All American Vlge Nrsg & Rhb

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish an environment that promotes resident sensitivity and safety and prevention of mistreatment for one resident (R3) out of four residents reviewed for abuse. Findings include: R3 is [AGE] years old, initially admitted in the facility on 10/08/2015. R3 medical diagnosis includes schizoaffective disorder, bipolar, psychosis. Per Minimum data Set (MDS) assessment, dated 04/02/2025, R3 has a score of 12; R3 has moderate impairment of his cognition. R4 is [AGE] years old, initially admitted in the facility on 07/12/2024. R4 medical diagnosis includes schizoaffective disorder, bipolar type, anxiety disorder, psychosis. Per Minimum Data Set (MDS) assessment; dated 04/11/2025, R4 has a score of 7; R4 has severe impairment of his cognition. Per clinical notes, R4 had multiple behavioral concern involving staff and other residents. R4 was given antipsychotic medication Haloperidol injection multiple times to manage behavior. Review of R4's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food is labeled, dated, and discarded after use by date/expiration date and failed to ensure reach-in refrigerator temperature, walk in refrigerator temperature and walk-in freezer temperatures were monitored 2 times per day. These failures have the potential to affect 138 residents living in the facility. The findings include: On 04/08/2025 at 9:22 AM, the reach-in refrigerator was inspected, and the following food items were found inside the refrigerator: *A container of nacho jalapeno peppers (1 gallon) with an open date of 02/08/25, and expiration date of 03/20/2025. V10, Dietary Service Director, said it should have been discarded. *A container of giardiniera mild pepper mix (1 gallon) with no open date and expiration date of 10/08/2025. *A container of sweet relish (1 gallon) marked with an open date of 04/07/2025, and no use by date. *A jar of creamy peanut butter (5lb) with no open date and the use by date was not readable.…

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 implement a plan to prevent Legionella (a bacteria that can cause a serious type of pneumonia/lung infection) growth in the facility's water system. This failure has the potential to affect all 137 residents residing in the facility. Findings include: On 04/08/2025 at 1:56 PM, V21 (Maintenance Director/Housekeeping Director) stated he has been working at the facility for approximately 5 months. V21 stated he does not have a plan in place to check the facility's water system for Legionella. V21 stated he does not have any documentation to show the facility has a plan in place to prevent Legionella in the facility. V21 stated he has been searching, and is unable to find any previous documentation to show the facility's water system has been tested for Legionella. V21 stated at his previous employment, he implemented Legionella water testing, but has not implemented Legionella testing and prevention at the facility. Facility census, dated 04/08/2025, documents a total of 137 residents reside in the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard medication without an expiration date in a cart serving 42 residents on the third floor; failed to follow pharmacy instructions on medication administration while administering an inhaler for one (R31) resident; failed to document medications as given for one (R55) resident; and failed to contact provider while administering late medications to one (R84) resident in a sample of 27. Findings include: 1. On [DATE] at 10:10 AM, V3(Licensed Practical Nurse-LPN) residents eMAR (Electronic Medication Administration) profile showed red on R55's medication profile for medications: Furosemide 40 Mg, Finasteride 5mg, Lisinopril 5mg, Memantine 10mg. V3 stated she gave the medication earlier, but forgot to sign as given. V3 stated the nurse administering medications should sign as soon as it is given to prevent medication error because another nurse might give the resident medication thinking it was not given, and it can also confuse the…

