Aperion Care International

Based on observation, interview, and record review, the facility failed to ensure that medications were given as ordered by the prescriber. This failure affected 6 (R2, R4, R5, R6, R7, R8) of 6 residents reviewed for improper nursing care. The findings include: R2's health record documented admission Date on 1/20/2024 with diagnoses not limited to Unspecified sequelae of cerebral infarction, Encounter for palliative care, Dysphagia following other cerebrovascular, Occlusion and stenosis of right carotid artery, Acquired absence of left leg below knee, Atherosclerotic heart disease of native coronary artery, Non-st elevation (nstemi) myocardial infarction, Type 2 diabetes mellitus without complications, Essential (primary) hypertension, Unspecified dementia. R4's health record documented admission Date on 11/28/2020 with diagnoses not limited to Other seizures, Type 2 diabetes mellitus without complications, Acute respiratory failure with hypoxia, Essential (primary) hypertension, Personal history of covid-19, Hypothyroidism, Anemia, Gastro-esophageal reflux disease without…

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 affirm the right of the resident to be free from physical abuse. This failure has affected 1 (R3) of 5 residents reviewed for abuse. Findings Include: On 6/11/24 at 11:03 AM, R4 speaks Spanish with little English, V23 (Housekeeper) assisted in interpreting to R4. R4 stated on 4/26/24, during the 3-11 shift R4 was in the dining room writing on a paper. R4 stated R3 bumped R3's wheelchair into R4's wheelchair. R4 denied hitting R3 in the back. On 6/11/24 at 11:37 AM, R3 stated R3 cannot remember what happened on 4/26/24. Surveyor asked if R3 feels safe in the facility? R3 stated R3 does not know. On 6/11/24 at 12:43 PM, V26 (Social Service Director) stated V26 has been on the 3rd floor in this facility for five years. V26 stated V26 was on vacation during the incident between R3 and R4, but V26 heard that there was a physical altercation between R3 and R4. Surveyor asked what intervention the facility put in place after the incident? V26 stated R4 was moved from 3rd floor to the 2nd floor. On 6/11/24 at 2:12 PM, V12 (Social…

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 incontinence care was provided in a timely manner for 1 (R9) of 3 residents who needed assistance with toileting reviewed for improper nursing care. The findings include: R9's health record documented admission Date on 9/17/2021 with diagnoses not limited to Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, Type 2 diabetes mellitus, Hyperlipidemia, Major depressive disorder, Unspecified atherosclerosis, Other seizures, Unspecified acute conjunctivitis left eye, Essential (primary) hypertension, Long term (current) use of anticoagulants, Personal history of other venous thrombosis and embolism, Gastro-esophageal reflux disease without esophagitis. On 6/12/24 at 11:09am Observed R9 lying on bed, alert, oriented x 3, verbally responsive. Stated he did a bowel movement and had called a little after 9am and staff stated to him that she still has other residents that she is taking care of. R9 said he has been waiting for 2 hours to be changed. 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 interview and record review, the facility failed to follow the facility abuse policy to perform criminal background checks for new residents within 24 hours of admission which affected R198, R199, R200, and R202 in the sample of 88 residents reviewed and has the potential to affect 192 residents in the facility reviewed for abuse. Findings include: On 4/29/24 at 12:25 pm, V13 (Admissions Director) stated that resident criminal back ground checks are done for residents when they come in within 24 hours. When asked if a resident is admitted at 9:00 am, should the criminal background check be done by 9:00 am on the following day, V13 stated, Yes. V13 stated that V13 will initiate the Criminal History Information Response Process (CHIRP) request by filling out the Resident Background Check with the new resident's first and last names, gender, birthdate and race and email the request to the facility's corporate office to process the CHIRP request. On 4/30/24 at 11:23 am, V13 (Admissions Director) stated that…

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 store biologicals in accordance with pharmaceutical recommendations; failed to store medications in a sanitary condition; failed to discard of expired medications; failed to maintain appropriate temperature in storing medications; failed to account for and store narcotics safely. This failure affects 22 residents (R104, R121, R11, R32, R126, R75, R76, R168, R144, R67, R144, R124, R114, R162, R140, R170, R27, R136, R28, R156, R30, R34) and has the potential to affect residents who receive medications on the first, second and third floor medication carts out of 88 residents sampled. Findings include: On 04/29/24 at 10:38 AM Surveyor observed medication storage fridge in the 3rd floor medication storage room with no thermometer in fridge. Temperature log for medication storage intact and shows all temperatures within stated range. V27 (Licensed Practical Nurse Unit Manager) stated we would not be able to track temperatures without 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 ensure that residents' food items in the facility kitchen are properly labeled, dated when received and when opened, and a food package is securely sealed after opening; failed to discard expired food items; failed to follow proper food storage practices and labeling food to prevent food-borne illnesses; failed to ensure that staff store their food and drinks out of the facility kitchen used for residents; failed to record the cooler and freezer temperature logs; failed to maintain the proper sanitation levels of the kitchen sanitation buckets; failed to accurately test the sanitation level of the sanitation buckets in the kitchen; and failed to ensure sanitation was maintained related to the cleanliness of the kitchen. These failures have the potential to affect all 185 residents receiving an oral diet in the facility. Findings include: 04/28/24 at 9:16 am, Surveyor entered the facility's kitchen area. Surveyor observed V14 (Dietary Cook)…

