Aperion Care Wesley

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against COVID-19 in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the COVID-19. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 3 residents (R1, R17 and R74) reviewed for COVID-19 immunizations in a total sample size of 49 residents and has the potential to affect all eligible residents that reside at the facility. This deficient practice has the potential to affect all 87 eligible residents that reside at the facility. Findings include: Review of records for R1, R17 and R74 from admission date to 1/14/25 and there were no findings of documentation of COVID-19 vaccine offering or education of the vaccine. Review of physician orders for R1, R17 and R74 from admission to 1/14/25 show no orders of COVID-19 vaccination. Immunization records for R1, R17 and R74 have no current COVID-19 vaccination…

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 clean the dryer lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 87 residents at the facility. Findings include: On 1/15/25 at 10:15 am, V1 (Administrator) said, the Laundry Manager (V19) is busy with Life Safety, but I know laundry and can answer any questions for you. On 1/15/25 at 10:45 am, this surveyor, with V1 (Administrator) observed 2 dryers in the laundry room. Dryer #1 was not in use but did have linen inside it. Dryer number 2 had just finished while V1 and this surveyor were present. This surveyor requested V1 (Administrator) to open the lint compartment dryer #1. The lint compartment floor was clean however the lint screen was fully covered with lint. This surveyor requested V1 (Administrator) to open the lint compartment dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. On 1/15/25 at 10:52am, V1 (Administrator) stated the dryer lint traps should be cleaned out daily…

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 two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 8 residents who are prescribed controlled substances from the 3rd floor medication cart and 6 residents who are prescribed controlled substances from the 4th floor medication cart. Findings include: On 01/14/2025 at 12:10 pm, review of the 3rd Floor medication cart with V15 (RN/Registered Nurse) surveyor observed the controlled substances count verification form for January 2025. The Nurse's Initials Off box was left blank for January 10, 2025 (night shift). The Nurse's Initials On box was left blank for January 13, 2025 (day shift). The Nurse's Initials Off box was left blank for January 13, 2025 (evening shift). On 01/14/2025 at 12:40pm, review of the 4th Floor medication cart with V11(LPN/Licensed Practical Nurse) surveyor observed the controlled substances count verification form for January 2025. The Nurse's Initials Off box was left blank for January 04,…

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: three medication carts out of the three medication carts reviewed were free of loose tablets, insulin pens that were dated with an open date and the temperature was properly logged for two of the three medication storage refrigerators reviewed. This deficient practice has the potential to affect 24 residents on the fourth floor, 23 residents on the third floor and 11 residents on the 2nd Floor [NAME] (East Wing) who receive medications from the medication carts and units. Findings include: On 01/14/ 2025 at 11:37am inspected the 3rd Floor medication cart with V15 (RN/Registered Nurse). The following was observed: V15 pulled 5 loose white tablets, 3 loose yellow tablets, and 1 loose white capsule from the second drawer of the 3rd floor medication cart. On 01/14/2025 at 12:24pm inspected the 4th Floor medication cart with V11 (LPN/Licensed Practical Nurse). The following was observed: V11 pulled 1 loose pale pink tablet, 2 loose orange tablets, 20 loose white tablets, 2 loose green tablets, 5 loose pink…

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 refrigerator temperatures for resident's personal refrigerators for 6 residents (R11, R42, R49, R56, R57 and R74). This failure has the potential to affect all 6 residents reviewed for safety of personal food items, in a total sample size of 49 residents reviewed. Findings include: On 01/13/25 at 11:23am R57's refrigerator observed with no temperature log and no thermometer inside R57's refrigerator. On 01/13/25 at 11:32am R11's refrigerator observed with refrigerator log dated 05/2024 with missing check dates. R11 had no additional refrigerator logs for any date beyond 05/2024 including 01/2025. On 01/13/25 at 11:37 R42's refrigerator observed with refrigerator log dated June with missing check dates. R11 had no additional refrigerator logs for any date beyond June including 01/2025. On 01/13/25 at 11:43am V10 (Licensed Practical Nurse/LPN) stated that R11, R42 and R57 did not have refrigerator temperature logs for January 2025. On 01/15/25 at 1:51pm V2 (Director of Nursing/DON) 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.