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

Based on observation, interview, and record review, the facility failed to provide a functioning call light system for eleven (R14, R22, R34, R47, R59, R64, R112, R118, R119, R133, R139) residents of 27 reviewed for call light. Findings include: On 4/8/25 at 12:55 PM, R133 was asked to activate the call light. The light bulb above R133's door did not light up, and there was no audible sound heard. On 4/8/25 at 12:58 PM, V18 (Certified Nursing Assistant) stated, There is a call light in each resident room. When it is pulled, it should light above the resident's door, and you should hear a sound. It also lights up at the nursing station panel. The call light is for emergency purposes; for the assistance of the resident. V18 pull the call lights in three resident rooms. Writer verified with V18 that no light came on over the door of the resident rooms. There was no audible sound heard, and the panel at the nursing station did not light up. On 4/8/25 at 1:10 PM, V2 (Director of Nursing) stated, The purpose of the call light is so the patient can get assistance when needed, to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed assert the right of the resident by searching a residents' room and personal property without the residents' knowledge and consent. This failure affects one (R33) resident in a total sample of 27 residents reviewed. Findings include: R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate. R33's MDS/Minimum Data Set, dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired. On 04/08/2025 at 11:32 AM, V8 (Certified Nursing Assistant/CNA) was sitting on R33's bed, and V8's right hand inside of R33's nightstand located adjacent to R33's bed. V9 (CNA) was sitting in a chair at the foot of R33's bed, with a water container placed on R33's bedside table. R33's closet 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 observation, interview, and record review, the facility failed provide privacy and confidentiality of personal information for one (R33) resident reviewed in a total sample of 27. Findings include: R33's facesheet documents R33 is a [AGE] year-old male admitted to the facility on [DATE], with diagnoses not limited to: Hemiplegia, cerebral infarction, schizoaffective disorder, glaucoma, lack of coordination, unsteadiness on feet, heart failure, and malignant neoplasm of prostate. R33's MDS/Minimum Data Set, dated [DATE], documents R33 has a BIMS/Brief Interview for Mental Status of 11/15, indicating R33 is cognitively impaired. On 04/08/2025 at 11:53 AM, R33 was sitting in the dining room located on the second floor of the facility. R33 was sitting in a wheelchair wearing a white hospital wristband on his right wrist, which displayed R33's full name, date of birth , age, and medical record number. Record review of R33's electronic health record documents R33 was last admitted to the hospital on [DATE],…

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 initiate a new PASARR screening for one (R79) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 27. Findings include: R79's facesheet documents R79 was admitted to the facility on [DATE]. R79's PASARR Notice of SLP/Supportive Living Program Setting Appropriateness outcome letter, dated [DATE], documents an SLP setting is appropriate for R79. R79's SLP Setting Appropriateness Outcome Explanation Notice documents, This SLP initial screen and SLP comprehensive assessment is good for up to 90 calendar days of the Notice Date listed on the Notice of SLP Setting Appropriateness Outcome If you do not go to a SLP setting within that time, you must have an updated SLP initial screen and SLP comprehensive assessment. On [DATE] at 11:15 AM, V20 (Business Office Manager/BOM) stated she has been working at the facility for only 11 days, and is responsible for inputting resident information into the PASARR screening system…

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 initiate a new Level I screen for a resident with known mental illness for one (R40) of five residents reviewed for Pre-admission Screening and Record Review (PASRR) in a total sample of 27. Findings include: R40's face sheet documents R40 was admitted to the facility on [DATE], with diagnoses not limited to: Hypertensive heart disease without heart failure, schizoaffective disorders, seizures, bipolar disorder, major depressive disorder, recurrent, unspecified, other obsessive-compulsive disorder. R40's Interagency Certification of Screening Results OBRA (Omnibus Budget Reconciliation Act)-I Initial Screen, dated 06/02/2004, indicates R40 has reasonable basis for suspecting MI (mental illness). R40's Minimum Data Set (MDS) Section I, dated 04/03/2025, indicates active diagnoses of depression and bipolar disease. On 04/10/2025 at 9:46 AM, V1 (Administrator) was asked about level I pre-admission screening and resident review (PASRR) screening for R40,…

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 physician orders by not monitoring a resident's stoma site (Ileostomy site) every shift for one resident (R70) out of 7 residents reviewed for nursing care in a total sample of 27 residents. Findings include: R70's face sheet documents R70 was admitted to the facility on [DATE], with diagnoses not limited to: Chronic obstructive pulmonary disease, unspecified, bipolar disorder, current episode depressed, severe, with psychotic features, and Ileostomy status. Minimum Data Set Section (MDS) section C (dated 04/01/2025) documents R70 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R70's cognition is intact. Care plan (dated 04/10/2025) documents R70 has an ostomy related to Ileostomy status. R70's physician order (dated 04/10/2024) states: Monitor the Stoma Site (Ileostomy site) for any signs of infection or changes in skin issues every shift (day, evening, night). For any concerns notify medical doctor. 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 that residents are free from expired food for one resident (R102) out of 7 residents reviewed for nutrition in a sample of 27 residents. Findings include: R102's face sheet documents R102 was admitted to the facility on [DATE], with diagnoses not limited to: Hypertensive heart disease without heart failure, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, lymphedema, not elsewhere classified, and gastro-esophageal reflux disease without esophagitis. Minimum Data Set Section (MDS) section C (dated 04/02/2025) documents R102 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R102's cognition is intact. R102's Care plan (dated 04/09/2025) documents R102 is on a therapeutic diet regular, with no added salt. On 04/08/2025 at 12:11 PM, R102 stated, This morning for breakfast, I received a milk that was expired. The date of expiration on the milk carton is 04/07/2025. The milk 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.