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 there is no accumulation of lint at the bottom of the lint compartment in an effort to provide a safe environment to the residents. These failures have the potential to affect all 192 residents in the facility. Findings include: On 04/29/2024 at 12:54pm, V16 (Housekeeping Director) opened the drawer of the lint compartment of dryer #1 and stated we (facility) clean the lint screen every day. This surveyor requested V16 to pull out the drawer of the lint compartment. There were accumulation of lint at the bottom of the dryer 1 that housed the lint compartment. V16 stated we don't mess with that, that's maintenance. On 04/29/2024 at 12:58pm, V25 (Laundry) stated that is an issue because lint could catch fire. Maintenance checks the washer and dryer once a week. V24 (Maintenance Director) was here 1 and ½ week ago because the lint compartment was flooded. On 04/29/2024 at 1:01pm, V24 checked the bottom of dryer 1 that housed the lint compartment and stated that is not good, it could catch fire. It is 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 have low air loss mattress at the correct weight settings for five residents (R73, R38, R8, R43 and R18) of five residents reviewed for pressure ulcers in a total sample of 88 residents. Findings include: 1. On 4/28/24 at 10:09am, R73 was observed on a low air loss mattress set at 180 pounds. When asked about R73's weight, R73 replied, Last month (R73) weighed 85 pounds. (R73) have a sore on my butt that they change every day. Facility presented document, title, Weights and Vitals Summary, dated 4/5/24, which shows R73's weight is 93.6 pounds. R73's MDS (Minimum Data Status), section M, dated 4/05/24, states that R73 is at risk for developing pressure ulcers/injuries, has 1 stage 3 pressure ulcer and should have a pressure reducing device for bed. R73's Preventive Interventions Worksheet, dated 4/23/24, documents, in part, a Braden scale of 12 which indicates R73 is at high risk for developing pressure ulcers. R73's Care Plan, 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 ensure the nebulizer mask was secured, when not in use, for one resident (R32) and oxygen tubing was dated for 3 residents (R74, R87 and R88). The failure affected 4 residents (R32, R74, R87 and R88) out of a sample size of 88 residents. Findings include: R88 has a diagnosis of Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, Hypoxemia, and Shortness of Breath. R88 has a Brief Interview of Mental Status score of 13. On 4/28/2024 at 10:15am surveyor observed R88's oxygen tubing with no date on it. On 4/30/2024 at 10:50am surveyor observed R88's oxygen tubing with no date on it. On 4/30/2024 at 10:54am V10 (Registered Nurse) stated the oxygen tubing should be dated. Physician Order Summary with active orders as of 4/30/2024 documents, in part, Apply oxygen per nasal cannula prn (as needed). Policy titled Oxygen and Respiratory Equipment Changing/Cleaning with a revised date of 1/07/2019 documents, in part, to provide guidelines to employees for changing all disposable respiratory…

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 that the dumpster's were closed and free from overflowing trash. These failures have the potential to affect all 192 residents residing at the facility. Findings include: On 4/28/24, V1 (Administrator) and V3 (Regional [NAME] President of Operations) confirmed that the resident census was 192 active residents on 04/28/24 at the facility. On 4/28/2024 at 11:33 am, Surveyor and V16 (Housekeeping Director) inspected the facility dumpster area and observed two dumpster's: one dumpster lid open and one dumpster lid unable to close with overflowing trash and boxes hanging outside the dumpster. On 04/28/24 at 11:35 am, V16 stated that the dumpster lids should remain closed for rodent and animal control at the facility. V16 stated that it is V16 and V24 (Maintenance Director) responsibility to check the dumpster area at the facility. The facility's document dated 2020 and titled Garbage and Rubbish Disposal documents in part: Guidelines: garbage and rubbish will be disposed of to ensure a clean and sanitary…

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 review, the facility failed to ensure staff appropriately performed hand hygiene between residents during meal tray pass in an effort to prevent spread of infectious microorganism. This failure affected 9 (R8, R25, R31, R54, R64, R100, R117, R180, R197) residents reviewed for infection control in the total sample of 88 residents. Findings include: On 4/28/24 at 12:40 pm, V48 (Dietary Aide) observed plating residents' lunch meal trays from the steam table in the dining room. V20 (Certified Nursing Assistant, CNA) observed standing waiting to pass prepared trays from the steam table, and V20 did not perform hand hygiene by using alcohol based hand sanitizer (ABHS) or hand washing. On 4/28/24 at 12:48 pm, V22 (CNA) now observed in dining room to pass lunch trays, and V22 did not perform hand hygiene. On 4/28/24 at 12:52 pm, R197 observed sitting at a dining room table in wheelchair. V20 (CNA) retrieved the prepared lunch tray from cart next to the steam table 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 ensure that the call light was accessible for one resident (R18) who was reviewed for call lights. This failure had the potential to affect 1 resident out of a sample of 88 residents. Findings include: On 04/28/24 at 11:59am, R18 was observed lying in bed, on her right side, with call light laying on the floor under R18's bed and out of reach. R18 is not capable of being interviewed. R18's admission Record documents, in part, R18's diagnoses including but not limited to: unspecified osteoarthritis, unspecified dementia, anemia, type 2 diabetes mellitus, chronic kidney disease, pressure ulcer of sacral region unstageable, pressure-induced deep tissue damage of right heel, and pressure ulcer of other site stage 4. R18's Staff Assessment for Mental Status, dated 4/17/24, documents, in part, that R18 has short and long-term memory problems and cognitive skills for daily decision making are moderately impaired. On 4/28/24 at 12:05pm, V21…

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 that residents who require assistance with ADLs (Activities of Daily Living) received the assistance. This failure affected three residents (R7, R40 and R189) out of a sample of 88 residents reviewed for ADL care. Findings include: On 04/28/2024 at 10:44am, R189 has facial hair on chin and upper lip, R189 stated staff was just here. I (R189) was not offered assistance to shave my (R189) lip and chin. I (R189) did not know that they (staff) can do that. Staff did not say anything about me having hair on my chin and lip. The hair on my lip and chin are irritating because they are long. Of course, I (R189) need staff to help shave myself. On 04/28/2024 at 10:45am, surveyor informed V6 (CNA) that R189 requested assistance with shaving her (R189) facial hair. V6 looked at R189 facial hair and stated 'Okay.' On 04/28/2024 at 11:23am, R40 has facial hair on her (R40) chin. R40 stated I (R40) need assistance with shaving my chin. I (R40) cannot do it myself (R40) because I (R40) am afraid I (R40) will cut…

