congestive heart failure. R60's MDS (Minimum Data Set) dated 1/31/23 shows R60 is always incontinent of bowel and bladder and requires total assistance in toilet use and personal hygiene. R60's Care Plan intitiated 3/26/23 shows R60 has a urinary tract infection: Clean peri area well. Females to wipe and cleanse from front to back. On 4/24/23 at 10:38 AM, V5 (Certified Nursing Assistant/CNA) removed R60's incontinence brief. R60's incontinence brief was saturated with urine. V5 cleansed R60 buttocks area but 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 monitor residents for weight loss for two of seven residents (R21, R2) reviewed for weight loss in the sample of 22. The findings include: 1. R21's Order Summary Report dated 10/22/19 shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, diabetes mellitus 2, aphasia, dysphasia, gastrostomy status, and major depressive disorder. An order to weigh four times weekly for weight loss every Monday, Wednesday, Friday, and Sunday was ordered on 3/2/23. R21's Care Plan initiated 8/9/21 shows R21 has enteral feedings as the primary source of nutrition due to the following conditions and risk factors: stroke, dysphagia, malnutrition, and weight loss. Monitor weights weekly. R21's Point of Care History for the last 30 days shows no weight were obtained. R21's Weights and Vitals Summary dated 4/25/23 shows R21 was weighed on 9/8/22, 10/14/22, 12/15/22, 1/18/23, and 2/21/23. R21's Nutrition Progress Notes dated 4/4/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to administer medication as ordered. There were 33 opportunities and 3 errors resulting in a 9.09% medications error rate. This applies to 1 of 5 residents (R301) reviewed for medication errors in the sample of 22. The findings include: On 4/25/23 at 8:15 AM, V22 (Registered Nurse/RN) administered medications to R301. V22 stated that the ordered Cod Liver Oil, Vitamin D 10 mcg and Vitamin C 100 mg were not available to be administered to R301. R301's Medication Administration Record (MAR) dated April 2023 shows that R301 has orders for Cholecalciferol (Vitamin D)10 mcg (2) tablets by mouth daily. R301 was admitted to the facility on [DATE](4 days prior). Since admission, this medication is marked as Unavailable 2x and administered 2 times. The MAR shows an order for Vitamin C 100 mg daily. This medication is marked as administered 4 times. Finally the MAR shows an order for Cod Liver Oil 1 capsule daily. This medication is marked 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.