Based on interview and record review, the facility failed to monitor and review antibiotic use for three (R79, R81, and R102) residents reviewed for antibiotic stewardship in a total sample of 27. Findings include: On 04/09/2025 at 2:53 PM, V6 (Infection Preventionist/IP/LPN) stated she has been the IP at the facility for approximately one month now. V6 stated she generated the antibiotic tracking/monitoring list today, with the help of other staff members. V6 stated this is the first time she has generated the tracking/monitoring list for residents on antibiotics. V6 stated prior to today, there was not a system in place to track and trend antibiotic use for residents in the facility. V6 stated she has been trying to clean up some things as much as she can since she's been working at the facility. V6 stated now that she is aware, she can now keep track of resident antibiotic use. V6 reviewed the antibiotic order report, dated 04/2025. V6 stated she is not sure why some residents are prescribed antibiotics without an end date. V6 stated she will follow up on this. V6 stated all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain mechanical heating equipment, failed to ensure mechanical and electrical heating equipment were not exposed to poor environment conditions (leakage of fluid from ceiling due to water heater tank), failed to maintain at least 75 degrees Fahrenheit during cold temperature, and failed to monitor temperature in the building during cold temperatures. These failures have the potential to affect all 144 residents living in the facility. Findings include: On 1/7/2025 at 09:09 AM, V3 (Maintenance Director) stated, The boiler control system got wet last Friday (01/03/2025) that caused the problem with the heating equipment of the facility. (V9, Heating and Cooling Repair Company) came to the facility on Sunday (01/05/2025) for repair. The front part of the building facing east was too cold during those times. V3 handed a receipt from V9, dated 01/05/2025, stating: Front East Side too cold. Checked heating zones and functional. Checked…

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 perform background check searches on the six offender Website links on the State Health Care Worker registry, and failed to ensure the initiation date of background checking were done prior to a new employee starting a work schedule. These failures have the potential to affect all the residents at the facility. Findings include: The (undated and untitled) facility provided document indicated V9 (Housekeeping/Laundry/Maintenance Supervisor) was hired on 09/26/24, V19 (Certified Nursing Assistant - CNA) was hired on 09/23/24, V20 (CNA) was hired on 09/23/24, and V22 (Certified Nursing Assistant) was hired on 10/09/24. The (undated and untitled) facility provided document indicated V9 works all floors and started working 09/30/24, V19 and V20 work on 2nd floor and started working on 10/05/24, and V22 works on 2nd floor and started working on 10/09/24. On 10/16/2024 at 10:01am, V4 (Business Office Manager) stated, It is required of the State Health Care Facilities to run the Health Care Worker Registries prior to hire to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and investigate an allegation of misappropriation of property for one (R1) of three residents reviewed for misappropriation of resident property in a total sample of three residents. Findings include: R1 ' s Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating R1 is cognitively intact. R1's social service assessment, dated 9/11/2024, documents R1 has corrective lenses for vision. R1's progress note, dated 09/26/2024 at1:49 PM, documents, (R1) continues to insist the glasses was stolen from her room. Writer (V4) mentioned maybe she just misplaced the glasses. (R1) became very upset stating to writer (V4) 'I know what I'm talking about, someone took my glasses because they were from a designer. I purchased them at a glasses store'. On 10/08/2024 at 11:42 AM, R1 stated it has been over three weeks, and the facility has not done anything about her stolen eyeglasses. R1 stated…