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 upon observation, interview, and record review, the facility failed to ensure that an adaptive device (splint/palm grip) was in place of a contracted hand for one resident (R18) who was reviewed for limited mobility. This failure had the potential to affect 1 resident out of a sample of 88 residents. Findings include: On 04/28/24 at 11:59am, R18 was observed lying in bed, on her right side, with no hand assistive device (splint/palm grip) in either R18's right or left hands. The splint/palm grip was observed laying on R18's bedside dresser. On 4/28/24 at 1:44pm, R18 was again observed without the splint/palm grip in place in either R18's right or left hands. V21 (Licensed Practical Nurse/LPN) stated, Yes, she (R18) does have an order for the (splint/palm grip) to be placed in her right hand. (V21) am not sure why it is not in her hand. It's to help prevent the contracture from worsening. V21 then picked up the splint/palm grip from R18's bedside dresser and placed it in R18's right hand. R18 is not capable of being interviewed. R18's admission Record documents, in part, R18's…

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

Based on observation, interview and record review, the facility failed to properly log personal refrigerator temperatures for two (R22 and R87) of two residents with personal refrigerators in their rooms on the total sample list of 88. Finding include: On 04/28/24 at 11:05 am, Surveyor observed R87 in R87's room awake, alert and oriented sitting in a wheelchair. Surveyor inspected R87's refrigerator and observed R87's refrigerator temperature at 40 degrees Fahrenheit (F), R87's refrigerator temperature logs sheet with missing temperatures and incomplete. R87 stated staff at the facility inspects R87's refrigerator about once a week. The facility's document dated Month: April, Year : 2024 and titled Medication Refrigerator Temperature log Location R87's: shows missing temperature logs for 04/02/24, 04/04/24, 04/07/24, 04/09/24, 04/11/24, 04/14/24, 04/17/24, 04/18/24, 04/21/24, 04/23/24, and 04/25/24. R87's face sheets shows that R87 has a diagnosis which includes but is not limited to morbid obesity due to excess calories, hyperlipidemia, hemiplegia and hemiparesis following…

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 ADL (Activities of Daily Living) care was provided for a dependent resident who required assistance with bladder and bowel incontinence for one of three residents (R3) reviewed for ADL care. Findings include: On 4/12/2024 at 1:15 PM R3 was observed sitting up in bed with head of bed elevated approximately 45 degrees, oxygen per nasal cannula gastric tube feeding was infusing at 70cc/hour (cubic centimeter/hour) on infusion pump at bedside, splint was noted to left hand. Bilateral side rails were elevated, low air loss mattress was on and functioning, bed, in low position, call light was not within reach (tied to right side rail, dangling on floor between side rail and bed frame). R3 was unable to answer questions. Roommate's call light activated at 1:29 PM. On 4/12/2024 at 1:30 PM, with V5 (CNA). Blue line noted to front of R'3 brief. V5 said that means she's wet. V5 opened R3's brief, brief was saturated with dark colored urine. V5…

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 properly assess and obtain a physician's order for newly identified skin alteration for one of three residents (R2) reviewed for wounds. Findings include: R2's medical record (Face Sheet) documents R2 is an [AGE] year-old admitted to the facility on 2.24.2022 with diagnoses including but not limited to: Cerebral Infarction, End Stage Renal Disease, Type 2 Diabetes, Peripheral Vascular Disease, Idiopathic Aseptic Necrosis of Right Foot, and Idiopathic Aseptic Necrosis of Left Foot. On 4/12/2024 at 3:53 PM V2 (ADON - Assistant Director of Nursing) said V11 (LPN-Licensed Practical Nurse/Treatment Nurse) notified me that resident R2 had to go out (to the hospital), it was serious. V2 said, when V8 (Agency LPN-Licensed Practical Nurse) assessed the wound (documented as skin tear by V8), V8 should have completed a head-to-toe assessment; head to toe assessments should be completed with each new wound. On 4/16/2024 at approximately 12:30 PM, V11 (LPN-Licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, facility failed to follow appropriate supervision measures during activities of daily for two (R5, R3) out of three residents reviewed for accidents and supervisions in a sample of 6. Findings include: R3 is an [AGE] year-old male. R3's diagnoses are but not limited to Parkinsons disease with dyskinesia, hypertension, major depressive disorder, lung disease, respiratory failure, repeated falls, dementia, and insomnia. R3's BIMS (Brief Interview for Mental Status) dated 1/2/2024, notes R3 is not alert. R3's care plan notes R3 has compulsive behaviors and can attempt to get out or climb out of his chair. R3 is unable to ambulate possibly due to Parkinsons disease with dyskinesia. R3 has impaired cognitive function, dementia, or impaired thought process possibly due to dementia. R3 is at risk for falls. Nurse's note dated 2/24/2024, notes nurse was called to nurses' station by aide due to R3 falling out of specialized chair. R3 alert to name only and is unable to state what…

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 dialysis as ordered for one resident (R1); and failed to administer scheduled medications for four residents (R3, R7, R8 and R9). These failures affected 5 residents out of the sample of 14 residents reviewed for quality of care. Findings include: R1's face sheet shows that R1 was admitted to the facility on [DATE] with diagnoses which include but not limited to end stage renal disease, dependence on renal dialysis, malignant neoplasm of endocrine pancreas, type 2 diabetes mellitus without complications, acute respiratory failure unspecified. R1's Brief Interview for Mental Status (BIMS) dated 09/19/23 documents that R1 has a BIMS of 14 which indicates that R1 is cognitively intact. R1's progress notes dated 09/16/23 at 7:27 am, authored by V26 (Licensed Practical Nurse, LPN) documents, in part: Resident has dialysis on Tuesday, Thursday, and Saturday. PCP (Primary Care Physician) was notified. R1's progress notes dated 09/16/23 at…