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 3 residents (R1, R17 and R74) reviewed for pneumococcal immunizations in a total sample size of 49 residents. Findings include: Review of records for R1, R17 and R74 from admission date to 1/14/25 and there were no findings of documentation of pneumococcal vaccine offering or education of the vaccine. Review of physician orders for R1, R17 and R74 from admission to 1/14/25 show no orders of pneumococcal vaccination. Immunization records for R1, R17 and R74 have no current pneumococcal vaccination listed. On 1/15/25 at 1:27pm, V21 (Regional Nurse Consultant) said that the facility hasn't had a pneumococcal vaccine clinic. Only Influenza vaccines…

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 call light was within reach for 1 resident (R63) and ensure the call light was working properly for 1 resident (R229) out of 49 residents reviewed for call lights. Findings include: On 01/13/2025 at 11:00am observed R63 lying on her right side in the bed, alert and oriented. Surveyor asked R63 Where is your call light cord/button located? R63 stated, It is somewhere in the bed with me. On 01/13/2025 at 11:02am observed R63's call light cord hanging off the left side of R63's bed towards the floor. On 01/13/2025 at 11:05am surveyor asked V6(CNA/Certified Nursing Assistant) to come into R63's room. V6 was asked, Where is R63's call light string? V6 stated R63's call light cord is located on the left side of the bed hanging towards the floor. V6 stated the call light should be attached to the resident and within close reach of the resident. On 01/13/2025 at 11:06am surveyor observed V6(CNA/Certified Nursing Assistant) move 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 ensure that residents have a clean, home like environment by providing clean linen for 2 residents (R1 and R54) and clean, home like room for 1 resident (R1). This failure affected 2 residents (R1 and R54), reviewed for resident's rights to enjoy a clean, comfortable, homelike environment, in a total sample of 49 residents. Findings include: On 1/13/25 at 10:27am, surveyor observed R1 lying in bed, on her back, with 2 areas of a brown substance on R1's bottom sheet of her bed. Also observed was multiple areas of a tan/beige substance on R1's floor and bed side dresser. When asked about the brown substance and tan/beige substance, R1 replied, I know the stuff on the floor and dresser is what they (staff) give me through my tube (tube feeding). I don't know what the brown stuff is. It's probable poo. They (staff) never clean in here. They (staff) don't care. Makes me wonder how their own houses look. R1's Face Sheet, documents medical diagnosis that include but are not limited to other abnormalities of gait and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct care plan conferences that allow the residents to participate in the development and implementation of their plan of care and failed to develop a comprehensive care plan within the required time frame. This failure affects 2 residents (R19, R328) in a sample of 49. Findings include: 1. Record review of R19's admission record documents in part R19 has the following diagnoses including, but not limited to: spinal stenosis, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, major depressive disorder, and epilepsy. Record review of R19's Minimum Data Set (dated 12/5/2024) documents in part a Brief Interview of Mental Status Summary Score of 13, indicating that R19 is cognitively intact. On 1/13/2025 at 11:32 AM, R19 denied that R19 is invited to care plan meetings or invited to participate the R19's plan of care. R19 stated that if there was a meeting that discussed R19's plan of care, R19 would want 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 complete and submit a comprehensive assessment within the required timeframes. This failure has the potential to affect 1 resident (R328) in a sample of 49. Findings include: Record review of R328's admission tracking minimum data set (MDS) documents in part an assessment reference date of 12/17/2024. Record review of R328's comprehensive MDS dated [DATE] documents that Sections A, GG, H, I, J, K, L, M, N, O, P, S and V of the MDS are incomplete. The MDS does not document a signature in section Z0500 Signature of RN Assessment Coordinator Verifying Completion. Additionally, no signatures are noted for V0200B Signature of RN Coordinator for CAA Process and Date Signed and V0200C Signature of Person Completing Care Plan Decision and Date Signed. This indicates that the MDS is incomplete. On 1/15/2025 at 1:06 PM V27 (Regional Director of Clinical Reimbursement) reviewed R328's MDS dated [DATE] and confirmed that the assessment was late. V27 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.