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

Based on interview and record review, the facility failed to ensure a nurse followed established procedures for documentation in a residents electronic medical record (EMR). This failure affected one resident (R1) out of three residents reviewed for quality of care. Findings include: R1's face sheet shows R1 has diagnoses which includes but not limited to hyperlipidemia, schizoaffective disorder, primary generalized osteo arthritis, legal blindness, unspecified ptosis of bilateral eyelids, central corneal opacity right eye, gastritis unspecified without bleeding, insomnia, and dysphagia. R1's Brief Interview for Mental Status (BIMS), dated 08/21/24, shows R1 does not have a BIMS score, and indicates R1 has memory problems and is severely impaired. R1's progress note, dated 08/21/24 at 1:02 am, authored by V8 (Licensed Practical Nurse, LPN) documents, While making rounds at 11:30 pm noted resident with lethargy. Obtain vital signs (temperature)T 99.9, (pulse) P114, (respiration) R16, (blood pressure) B/P 115/63, (oxygen saturation) SPO2 89%. (R1's) physician made aware with order 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 maintain an effective pest control program to keep pests out of the facility. This deficient practice has the potential to affect all 138 residents residing at the facility. Findings include: On 08/04/24 at 9:43 AM, R9 was sitting on the bed in R9's room. R9's room appeared clean. No garbage or debris was on the floor. R9 stated R9 has been at the facility for a couple of weeks and said, I've seen mice in my room since I've been here. I see them at night and during the day. R9 stated sometimes when R9 is taking a shower, R9 sees mice in the shower room, and R9 has also seen mice in the unit day room. R9 stated, No one has asked me if I've seen mice in my room, and other residents have also seen the same mice I have in the shower and in the day room, so I thought it's part of the norm here. I didn't think to tell anyone. I assumed they already knew it was a problem. R9 stated seeing the mice make him squeamish and said, I don't want mice in the same space that I'm living in. R9 stated he's never seen any 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 label and dispose of food items after the use by date. These failures have the potential to affect all 134 residents receiving oral nutrition at the facility. Findings Include: On 3/4/24 at 9:34 am, observed in the dry storage room, a bin of rice labeled with a use by date of 3/1/24; a bin of oats labeled with a use by date of 3/1/24; and a bin of grits labeled with a use by date of 1/16/24. All labels observed for an open date was blank. V17, Dietary Manager, stated the date on the label is when the items was put into the bin. The surveyor inquired to V17, how does V17 know when the items were put into the bin when the date on the label is blank and the use by dates is 3/1/24 for the rice and oats and use by date for the grits is dated 1/16/24? V17 stated, I don't know why the staff labeled the bins like that, it's not right. Surveyor inquired how should the label be filled out. V17 stated, The entire label should be filled out. On 3/5/24 at 2:45 pm, observed in the dry storage room, the rice bin, the oats…

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 perform appropriate hand hygiene during dining, failed to appropriately sanitize dining tables between residents on the Main Dining room during dining, and failed to bag linens prior to sending the linens to the laundry area via the chute in an effort to prevent the spread of infectious microorganism. These failures have the potential to affect all the residents at the facility. Findings include: 1. The (undated) Facility Meal times documented lunch meal times at the Main Dining room were at 12:00pm and 12:30pm. On 03/04/2024 at 12:30pm, during the dining observation on 1st floor, some residents were leaving the dining area, and some residents were standing by waiting for available tables. V13 (Housekeeper), with gloved hands, was observed going to one of the tables, wiping the table with a green cloth with his left hand, while holding a yellow pack of disinfecting wipes with his right hand. V13 placed the used green cloth to his right hand, and took a piece of the disinfecting wipe from the pack with his…

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 an environment free from hazards. This failure has the potential to affect two residents (R79 and R117) and all 45 residents on the third-floor unit at the facility. 1. On 03/04/24 at 12:45 pm, surveyor and V7 (Licensed Practical Nurse, LPN) inspected the third-floor medication cart and observed a shaving razor hanging outside of the sharps container, not properly disposed of. V7 stated, I don't know who put that there. When V7 was asked regarded the shaving razor hanging from the sharps container, V7 stated, The sharps container is not full. It (referring to the razor) should be pushed all the way inside of the sharps container. When V7 was asked regarding the importance of properly disposing shaving razors, V7 stated, I or someone can cut themselves. On 03/6/24 at 11:03 am, V2 (Director of Nursing, DON) stated shaving razors should be properly discarded inside of the sharps containers. V2 explained shaving razors should not be visibly hanging out of the sharps containers and razors that are hanging…