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

Based on observation, interview, and record review the facility failed to ensure licensed nursing personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect all 20 residents receiving medications from the 1st floor third set medication cart. Findings include: On 12/19/2023 at 9:46am surveyor review of the 1st floor third set medication cart with V10 (LPN/Licensed Practical Nurse) observed the controlled drug shift count sheet for December 2023. The nurse's initials in the nurse leaving and the nurse arriving boxes were blank for certain dates. The controlled drug shift count sheet at the end and beginning of the shift was not completed. This occurred for the following dates and shifts: On 12/1/2023 for the 7am-3pm shift, there are missing initials from the nurse arriving. On 12/1/2023 for the 3pm-11pm shift, there are missing initials from the nurse leaving and the nurse arriving. On 12/1/2023 for the 11pm-7am shift, there are missing initials from the nurse leaving. On 12/2/2023 for the 7am-3pm shift, there…

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

Based on interview and record review the facility failed to provide consistent transportation services to medical appointments for one resident (R5) out of the sample of fourteen residents. This failure caused R5 to miss medical appointments. Findings include: R5's diagnosis includes but are not limited to Chronic Systolic (Congestive) Heart Failure, Unspecified Asthma With (Acute) Exacerbation, Chronic Obstructive Pulmonary Disease, Unspecified, Other Seizures, Essential (Primary) Hypertension, Lymphedema, Not Elsewhere Classified, Acute Kidney Failure, Unspecified, Other Abnormalities Of Gait And Mobility, Need For Assistance With Personal Care, Other Hypotension, Urinary Tract Infection, Site Not Specified, Extended Spectrum Beta Lactamase (ESBL) Resistance, Anorexia, Other Secondary Hypertension, Malignant Melanoma Of Skin, Unspecified, Peripheral Vascular Disease, Unspecified, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Obstructive Sleep Apnea (Adult) (Pediatric), Anxiety Disorder, Unspecified, Hyperlipidemia, Unspecified, Chronic Respiratory Failure With…

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 a care plan meeting was provided quarterly to a resident and a resident's family member. This failure affected one resident (R2) reviewed for care plan meetings in the total sample of 14 residents. Findings include: On 12/18/23 at 11:50 am, when asked about R2 having care plan meetings and V22 (R2's Power of Attorney, POA) attending the care plan meetings, R2 stated, R2 doesn't remember having care plan meetings. R2's admission Record, documents, in part, diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, psoriasis, type 2 diabetes mellitus, pleural effusion, seizures, history of falling, acute cholecystitis, right upper quadrant pain, acute kidney failure, chronic kidney disease stage 3, lack of coordination, need for assistance with personal care, vitamin D deficiency, hypertension, hyperlipidemia, and long term use of insulin. R2's Minimum Data Set (MDS), dated [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 observation, interview, and record review, the facility failed to ensure that a resident with aspiration precautions who depends on staff assistance for ADL (Activities of Daily Living) care received assistance for feeding and maintaining clean clothes. These failures affect one resident (R2) reviewed for ADL care in the total sample of 14 residents. Findings include: R2's admission Record, documents, in part, diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, dysphagia, psoriasis, type 2 diabetes mellitus, pleural effusion, seizures, history of falling, acute cholecystitis, right upper quadrant pain, acute kidney failure, chronic kidney disease stage 3, lack of coordination, need for assistance with personal care, vitamin D deficiency, hypertension, hyperlipidemia, and long term use of insulin. On 12/18/23 at 11:50 am, R2 was observed lying in bed with the head of bed (HOB) at an approximate angle of 45 degrees. R2 was observed wearing a gown 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 observations, interviews and records review, the facility failed to follow their policy on resident rights by failing to maintain confidentiality of personal and medical records for two residents (R1, R12) of four reviewed. Findings include: R1 is an [AGE] year-old individual with a BIMS (Brief Interview for Mental Status) score of 6/15, indicating has severe cognitive impairment. BIMS is dated 7/28/2023. On 09/06/2023 at 12:10pm, R1 was observed sitting in the dining room sitting with her family member. R1's family member agreed to wait for R1 as R1 was taken to her room for skin assessment. R1 was observed with a white wristband on her left hand. V12 (Licensed Practical Nurse-LPN) said R1 was discharged back to the facility on 9/5/2023 after a recent hospitalization. On the wrist band was written R1's date of birth , gender, age, account and medical record number, name of nearby hospital R1 had gone to. V12 said the wrist band should have been removed from R1's wrist after R1 was identified as 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 follow its policy and procedures for the Restorative Program by not providing documentation on restorative services and quarterly restorative progress notes that detail the progress or lack of progress in the restorative services; and, not completing a quarterly restorative care plan to reflect the individual needs for one (R5) out of three residents reviewed for restorative services. Findings include: R5's Physician Order Sheet/POS documents in part, Start date 08/24/2023- Right Palm- clean with soap and water and apply carrot device (CNA may apply). On 09/05/2023 at 10:00AM, R5 observed laying on an air mattress bed on her right side with a gown on and bed sheets pulled over her entire body. A green wedge pillow observed on R5's right side behind R5's right shoulder. R5 is not interviewable and unable to verbally make needs known. On 09/05/2023 at 10:22AM, V15 (Certified Nursing Assistant/CNA) located inside of R5's room and pulls back R5's bed sheets. Surveyor observed that R5 had bilateral contractures of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of record review and interview the facility failed to document performing enteral feeding ordered by physician for 1 out of 3 residents (R3) reviewed for nutritional and hydration status. R3 had weight loss and was dependent on enteral feeding for her nutritional and hydration needs. Findings include: R3 is [AGE] years old, initially admitted on [DATE] and was discharged from facility on 07/07/2023. R3's diagnosis includes dysphagia and diverticulum of esophagus. R3 was NPO/Nothing Per Orem (means nothing by mouth) and uses enteral tube feeding for all nutrition and fluids, including taking of medication per physician's order. R3's medication administration record (MAR) from April to July 2023, that includes physician order for enteral feeding and water flushing, does not document as performed. There were multiple days that were not signed or initialed that rendered physician orders cannot be determined they were performed. V49 (Dietitian) Nutritional Progress Note dated 05/24/2023 documents that…