Based on observation, interview, and record review, the facility failed to ensure that 2 residents (R1 and R54) who depend on staff assistance for ADL (Activities of Daily Living) care and grooming receive nail care and 1 resident (R1) receive hair care. This affects 2 residents (R1 and R54) in the sample of 49 residents reviewed for accommodation of needs. Findings include: On 1/13/25 at 10:27am, R1 said, My fingernails and hair aren't any better. My hair is all matted. This surveyor observed R1 with long, discolored fingernails on both hands and brown substances underneath the nail beds and R1's hair appeared tangled, tousled, and unkempt. R1 stated, I've asked the nurses to cut my nails and fix my hair but look . I'm a mess. I doubt my hair can even be unmatted. R1's Face Sheet, documents medical diagnosis that include but are not limited to type 2 diabetes mellitus; other abnormalities of gait and mobility; cerebral infarction; dislocation of internal left hip prosthesis; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; need for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dressings were changed daily (as per physician order) for one resident (R24) with pressure ulcers, who is also at risk for further pressure ulcers; and failed to have the low air loss mattress at the correct weight settings for one resident (R54) with pressure ulcers, who is also at risk for further pressure ulcers. This failure has the potential to affect two residents (R24 and R54), reviewed for pressure ulcer prevention interventions, in a total sample of 49 residents. Findings include: On 1/13/25 at 10:53am, surveyor observed R54 sitting on the side of his bed, on a LAL (low air loss) mattress, with the LAL mattress weight setting set at greater than 350 pounds. When asked if R54 has any pressure wounds, R54 replied, I have one on my butt, I'm not sure when it's supposed to be changed. Every day, I think. When asked how much R54 weighs, R54 replied, I think about 150. I think I'm losing weight though. When asked if R54'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 interview and record review, the facility failed to ensure that oxygen cylinders were secured and that personal heaters were not in use. This failure has the potential to affect all 87 residents that reside within the facility. Findings include: Record review of facility census documents in part that 87 residents reside in facility. Record review of R3's admission record documents in part that R3 has the following diagnoses including but not limited to: chronic obstructive pulmonary disease, pulmonary fibrosis, depression, anxiety and dependence on supplemental oxygen. Record review of R3's Minimum Data Set (dated 11/04/2024) documents in part a Brief Interview of Mental Status score of 15, indicating that R3 is cognitively intact. On 1/13/2025 at 11:02 AM, observed an oxygen cylinder freestanding, unsecured next to R3's bed. R3 stated that the oxygen cylinder used to be in a holder, but the facility took the holder away a couple of months ago. On 1/13/2025 at 11:32 AM, V10 (Agency Licensed Practical…

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 ensure a tube feeding syringe was changed daily on 1 resident (R1). These failures have the potential to affect 1 resident (R1) reviewed for tube feeding management in the total sample of 49 residents. Findings include: On 1/13/25 at 10:27am, surveyor observed R1's tube feeing syringe with an open date of 1/9/25. When asked if R1 noticed staff changing the tube feeding syringe recently, R1 replied, Doubt it. I can't even get my hair washed or brushed. Look, my hair is all matted. R1's Face Sheet, documents medical diagnosis that include but are not limited to dysphagia, oropharyngeal phase; gastro-esophageal reflux disease without esophagitis; gastrostomy status; and dysphagia following cerebral infarction. R1's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 10/11/24, suggests moderate cognitive impairment. R1's Care Plan, revised date 11/27/24, documents, in part, (R1) requires tube feeding GT (gastrostomy tube) r/t (related to) gastrostomy status secondary to CVA (cerebral vascular…

