Central Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their fall clinical protocol for one (R1) resident out of four residents reviewed for falls in a total sample of five residents. Findings include: On 04/22/2025, at 11:38 AM, V3 (Registered Nurse/Nursing supervisor) states that upon checking on R1 at 9:30 AM, he was eating breakfast by himself. Staff did the rounds again. Staff has the 72 hours post fall procedure, because he fell at 6:30 AM, I think. We are going to recheck again what happened. V2 stated when I saw him around 10:00 am, I (V3) saw that his (R1s) left side was getting a little bit weaker, because that's his strong side. His right-side is usually the weak side. V3 stated, I (V3) checked his vital signs immediately. I think R1s oxygen saturation became low. V3 stated I (V3) documented in the electronic medical record, in the nurses' note, and documented the vital signs. I (V3) asked someone to be with R1 and I called 911. V3 stated I (V3) informed the doctor and the daughter 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (R2) during incontinence care out of three residents reviewed for resident rights. Findings include: On 1/14/2025, at 9:53 AM, V6 (Laundry and housekeeping) stepping out of the laundry room. This surveyor asked V6 where the clean towels are. V6 showed this surveyor the folding laundry room. There were two towels in the folding laundry room. On 1/15/2025, at 2:29 PM, R2's room door closed with small linen cart in front of the room, no washcloth towels or regular towels noted. R2 agreed for this surveyor to observe V11 (Certified Nursing Assistant) providing patient care to R2. R2 lying on her bed, and in no apparent distress. V11 seen throwing one soiled towel in a clear bag. R2 is turned to her left side, facing the window, but able to turn her head to view the front end of her bed. V11 walked outside of R2's door and approached the small linen cart. R2 states they are always running out of towels 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 record reviews, the facility failed to provide timely nail trimming and care for one resident (R1) in the sample of three residents (R1, R2, R3) when reviewed for activities of daily living (ADL) care. Findings include: R1's admission Record documents, in part, diagnoses of moderate intellectual disabilities, acute kidney failure, major depressive disorder, hypertensive heart disease without failure, anxiety disorder, schizoaffective disorder, and scabies. R1's Minimum Data Set (MDS) dated [DATE], documents in part a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. R1's Functional Abilities and Goals for Self-Care documents, in part, that for shower/bathe self is coded as partial/moderate assistance where helper does less than half the effort, and for personal hygiene as the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands is coded as supervision or…

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 implement fall prevention interventions for high fall risk residents; failed to supervise high fall risk residents; and failed to perform quarterly fall risk assessments which affected two residents (R2 and R3) in the sample of three residents when reviewed for improper nursing care. Findings include: 1) R2's admission Record documents, in part, diagnoses of Parkinson's disease without dyskinesia, hemiplegia and hemiparesis following cerebral vascular accident (CVA) affecting right dominant side chronic obstructive pulmonary disease, heart failure, peripheral vascular disease, hypertensive heart disease, schizoaffective disorder, anxiety disorder, Alzheimer's disease, psychosis, dementia, osteoarthritis, seizures, mood disorders, anemia, syncope and collapse, and gastritis without bleeding. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score is not conducted due to R2…

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 review of records, facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness for all the residents in the facility. Findings include: 08/07/24 10:04 AM, surveyor observed V9 (Head cook) pureeing veal patty. After pureeing the veal patty, V9 asked V8 to wash the blender pitcher and the rubber spatula. V8 washed the blender pitcher and rubber spatula in the washer container, and then moved the pitcher and spatula to the rinse container and then the sanitizing compartment. The blender pitcher and spatula were moved to the sanitizing compartment at 10:17 AM. Another Kitchen aide moved the blender pitcher and spatula to the table at 10:19 AM. At 10:20 AM, V9 (cook) used the blender pitcher and spatula to puree the pasta. There was still sanitizer dripping in blender pitcher and spatula. V8 stated that you have to wait for the blender pitcher to dry completely before using it to puree another dish otherwise that could contaminate the food. Facility's Manual sanitizing in three-compartment sink…

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 review of records the facility failed to ensure urinary catheter bag of 1 resident (R478) maintains in sterile position not in contact on the floor as per policy. The facility failed to ensure linens that are being folded do not touch the floor and to maintain clean and sanitary condition of blower equipment that circulates air in the clean linen room per their policy. The facility failed to document in their infection prevention policies and procedures that review date done at least annually. These failures have the following effects: Potential to affect 1 resident (R478) prevention of urinary tract infection (UTI) to reoccur. Potential to contaminate and affect all 180 residents that uses linens in the facility. Potential to affect all 180 residents in implementing policies and procedure that are outdated and not currently in accordance with national standard. Findings include: On 08/06/2024 at 11:54 AM, R478 was seen sleeping on the bed with urinary catheter connected and catheter bag lying flat on the floor. V2 (Director of Nursing) made…