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 its policy and procedures for the Restorative Program by not ensuring that a licensed nurse supervised the restorative program. This failure affected one resident(R5) reviewed for restorative care and services. Findings include: Record review of R5's care plan 08/21/2023 documents that R5 does not have a Restorative Care Plan to address R5's restorative needs. R5 is not care planned for contractures and the use of a carrot device for her right palm. On 09/05/2023 at 10:00AM, R5 observed laying on an air mattress bed on her right side with a gown on and bed sheets pulled over her entire body. A green wedge pillow observed on R5's right side behind R5's right shoulder. R5 is not interviewable and unable to verbally make needs known. On 09/05/2023 at 10:22AM, V15 (Certified Nursing Assistant/CNA) located inside of R5's room and pulls back R5's bed sheets. Surveyor observed that R5 had bilateral contractures of upper and lower extremities with R5's right hand contracted into a tight closed fist. 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 identify resident food intolerance and provide food that accommodates resident food preferences and intolerances. This failure affected 1 (R2) out of 3 residents reviewed for dietary services. Findings include: On 09/05/23 at 11:25 AM, R2 stated I don't eat pork and I'm lactose intolerant and cannot tolerate milk or any food items containing cheese, yogurt, cottage cheese, or ice cream. R2 stated the kitchen sends R2 pork and foods containing lactose that R2 cannot eat all the time. R2 showed surveyor picture from R2's mobile phone of a ham and cheese sandwich R2 stated R2 received on Saturday (date not specified). R2 stated see? They keep sending me ham and cheese sandwiches when they know I cannot eat it! R2 stated this mistake has not happened just 1 time, or 2 times or 3 times but keeps happening over and over. R2 stated they've sent me pork and food with cheese in it so many times I've lost count. R2 stated that it says no pork 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.

Based on interview, and record review, the facility failed to ensure controlled substances were counted, and documented, at the beginning and end of each shift for 123 out of 161 shifts. This failure has the potential to affect 154 residents. Findings include: On 07/11/2023 at approximately 9:25AM, V5 (LPN/Licensed Practical Nurse) stated that she did not perform a narcotic drug count. V5 was responsible for the 3rd floor Team 1 medication cart. On 07/11/2023 at approximately 9:25AM, review of the Controlled Drug Count Sheet for the month of July 2023 for cart identified as Team 1 medication cart located on the 3rd floor of the facility indicated for 29 shifts in July 2023, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 07/01/23, 1st shift (7am-3pm), 2nd shift (3pm-11pm), and 3rd shift (11pm-7am) On 07/02/23, 1st shift (7am-3pm), 2nd shift (3pm-11pm), and 3rd shift (11pm-7am) On 07/03/23, 1st shift (7am-3pm), 2nd shift (3pm-11pm), and 3rd shift (11pm-7am) On 07/04/23, 1st shift (7am-3pm), 2nd shift (3pm-11pm), and 3rd…

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 proper sanitation and food storage practices as evidenced by food not properly labeled, and food not properly stored. These deficient practices have the potential to affect all 200 residents receiving food prepared in the facility kitchen. Findings include: On 7/11/23 at 09:15 AM during the initial kitchen tour with V7 (Dietary Manager) the following items were found in the walk-in refrigerator: 1.) 1 open carton of liquid scramble eggs no open or expiration date, 2.) 25 open/uncovered slices of cheese, no open or expiration date, 3.) uncovered plate with slices of cheeses, tomatoes, and onion slices no preparation date or discard date, 4.) 20 ground beef patties not packaged, no open date or discard date, 5.) open half-filled cup of coffee with an outside company logo on the cup sitting on the shelf with open food items. On 7/11/23 at 9:34 AM the following items were found in the walk-in freezer: 1.) open/uncovered package of hamburger patties, with white and gray color, no open date or discard 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.

Based on observation, interview, and record review the facility failed to: ensure medications were given when scheduled, ensure medications were given when the Medication Administration Record was signed, ensure Medications that were given late were documented, and failed to provide care according to professional standards for ten (R6, R28, R47, R62, R64, R81, R115, R141, R171, R180) residents out of a sample of 37 residents reviewed. Findings include: On 07/12/2023 at approximately 8:13AM, surveyor located on the second floor of the facility observing a medication administration pass with V12 (LPN). R62's electronic medication administration record (eMAR) dated 07/01/2023 - 07/12/2023 documents: - Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act- 2 puffs inhale orally two times a day scheduled at 9:00AM. - Gabapentin 100mg- 1 cap by mouth three times a day scheduled at 9:00AM. On 07/12/2023 at 8:13AM, surveyor observed that these medications were not given during the 9:00AM medication administration pass with V12 (Licensed Practical Nurse/LPN). V12 stated that 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 incontinence care, grooming care, and feeding assistance to eight (R7, R13, R28, R47, R73, R74, R143, R362) dependent residents reviewed for Activities of Daily Living/ADL care. Findings include: On 07/11/2023 at approximately 12:20pm, surveyor and V10 (Certified Nursing Assistant/CNA) located inside of R362's room. Surveyor observes that R362's incontinence briefs are visibly soiled. R362 is not interviewable. V10 stated that she started her shift at 7:00AM but did not get the chance to change R362's incontinence briefs. V10 stated that she was too busy giving another resident a bed bath and did not have time. V10 stated I see that R362's diaper is soiled with urine because it looks big and bulky. When R362 urinates, there is a line on her diaper that turns blue in color, which indicates that the diaper is soiled. I need to change R362's diaper now. R362s' Face sheet documents that R362 was admitted to the facility on [DATE] 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 label/date 4 (R7, R13, R28, R155) of 4 residents oxygen tubing, failed to properly store 2 (R28, R155) of 2 residents oxygen tubing to prevent contamination, failed to follow physician's orders for 3 (R7,R28 R183) of 3 residents, failed to have a physician order for 3 (R13, R62, R153) of 3 residents oxygen use and failed to change R13's oxygen humidifier, and care plan R7 and R13's oxygen use in a sample of 37. Findings Include: Resident R155 has a diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Shortness of Breath, and Anxiety Disorder. Care Plan: R155 has COPD and has potential for complications such as Shortness of breath when lying flat, decreased endurance, decreased strength, and decreased activity intolerance. Date Initiated: 04/01/22. R155 uses oxygen as ordered, R155 is at risk for complications related to its use. Change oxygen apparatus, tubing per protocol and as needed to reduce risk…