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 staff failed to secure in a bag the oxygen tubing and nasal cannula when not in use for one resident (R21) and failed to properly date the oxygen tubing, humidifier bottle, and nebulizer tubing for one resident (R11). Findings include: R21's diagnosis includes, but are not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, muscle weakness (generalized), unspecified dementia, unspecified severity, with other behavioral disturbance, chronic systolic (congestive) heart failure, hypertensive heart disease with heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. R21 has a Brief Interview for Mental Status (BIMS) dated 11/13/2024 which documents that R21 has a BIMS score of 07, indicating R21's cognition is severely impaired. R21's Physician Order Summary Report dated 01/14/2025 documents, in part, Continuous oxygen at 2-3 LPM (liters per…

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 there were sufficient staff to meet the resident's needs. This failure caused R328 to not have an intravenous antibiotic administered; failed to have an intravenous antibiotic administered timely; failed to have R328's comprehensive assessment completed timely; failed to have R328's plan of care to be developed within the required timeframe. This failure affects 1 (R328) resident in a sample of 49. Findings include: Record review of the facility's staffing schedule/assignment for 1/13/2025 documents in part that an agency nurse was supposed to begin at 9:30 AM. The staffing records do not indicate the agency nursing staff's names or titles (registered nurse vs licensed practical nurse). Record review of R328's admission record documents in part R328 has the following diagnoses including, but not limited to: osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of bladder, and colitis. Record review of R328's Brief Interview…

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

Based on observation, interview, and record review, the facility failed to administer medications per physician's order for 2 residents (R63 and R379.) The Facility had 2 medication errors out of 25 opportunities resulting in an 8% medication error rate. Findings include: On 1/14/2025 at 9:12 am, observed V2 (Director of Nursing-DON), administer prefilled syringe Enoxaparin Sodium 30 mg/0.3 ml injection to R63's Left Thigh instead of the 20 mg/0.2 ml dosage per physician's order. V2 did not discard 0.1 ml before administering Enoxaparin Sodium injection and administered Enoxaparin 30mg/0.3 ml to Left Thigh. On 1/14/2025 at 1:54 pm, V2 (DON), stated that she believes R63's medication dosage for Enoxaparin Sodium is 30mg or 20mg and that she administered 30 mg of the medication. V2 was asked if she discarded 0.1 ml before administering Enoxaparin Sodium and V2 stated No, I don't think so. V2 stated that administering more than the prescribed dosage of the medication can cause excessive bleeding. V2 stated that when a medication error occurs it must be reported to the DON and Physician…

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 were free of serious medication errors. This failure affects 1 resident (R328) in a sample of 49. Findings include: Record review of R328's admission record documents in part R328 has the following diagnoses including, but not limited to: osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of bladder, and colitis. Record review of R328's Brief Interview of Mental Status (BIMS) assessment dated [DATE], documents in part that R328 has a BIMS summary score of 15, indicating that R328 is cognitively intact. Record review of R328's medication administration record documents in part that R328 has active orders for Ampicillin 12 g in 0.9% normal saline Use 12 gram intravenously one time a day for sepsis until 01/20/2025 23:59 ampicillin 12g in 0.9% NSS 500ml daily in continuous pump, and Vancomycin HCl Intravenous Solution 1500 MG/300ML (Vancomycin HCl) Use 1500 mg intravenously every 8 hours for Osteomyelitis until…

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 their policy and procedure to maintain air temperatures between 68 degrees Fahrenheit (F) to 79 degrees F within resident rooms and common areas in winter months which affected R2 and has the potential to affect all 82 residents in the facility. Findings include: R2's admission Record documents, in part, that R2's diagnoses include dementia and epilepsy. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that the Staff Assessment for Mental Status was conducted due to R2 rarely being understood with R2's cognitive skills for daily decision making as moderately impaired with short and long term memory problems. On 12/9/24 at 12:48 pm, when asked how often does V3 (Maintenance Director) check the air temperatures in the facility. V3 stated, I am supposed to do it every day. I cannot every day. There's just no time. I will do when someone is complaining. On 12/9/24 at 12:55 pm, this surveyor and V3 performed an…