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 incoming and outgoing nurses counted the controlled medications during shift change. These failures has the potential to affect all 45 residents on the third-floor unit and all 45 residents on the fourth-floor unit at the facility. Findings include: On 03/04/24 at 1:10 pm, Controlled Substances Check form for the 3rd floor unit medication cart had missing signatures for the oncoming nurse on 03/02/24 11:00pm to 7:00am shift, and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift. V7, Licensed Practical Nurse/LPN stated, I don't know why it's not signed. That was not during my shift. When V7 was asked regarding the importance of the controlled substance check form, V7 stated to make sure the narcotics are all there. The facility's document, dated March 2024 and titled Controlled Substances Check Form Station 3rd floor, shows missing signatures for 03/02/24 11:00pm to 7:00am shift and 03/03/24 outgoing nurse for the 7:00am to 3:00pm shift. On 03/5/24 On at 11:12am, the Controlled Substances Check…

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 privacy with a ceiling suspended curtain (missing privacy curtain) for five residents (R2, R17, R26, R29 and R66). This failure affected 5 out 39 residents in the total sample. Findings include: R17's Brief Interview for Mental Status (BIMS), dated 02/14/24, documents R17 has a BIMS score of 15, which indicates that R17 is cognitively intact. R17's Face sheet documents R17 has diagnoses that include but not limited to: schizoaffective disorder, bipolar, hypertensive heart disease, depression, and overweight. R26's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R26 has a BIMS score of 7 which indicates that R26 has some cognitive impairments. R26's Face sheet documents R26 has diagnoses that include but not limited to schizophrenia, chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, depression, and peripheral vascular disease. R66's Brief Interview for Mental Status (BIMS), dated 02/19/24, documents R66 has a BIMS score of 14, which indicates…

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 handrails on the 3rd floor were firmly secured to the wall. This failure has the potential to affect all 45 residents on the third floor. Findings include: The (03/04/2024) facility resident's census on the 3rd floor was 45. On 03/04/2024 at 11:48am on 3rd floor, the handrail located near the men's bathroom was not firmly secured to the wall. On 03/04/2024 at 11:49am on 3rd floor, the handrail located near the exit was not firmly secured to the wall. On 03/04/2024 at 11:53am, V11 (Assistant Maintenance Director) checked the handrail located near the 3rd floor's Men's bathroom and stated, It is not fixed to the wall. On 03/04/2024 at 11:55am, V11 checked the handrail located near the 3rd floor's exit door, and stated, It is not fixed to the wall. On 03/04/2024 at 12:11pm, V10 (Environmental Services Director) stated, The purpose of the handrail is to provide support to the residents, something for the resident to hold on to. The handrails are for residents who need support to prevent them from…

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 a five percent (5%) or lower medication error rate. There were two medication errors out of 27 medication opportunities, resulting in a 7.41% medication error rate and affected two residents (R1, and R47) observed for medication pass. Findings include: 1. R47's face sheet documents R47 has a diagnosis which include but are not limited to: schizophrenia, and unspecified psychosis not due to a substance or known physiological condition. R47's Physician Order Sheet (POS) order date 02/07/24 through 03/07/24 shows R47 has an order for Aripiprazole 5 mg (milligrams) ½ tablet (2.5 mg) orally by mouth every day. Diagnosis: Other schizophrenia. R47's Brief Interview for Mental Status (BIMS), dated 01/23/24, documents R47 with a score of 15, which indicates that R47 is cognitively intact. On 03/05/24 at 8:26 am, V16 (Licensed Practical Nurse, LPN) was observed on the second floor at the second-floor medication cart. V16 prepareed and counted 10 pills total that were administered to R47. V16 stated, Abilify…

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, facility failed to follow their policy to ensure residents are free from physical abuse by providing necessary care in services, thus resulting in a male resident (R1) physically assaulting another male resident (R2) for two out of 24 residents reviewed for physical abuse. Findings include: R1's care plan documents in part: Problem: BEHVAIORAL SYMPTOMS: The resident displays behavioral symptoms related to: (X)Severe mental illness. These behavioral symptoms are manifested by: Verbally inappropriate behavior, Comments, details and frequency: Resident has a history of displaying aggressive behaviors. R1's Psychosocial Assessment (11/21/2023) documents in part: Barriers to learning, psychosis. On 12/19/2023 at 10:15 AM, R1 was interviewed in the conference room. R1 was observed being seated in his wheelchair. R1 stated he has gotten into fights in the past. He said his last fight was on the patio where someone said something to him, and he punched him in the face. On 12/19/2023 at 11:00 AM, V3 (Licensed Practical Nurse) stated he heard there was 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.