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 adequate staffing was available to provide care, toilet and/or change residents, for 8 (R3, R6, R28, R47, R88, R115, R165, R362) of 8 residents reviewed for staffing concerns, in a sample of 37. Findings Include: On 07/11/23 at 01:09 PM R88 stated there is not enough staff to take care of our needs. On 07/06/23 evening shift there were only two CNA's (Certified Nurse Assistants) and one nurse on the floor. It took a long time before we were changed. On 07/11/23 at 01:43 PM R115 stated there are not enough CNA's (Certified Nurse Assistants), and it will be 3 hours before you are taken care of. I look at the time on my phone. This is an ongoing problem. On 07/11/23 at 03:40 PM V17 (Certified Nurse Assistant) stated On 07/06/23 I worked on the second floor and arrived at about 03:15 PM. It was only two CNA's (Certified Nurse Assistants) and one nurse working on the second floor during the evening shift. I think there were 72 residents on the floor. Someone was supposed to come to the floor to help but no one ever came.…

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 were locked and secured while unattended and failed to remove and discard expired liquid antibiotic medication that had been open in one of two medication storage rooms reviewed for medication labeling and storage. These failures have the potential to affect 141 residents residing in the facility. Findings Include: On 07/11/2023 at approximately 9:35AM, surveyor located on the third floor of the facility. V5 (Licensed Practical Nurse) observed leaving medication cart (identified as Team 1 medication cart) unlocked and unattended. On 07/11/2023 at approximately 10:21AM, surveyor located on the first floor of the facility. V9 (Licensed Practical Nurse) observed leaving medication cart (identified as Team 1 medication cart) unlocked and unattended with the keys inside the lock. On 07/12/2023 at approximately 7:55AM, surveyor located on the second floor of the facility. Surveyor observed that medication storage room was unlocked and unattended with the door kept open using a utility cart. 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.

Based on observations, interviews, and record reviews, the facility failed to follow residents' food preferences for 6 (R43, R49, R81, R115, R171, R180) residents out of a total sample of 37 residents. Findings include: During lunch observations on 07/11/2023 at 01:15 PM, R43 and R81 called surveyor over to their table. R43 stated the facility did not provide what is on the meal ticket. R43's meal ticket documents in part beef soft taco with bread and margarine. Facility gave R43 noodles with ground beef on top. R43 stated facility also forgot the butter or margarine on the tray. R43 and R81 stated the facility does this often where staff do not follow what's on the meal ticket. R81 stated [R81] was still waiting on their lunch tray because the facility forgot about the fruit plate and grilled cheese R81 requested. Staff told R81 that they had to request the items from the kitchen. At 2:48 PM, V7 (Dietary Manager) stated the menu runs on a 28-day schedule. V7 stated the facility is on week three of the menu cycle. V7 stated for lunch today, the renal residents were supposed 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 follow their policy to ensure the call light is within reach for 1 (R11) out of 3 residents reviewed for call lights in a sample of 37. Findings Include: 07/11/23 10:25 AM, surveyor observed R11 sitting on the left side of the bed in her wheelchair watching TV. Surveyor noticed R11's call light on the right side of the bed and not within reach of R11. Surveyor asked R11 if she could reach the call light. R11 stated she doesn't even know where the call light even is. On 07/13/2023 at 11:15 AM, V4 (3rd floor Unit Manager) stated that it is the expectation for nurses and CNAs to round on residents every two hours. V4 stated that in these rounds, the staff is to ensure safety for the resident by making sure the call is within reach, bed in low position, what they need is within reach and if their needs are met. If these things are not followed you run the risk of a fall incident. R11's MDS Section C (04/17/2023) documents in part: R11's BIMS score is 14, which means R11 awareness is cognitively intact. R11's 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 observations, interviews, and record reviews, the facility failed to follow physician's orders and apply a resident's (R74) left-hand splint, document refusals, and update the comprehensive care plan for 1 out of a total sample of 37 residents. Findings include: R74's face sheet documents in part left sided weakness/paralysis, left hand contracture, and lack of coordination. R74's physician orders document in part: Apply left hand splint as tolerated on in am [morning], off in pm [evening]. May release for ADL [Activities of Daily Living] care and activities as needed; observe skin and report any changes. Order is active and was last revised in 04/01/2021. R74's comprehensive care plan documents in part that R74 requires the use of a left-hand splint for contracture management. Interventions initiated 12/06/2017 document in part: Apply device per therapy or manufacture instructions and Establish wearing schedule: on during the day shift as tolerated. Intervention initiated on 01/12/2021 documents in part M.D. [Medical Doctor] order-Apply left-hand splint as tolerated on 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.

Based on observation, interview and record review, the facility failed to follow their policy to ensure the safety of a resident during transfer using mechanical lift for 1 (R50) out of three residents reviewed for accidents and hazards in a sample of 37. Findings Include: On 07/11/2023 at 11:45 AM, surveyor observed R50 laying in her room in bed. On 07/11/2023 at 11:50 AM, surveyor observed V6 (Certified Nursing Assistant) wheel in a mechanical lift into R50's room. Surveyor waited outside R50's room until Certified Nursing Assistant/CNA came out. On 07/11/2023 at 12:02 PM, surveyor observed only V6 wheel out R50 on her Geri chair with no other healthcare staff members in the room. On 07/11/2023 at 12:05 PM, V6 stated that R50 does not walk and requires a hoyer lift for transfer to the geri chair. V6 stated that it was just herself who transferred R50 to the geri chair using the mechanical lift. V6 stated there are supposed to be two people when using the mechanical lift when transferring a resident. On 07/12/23 at 01:15 PM, V2 (Assistant Administrator) stated that it is important…