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

Based on observation, interview, and record review the facility failed to ensure that the medication cart and treatment carts were locked when not in use and when not in visual proximity of the nurse to prevent tampering and accidental hazard. This failure has the potential to affect all the resident on the 1st, 2nd and 3rd floor of the facility. Findings include: On 08/14/24 at 11:24am, the 3rd floor medication cart was noted unlocked and not within the visual proximity of the V7 RN (Registered Nurse).cAt 11:25pm, V7 stated that the facility protocol/ policy is that the medication cart should be locked when not in use or when the nurse is not around to see the cart. At 11:35am, the nurse's station door was noted left wide open with a medication left unlocked and no nurse in attendance in the nursing station. When the surveyor brought this observation to V9's LPN (Licensed Practical Nurse) attention and asked about the facility policy/protocol on medication storage and medication cart, V9 stated that the medication should be stored in a locked medication cart. V9 stated I (V9) just…

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 current standards of infection control practices on use of gloves. This failure has the potential to affect all the 24-resident residing on the 3rd floor of the facility. Findings include: On 08/14/24 at 11:22am, V7 RN (Registered Nurse) was observed on the 3rd floor walking around with gloved hands. V7 stated I was just trying to get to the nurse's station so I (V7) can take them off and wash my hands. When asked about the facility policy/protocol for infection prevention and control, V7 stated gloves are not to be worn in the hallways, I (V7) should have removed them after I (V7) used it. At 11:36am, surveyor noted R6 walk out of the isolation room and without hand hygiene went straight to the clean cart with supplies in the hallway touching the supplies and taking out supplies. When V9 LPN (Licensed Practical Nurse) was made aware of the observation. V9 stated that the clean cart is usually placed near the nurse's station. V9 stated R6 is on contact precaution isolation for MRSA in the right wound…

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 call light is within reach for two residents (R2 and R3) in the sample reviewed for call lights. This failure affected R2 and R3 whose call light were not within reach while in bed. Findings include: On 08/14/24 at 10:50am, R2 observed in bed with call light not within reach. R2 was asking for help from the surveyor and when asked to use the call light to call the facility staff R2 stated I don't know where it is. R2's call light was observed on the floor not within R2's reach. When this observation was showed to V4 LPN (Licensed Practical Nurse) assigned to R2 and was asked about the facility policy and protocol. V4 stated the residents should have the call light within their reach. At 11: 05am, R3 noted in bed shouting for help with incontinent care call light noted on the bedside floor. V5 and V6 CNA (Certified Nurse's Aides) stated rounds are made every two hours and call lights should be within the resident reach in case they need help. At 12:21pm, V2 (Director of Nursing) stated call lights…

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 personal hygiene and incontinent care was provided for two residents R2 and R3 who rely on staff assistance with ADLs (Activity of Daily living). This failure affected R2 and R3 who were not rendered incontinent care in a timely manner, and this has the potential to affect all the 20 residents residing on the 4th floor. Findings include: On 08/14/24 at 10:50am, R2 observed in bed all covered up. R2 asked whether the surveyor will help in cleaning R2 up because R2 is wet and had stool although R2 was trying not to let it out for a long time. R2 stated I also a have migraine headache and it's hurting bad since during the night. V4 LPN was made aware and V4 stated the CNA's (Certified Nurse's Aides) are busy and have not gotten to R2 yet but V4 will get another (CNA) to help. At 10:58am, V5 (CNA) assigned to R2 stated she has been busy taking care of other resident and has not assisted R2 in incontinent care. When the surveyor…

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 accurately log dish machine temperatures. This failure has the potential to affect all 66 residents who receive oral nutrition in the facility. Findings include: On 1/22/24 at 10:00 am surveyor reviewed the dishwashing temperature log with V26 (Dietary Manager) and observed lunch temperature prefilled with a temperature of 165 (wash) and dinner temperature prefilled with a temperature of 185 (final). Prefilled temperature for 1/23/24 for dinner 165 (wash) and 185 (final). Prefilled temperature for 1/24/24 for dinner 185 (wash) and 185 (final). On 1/22/24 at 10:15 am, Surveyor inquired to V26 (Dietary Director) why is temperatures recorded on the log for lunch and dinner for 1/22/24, 1/23/23; and 1/24/24 for dinner? V26 stated that the log sheet should be filled out after the wash cycle and final rinse is complete. I do not know why it was already filled out. On 1/22/24 at 10:20 am, Surveyor inquired to V29 (Dishwasher), why was lunch and dinner prefilled on the dishwashing temperature log? V29 (Dishwasher)…

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 assess a resident's ability to safely self-administer medications and/or treatments. This failure affected 1 (R57) resident reviewed for self-administration of medication and has the potential to affect 7 ambulatory residents on the 2nd floor in the total sample of 41 residents. Findings include: The (undated) Ambulatory residents list on the 2nd floor documented that there were 7 ambulatory residents on the 2nd floor. On 01/22/24 at 10:36 AM, there was a tube of cortisone lotion in R57's room. This observation was pointed out to V5 (Registered Nurse). V5 stated I (V5) don't think she (R57) has an order to have the cortisone lotion at bedside. Let me (V5) check her (R57) record. On 01/22/24 at 10:43 AM, V5 stated I (V5) have her (R57) cortisone in the cart. I (V5) don't know why she (R57) has another cortisone lotion in her (R57) room. On 01/23/2024 at 3:02PM, V2 (Director of Nursing) stated there should be no medications at bedside for patient safety and facility safety. Medications used for treatment should…

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 four residents (R5 R6, R7, and R28) who depend on staff assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected four of 41 residents reviewed for ADL care and shaving. Findings include: On 01/22/24 at 10:30 am, R5 was observed in R5's room in bed awake and alert with facial hair to R5's lip and chin. When R5 was asked regarding R5 being shaved at the facility, R5 stated, They (referring to staff) don't trust me with a razor, so they give me a razor whenever they are up to it. When R5 was asked regarding if R5 wanted to be shaved R5 stated, Well yes, if I (R5) had a razor. On 01/22/24 at 10:35 am, R28 was observed in R28's room in bed awake and alert with facial hair (beard) to R28's lip and chin. When R28 was asked regarding R28 being shaved at the facility, R28 stated, I (R28) do not know how long it's been since I've been shaved. They (referring to the staff) shave me whenever they…

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 medication carts are secured and locked while unattended. These failures have the potential to affect 46 residents residing on the second and third floors. Findings include: On 1/23/24 at 9:40am, with V33 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple employees and residents were seen passing by the medication cart while V33 was preparing medications to administer to R314. V33 stated that the medication cart contains all 21 resident's medications on the second floor. V33 went into R314's room to administer her (R314) medications and left the medication cart in the hallway, unlocked and unattended. While V33 was administering medications to R314, the medication cart was not visible to V33. When asked why the medication cart should be locked when unattended, V33 stated that anyone can come and open the medication cart. On 1/23/24 at 10:20am, with V4 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple…

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 ensure staff donned and doffed appropriate PPE (personal protective equipment) prior to entering and before exiting Droplet and Contact Precaution rooms in an effort to prevent the spread of infectious microorganism including COVID-19. This failure affected 2 (R4 and R30) residents reviewed for communicable disease and have the potential to affect all 25 residents on the 3rd floor. Findings include: The (01/22/2024) facility census documented that there were 25 residents on 3rd floor. On 01/22/2024 at 1:04pm, there was a sign posted by R30's door Droplet & Contact Precautions. V6 (Housekeeping) was wearing a surgical mask and gloves. V6 entered R30's room without donning gown and Face shield, wiped R30's bathroom; exited R30's room without doffing the gloves, got the mop from the housekeeping cart and reentered R30's room without changing gloves, and without donning gown, N95 mask and Face shield. V6 mopped R30's bathroom and floor; exited R30's room without doffing gloves, placed mop head in the bucket.…