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 their policy to ensure a resident was receiving nutrition via a G-tube according to physician orders for 1 (R173) out of three residents reviewed for tube feedings in a sample of 37. Findings include: On 07/11/23 at 10:00 AM, surveyor observed R173 laying in his room with the tube feeding equipment attached to his G-tube. Surveyor observed the tube feeding to be Jevity 1.2, 1.5L bottle, date 7/11/2023, start time: 03:00 AM. Tube feeding machine however was off and all 1500mL was still remaining in the bottle. On 07/11/2023 at 11:30 AM, surveyor again noticed R137's tube feeding bottle, full at 1500 mL and attached to his G-tube with the machine turned off. On 07/11/23 at 11:30 AM, surveyor asked V5 (Agency Licensed Practical Nurse) why R173's tube feedings was not running. V5 stated that's because it is a bolus feeding and they start it at 5 PM every day. Then surveyor asked V5, the order says start at 5:00 PM at 80mL for 21 hours till 1680mL administered, so how many mL should have been administered…

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 a medication error rate of less than 5% for two (R62, R156) of four residents reviewed for medication administration resulting in a 12% error rate. Findings Include: R62 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction, Type 2 Diabetes, Chronic Kidney Disease, Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. R62's electronic medication administration record (eMAR) dated 07/01/2023 - 07/12/2023 documents: Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act- 2 puffs inhale orally two times a day scheduled at 9:00AM. Gabapentin 100mg- 1 cap by mouth three times a day scheduled at 9:00AM. On 07/12/2023 at 8:13AM, surveyor observed that these medications were not given during the 9:00AM medication administration pass with V12 (Licensed Practical Nurse/LPN). On 07/12/2023 at 8:13AM, V12 stated that the medications prepared for R62 was all the medication scheduled for R62's 9:00AM medication pass. R156 has diagnosis not…

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

Based on interview and record review the facility failed to ensure medications were administered as ordered by the residents' physician for three (R62, R156, R364,) residents in a sample of 37 residents. Findings Include: On 07/11/2023 at11:26AM, R364 stated that he has not received his anxiety medication (Identified as Alprazolam) for several days and has been asking the staff where his medication is located. R364 stated that his anxiety has been increasing since he has not been getting his medication when he needs it. On 07/11/2023 at 11:42AM, surveyor located on the first floor of the facility with V9 (Licensed Practical Nurse/LPN). V9 states that R364's Alprazolam medication is available. Surveyor observed R364's Alprazolam medication inside of medication cart identified as Team 1 medication cart. R364's Alprazolam medication bingo card observed full of a 30 pill quantity count, no medication has been dispersed from the bingo card. R364's physician order sheet/POS documents the following order: Start date: 07/01/2023 Alprazolam 1mg- Give 1 tab by mouth every 12 hours as…

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

Based on observation, interview and record review, the facility failed to follow their policy to ensure proper infection control guideline practices were followed regarding personal protective equipment not being worn when entering a contact isolation room for 1 (R200) out of 3 residents reviewed for transmission-based precautions in sample of 37. Findings include: On 07/11/2023 at 10:40 AM, surveyor saw R200's call light going off in his room. Surveyor also noticed R200's door was closed with contact isolation sign posted on the front of the door. On 07/11/2023 at 10:48 AM, surveyor observed V5 (Agency Licensed Practical Nurse) enter R200's room without wearing gown and gloves. Surveyor observed V5 in R200's room without gown or gloves handling R200's linen. On 07/11/2023 at 10:55 AM, V5 stated that R200 is on contact isolation for ESBL of his wound. V5 stated that there is a drawer outside the room with all the gowns and gloves inside the drawer. V5 also stated that you are supposed to wear gown and gloves prior to entering the room. V5 stated that she did not wear the gown. 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.

Based on observations, interviews, and record reviews, the facility failed to date opened food in the dry food storage and freezer; failed to ensure the level of chemical sanitizer in the dishwasher, three compartment sink, and sanitizing buckets were at the appropriate ppm (parts per million); and failed to maintain a clear working environment (Kitchen). These failures have the potential of affecting 189 residents who are on an oral diet and receiving food from the kitchen. Findings include: On 7/31/2022 at 9:32am, Dish wash washer machine was observed being used to wash dishes. A load of dishes was put in the dishwasher and testing trip was added. Testing strip remained white after washing cycle. V8 (Dietary Aide) said that the testing trip is supposed to turn black when the dishwasher is done cleaning. V10 (Cook) said this strip did not turn black; it is still white. On 7/31/2022 at 9:36 am V8 (Dietary Aide) put in another load in the dishwasher and a testing trip was added. Testing trip remained white when the dishwasher cycle was done. V8 said this strip did not turn black; it…

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 label refrigerated stored insulin with a label open and expiration date; and destroy and reorder medications with missing, incomplete, or expired labels for 6 [R12, R42, R61, R89, R154, and R175] of 73 residents residing on the third- floor reviewed for medication storage. Findings include: On [DATE] at 08:35 AM During medication storage observation on the third floor with V14[ RN-Unit Manager], observed the following refrigerated open insulins: R61's Lispro open insulin half- filled dispense dated [DATE]; R175's Aspart Insulin dispense date [DATE]; R42's Lantus Insulin dispense dated [DATE]; R12's Humalog Insulin dispense date [DATE]; R89's Humalog insulin dispense date of [DATE]; and R154'Novolin 70/30 insulin dispense date of [DATE]. On [DATE] at 08:50 AM V14 stated, The insulin is supposed to be dated once it is open, and after 28 days the insulin needs to be discarded and reordered. If expired insulin is used, it can cause…