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 device was within reach for one resident (R114). This failure has the potential to affect one resident out of a sample size of 41 residents. Findings Include: R114 has a diagnosis of but not limited to Urinary Tract Infection, Paroxysmal Atrial Fibrillation, Depression, and Abnormalities of Gait. R114 has a Brief Interview of Mental Status score of 99. R114's Minimum Data Set, dated [DATE] documents Impairment on both sides for lower extremity. On 1/22/2024 at 10:58am surveyor observed R114 sitting in a chair that was across from his bed where the call light would not reach. Surveyor inquired if R114 could reach the call light and R114 said no. On 1/22/2024 at 11:01am V3 (RN) stated it (call light device) is here, but I don't think he (R114) can reach it and R114 does understand the purpose and how to use the call light. On 1/24/2024 at 1:25pm V2 (DON) stated the call light device should be anywhere the patient is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents lying on a low air loss mattress were not over layered with sheets, incontinence briefs and/or pads for 2 residents (R9 and R41); and failed to ensure the low air loss mattress was set based on the resident weight for 1 resident (R23). These failures affected 3 (R9, R23, and R41) residents reviewed for prevention of pressure injury/ulcer in the total sample of 41 residents. Findings include: On 01/22/24 at 10:14am, R23 was lying on low air loss mattress. The setting was at 300 pounds. This observation was pointed out to V5 (Registered Nurse). V5 stated the setting is at 300lbs; the setting of the low air loss mattress is based on the resident's weight. I (V5) don't know why its set like that. On 01/23/2024 at 2:36pm, V37 (Treatment Nurse) stated the low air loss mattress is used to prevent pressure injury. The setting is always based on the resident's weight. We (facility) need to have the correct firmness of 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 observations, interviews and record reviews, the facility failed to check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate temperature in a resident's personal refrigerator. These failures affected 3 (R10, R42 and R57) residents reviewed for personal food in the total sample of 41 residents. Findings include: On 01/22/24 at 10:20 AM, there was a refrigerator inside R10's room. This surveyor requested V5 (Registered Nurse) to check the refrigerator. V5 opened the refrigerator and checked the temperature and it stated temperature is 48F. Surveyor requested to check for temperature log, V5 checked for the temperature log and stated there is no temperature log. Inside R10's refrigerator were a tub of yogurt, cartons of milk and juice. On 01/22/24 at 10:36 AM, there was a refrigerator inside R57's room. This surveyor requested V5 to check the refrigerator. V5 stated the temperature is 42F. There are bottles of boost and soda. There is no temperature log. On 01/23/2024 at 3:04pm, V2 (Director of Nursing) stated we have…

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 kitchen was free of expired food products and failed to ensure the kitchen was free from potential contamination. These failures have the potential to effect 71 residents that take food by mouth of 72 residents residing in the facility. Findings include: On 3/14/23, Surveyor observed an opened bag of frozen french fries in a freezer with a manufacturer expiration date of 8/4/22 and an opened date of 1/29/23 written on the bag by staff. On 3/14/23, Surveyor observed 4 containers of basil pesto in a freezer with manufacturer best by date of 1/7/23. On 3/14/23, Surveyor observed 6 plastic containers of jellied cranberry sauce in the dry storage area with manufacturer expiration date of 5/8/21. On 3/14/23 at 10:15 AM, V35 (Dining Service Director) stated Staff should check the expiration dates before opening items. On 3/14/23, Surveyor observed V37 (Field Tech with pest control) enter the kitchen dishwasher area with mask worn below the chin, not covering mouth or nose, and wearing a winter skull hat.…