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 appropriate use of personal protective equipment (PPE) worn by staff caring for residents on contact and droplet isolation precautions for confirmed or suspected COVID-19. This failure affected three residents (R300, R301, and R116) reviewed for infection control in a sample of 35 residents. The facility also failed to sanitize shared medical equipment between each resident use for 4 [R75, R53, R154, and R181] of 25 residents reviewed for medication administration observation. Findings include: On 08/01/2022 at 10:11am, surveyor observed a sign outside of R301 and R116's shared room located on the first floor of the facility. The sign read, Yellow Zone Droplet and Contact precautions, full PPE to be used when entering rooms, clean hands, wear N95 mask, gown, and eye protection. Surveyor observed isolation cart outside of R301 and R116's room with the following items inside: N95 masks, gowns, and gloves. On 08/01/2022 at…

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

Based on observation, interview, and record review, the facility failed to provide privacy for 3 [R53, R122 and R154] residents reviewed for dignity in a sample of 35. Findings include: On 07/31/22 at 09:51 AM observed V20 [Registered Nurse] administer an injection of insulin to R154's abdomen without pulling the privacy curtain closed or closing the bedroom door. R154's roommate [R82] was present, staff and visitors walking in the hallway. On 07/31/22 at 10:00 AM V20 stated, I forgot to pull close the privacy curtain or close the bedroom door. I was standing in front of R154, I do not think anyone seen his stomach. On 07/31/22 at 10:53AM observed V21 [Housekeeper] walk into R53's room without knocking on the door. On 07/31/22 at 10:56 AM V21 stated, I did not knock on the door because the nurse was already in the room. On 08/02/22 at 12:54 PM, V2 [Director of Nursing] stated, All resident must be provided privacy at all times. All staff knows to knock on the door and announce themselves before entering a resident's room. All nurses must provide privacy when performing nursing task…

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 follow their policy to assess a resident for pass privileges, obtain an order for a resident's pass privileges and notify the resident's primary physician of a resident's failure to return to the facility after going out on pass. This failure affected one resident (R101) in a sample of 35 residents. Findings include: On 8/2/2022 at 12:00PM, V17 (Social Service Director) stated that there is no social service assessment for R101 within 72 hours of admission to go out on pass due to a social worker terminating employment with the facility. R101 was in and out of the hospital when assessments were due. V17 stated that R101 was in the hospital at the 72 hours and back in the hospital when time to do 72 hours again. V17 stated that the assessment done on 7/29 is because V17 was doing an audit of 2nd floor because the social worker left. On 8/2/2022 at 12:35PM, V45 (R101's Primary Physician) stated that V45 was not aware that R101 did not return to the facility from pass. On 8/2/2022 at 1:21PM, V2 (Director of Nursing) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide ADL (Activity of Daily Living) care to residents who are dependent on staff assistance with ADL's. This failure affected R29 and R299 in a sample 35 residents reviewed for incontinence care and personal hygiene. Finding include: On 07/31/22 at 11:10 AM, observed V11 [R29's Significant Partner] providing incontinence care after a large bowel movement. V11 stated, Every time I come visit especially in the morning, I clean R29 up and change her under brief. When I ask for staff assistance, they take over an hour or don't come at all to provide care. On 07/31/22 at 11:15 AM, R29 stated, My butt hurts and burn because the bowel movement is left on my skin for a long time. I do not have any bed sores and do not want to get any. On 08/01/22 at 7:53 AM, observed R29 resting in bed with a foul odor of feces coming from R29. R29 stated, I need to be changed, my butt is hurting and burning. The CNA [Certified Nurse Assistant] cleaned me up 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 ensure two residents (R181 and R154) did not receive expired insulin medications; failed to ensure R181 did not receive insulin medication from another resident's insulin vial. In addition, failed to ensure the 5 rights of medication pass were followed during medication pass for 2 residents(R181and R154); the nurse did not identify right resident to right medication. These failures could result in R181 and R154 experiencing decreased medication effectiveness and potential infection from another resident's vial use. Findings include: On [DATE] at 09:32 AM, during medication administration observation, V18 [Licensed Practical Nurse/LPN] administer R181 4 units of Humalog insulin 100unit/ml (Lispro). The name on the half -filled insulin vail was another resident (R89) Humalog insulin. This vial did not have an open or expiration date on it. On [DATE] at 09:34 AM V18 stated, R181 do not have any Humalog insulin available. The facility does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to review the quarterly restorative observation assessment for significant changes; and, update and document the assessment goals, interventions, and resident tolerance of the assessment goals. In addition, the facility failed to replace the missing right hand palm guard for one [R180] of 35 residents reviewed in the sample for limited range of motion. This failure could potentially result in R180 developing right hand contracture. Findings include: On 07/31/22 at 12:25 PM, observed R180 in the dining room with her right hand contracted. On 07/31/22 at 12:26 PM V13 [R180's Family Member] stated, R180's right hand contracture is getting worse since her palm guard has been missing. I noted palm guard to be missing around Mother's Day 2022. Reviewed R180's medical chart read: admitted on [DATE]. Medical diagnosis of mood disorder, chronic obstructive pulmonary disease, anemia, hyperlipidemia, dementia, major depressive disorder, LMAO cognitive…

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 change oxygen tubing and failed to properly label oxygen tubing for two residents (R5, R97) reviewed for oxygen therapy in a sample of 35 residents. Findings include: On 7/31/2022 at 1:04pm during interview with R5 inside of R5s' room, R5 observed lying in bed in semi-Fowlers' position. R5 receiving oxygen therapy via nasal cannula with oxygen tubing connected to oxygen concentrator next to R5's bed. Surveyor observed that R5's oxygen nasal cannula tubing was not labeled with a date. On 07/31/22 at 1:14pm, surveyor and V33 (LPN) walk inside of R5's room and V33 observed R5's nasal cannula tubing. Surveyor asks V33 does R5's oxygen tubing need to have a date labeled on the tubing. V33 stated Yes, the oxygen tubing is supposed to be changed every Sunday on the 3-11pm shift and the tubing is supposed to have a date on it. I do not see a date on R5's oxygen tubing. V33 verbalized that if R5's oxygen tubing is not changed and dated then there could be a risk for infection to R5. On 08/02/2022 at 9:25am, R97…

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.