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

Based on observation, interviews, and record reviews, the facility failed to follow the Covid-19 Vaccine Policy for Staff by not including in the Staff Matrix multiple Certified Nursing Assistants vaccination status working through agency agreement performing direct care to residents. These failures have the potential to affect 72 residents living in the facility in preventing the risk of Covid-19 infections. Findings include: On 03/15/2023 at 11:58 AM, V3 (Infection Preventionist / Assistant Director of Nursing) submitted a Matrix for staff vaccination status. V3 was asked if all staff performing direct care to residents are included on the Matrix? V3 said, Yes, all staff are included. Therapist that are working with residents are on the last part. Upon full review of the Matrix there was no Nursing Staff that was working directly with the residents listed on the Matrix. V3 was asked about the lack of nursing staff from the agency working on the floor? And that on 03/14/2023 V10 (Certified Nursing Assistant / Agency) was seen working direct care to residents. V13 said, Oh, I missed…

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 provide an accurate person-centered care plan for ADL (Activities of Daily Living) related to transfers for 2 out of 19 residents reviewed for accuracy of care plan. This failure has the potential for facility staff to follow incorrect care plan interventions related to transfers. Findings include: On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped working. V10 went to the door with her head outside of the door looking side to side for staff but was not able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took the remote control of the lift, but no matter how many times V10 pushed the button to make R63 move down, the lift does not respond. Writer then went to the Nurse's Station and informed V11…

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 their safety protocols on transfers of 2 out of 4 residents (R63 and R11) of the the total sample of 19 residents reviewed for hazard and accidents transferring 2 residents with mechanical lifts (sit-to-stand and Hoyer) with only 1 person performing the transfers. These failures have resulted in 1 resident (R63) hanging suspended on the sit-to-stand lift complaining of pain; and another resident (R11) having the potential for fall. Findings include: On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped working. V10 went to the door with her head outside of the door looking side to side for staff but was not able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took the remote control of the lift,…

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 account for the correct number of narcotics in the residents individual controlled substance record for 1 (R67) out of 3 residents reviewed for pharmaceutical services in a sample of 19. Findings include: On 03/15/23 at 11:38 AM, surveyor counted narcotics with V11 (Registered Nurse) on the 3rd floor medication cart. While counting with V11, R67's Lorazepam every 4 hours as needed pill box has 14 pills and 32 pills in R67's Lorazepam every 6 hours scheduled pill box. On 03/15/2023 at 11:39 AM, surveyor reviewed the Individual control substance record for R67's Lorazepam with V11. R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4 PRN (every 4 hours as needed) documents in part: 2/16 amount remaining 19. 2/17 amount remaining 18 with no nurse's signature. 2/18 amount remaining 1 with V11's signature. R67's Narcotics Individual Controlled Substance Record for Lorazepam scheduled Q6 (every 6 hours) documents in part: 3/15 amount remaining 30 pills remaining. 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 observation, interview, and record review, the facility failed to follow their policy to ensure the narcotics in the refrigerator are stored in a separate locked container separate from any non-controlled medications for 2 medication refrigerators reviewed for medication storage and labeling. Findings include: On 03/15/2023 at 12:25 PM, surveyor observed and reviewed the 4th floor refrigerator with medications. Surveyor observed the medication refrigerator is in the nurse's station where the nurse sits to document. There is no locked door to go into the nurse's station. Surveyor found liquid lorazepam, and liquid morphine, not in a separate lock box, and with all other medications such as insulin. There was an empty separate brown lock box was broken and not locking. On 03/15/2023 at 12:27 PM, V34 (Registered Nurse) stated that he (V34) is the nurse for all of the 4th floor. V34 stated there is no separate locked medication room. V34 stated the refrigerator is next to them where the nurse sits in the nurse's station. V34 stated the narcotics should be behind a double lock…

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.