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 professional standards of medication administration documentation after administration of medication to prevent medication errors for 19 of 19 (R4, R7, R8, R32, R50, R59, R65, R67, R82, R83, R91, R92, R101, R109, R126, R137, R142, R167, and R172) residents reviewed for medication pass. This failure affected 19 residents whose medications were not documented in a timely manner. Findings include: On 08/07/2024 at 8:25AM, surveyor located on the first floor of the facility with V15 (RN/Registered Nurse). V15 states she has completed her 9:00AM medication pass. V15 stated she began her medication pass at approximately 6:45AM today for resident's 9:00AM scheduled medications. V15 states she is responsible for medication cart #2 on the first floor of the facility. On 08/07/2024 at 9:05AM, surveyor observed that V15 is no longer located at the first-floor nurses' station and the hard chart MAR (medication administration record) for medication cart #2 is no longer on top of medication cart #2. Surveyor inquires…

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 2 out of 16 shifts. This failure has the potential to affect 45 residents. Findings include: On 08/06/2024 at 12:21PM, surveyor located on the fourth floor of the facility with V14 (LPN/Licensed Practical Nurse). V14 was responsible for the 4th floor medication cart. V14 states that she performed a narcotic drug count but did not sign the sheet. Surveyor observed that V14's signature was missing for 08/06/2024 on the Shift Change Accountability Record for Controlled Substances 7am-3pm oncoming shift. Surveyor also observed that the Shift Change Accountability Record for Controlled Substances for the 4th floor medication cart had missing signatures for the 7am-3pm oncoming and off going shift on 08/02/2024. Observation of the Shift Change Accountability Record for Controlled Substances for the month of August 2024 for the 4th floor medication cart indicated for 2 shifts in August 2024, nurses had not counted and documented…

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 a.) ensure medications were locked and secured while unattended and b.) remove and discard expired house stock medication in three of six medication carts reviewed for medication labeling and storage. These failures have the potential to affect 40 residents residing in the facility. Findings Include: On 08/06/2024 at 1:55PM, surveyor located on the second floor of the facility. V13 (Licensed Practical Nurse) observed leaving medication cart (identified as medication cart #2) unlocked and unattended. V13 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V13 states there is potential for the residents to overdose, or residents can self-administer another resident's medication and it would be a medication error. On 08/07/2024 at approximately 9:00AM, surveyor located on the first floor of the facility with V15 (Registered Nurse/RN). Surveyor observed a house stock medication (identified as Vitamin B6) available for resident use inside of the first…

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 refer two (R14, R33) of eight residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review in a sample of 35. Findings include: R33's current face sheet documents R33 is a [AGE] year-old individual with medical diagnoses that include but not limited to: paranoid schizophrenia, major depressive disorder, single episode, unspecified, depressive disorder not elsewhere classified. R33's face sheet further documents R33's medical diagnosis dated 09/17/2018 as paranoid schizophrenia, 11/12/2014 as depressive disorder not elsewhere classified, and unspecified schizophrenia unspecified condition. R33's initial admission date is documented as 11/12/2014, and admission dated as 09/17/2015. Record review documents R33 has an initial level I PASRR (preadmission screening and resident review) screening dated 03/04/2014. There is no documentation showing R33 was screened for level II PASRR. On 08/08/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide toenail care for two (R1, R143) residents reviewed for ADL (activities of daily living) care in a total sample of 35 residents reviewed. Findings include: On 08/06/2024 at 11:18AM, R1 observed lying in bed inside of her room without any socks on. Surveyor observed R1's toenails were long and overgrown on both of her feet. R1's toenail on her right great toe and left great toe observed overgrown to approximately ½ inch past the tip of R1's great toes. R1's other toes on both of her feet observed overgrown to approximately ¼ past the tip of R1's toes. R1 states she would like to have her toenails cut because it has been more than two months since she had them cut in the facility. R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, and mild cognitive impairment. R1's MDS/Minimum Data…

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 records review, the facility failed to address behaviors which could endanger one (R92) health of eight residents reviewed in a sample of 35. Findings include: R92 current face sheet documents R92 is an [AGE] year-old individual with medical diagnoses that include but not limited to: unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified, unspecified osteoarthritis, unspecified site. R92's Brief Interview for Mental Status (BIMS) dated July 5, 2024, as 3/15, indicating R92 has severe cognitive impairment. R92's Functional Abilities documents R92 id dependent on eating, oral hygiene, toileting/bathe self, upper/lower body dressing, putting on/off footwear, personal hygiene and need 0r needs maximal/substantial assistance rolling left and right. On 08/06/2024 at 12:40pm, surveyor observed R92 in his room lying in bed, with bed flat and in low position. R92 was observed chewing on something in his mouth. 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 review of records and interview the facility failed to determine, offer and document 2 residents (R481, R157) immunization (influenza and pneumococcal) status as per policy. Failed to review policy and procedure related to immunizations. These failures have the potential to affect 2 residents (R481, R157) in minimizing the risk of acquiring, transmitting, or complications from influenza or Pneumococcal pneumonia. Findings include: R481 and R157 were without record of any immunization since admission in the resident electronic record under immunization tab. On 08/07/2024 at 11:04 AM, V7 (Infection Preventionist/Registered Nurse) during review of infection control and prevention related to immunization of residents. V7 stated that immunization of all residents are documented on the immunization tab on the electronic record. V7 stated that he has to look it up on other documentation. R157 who was admitted on [DATE]. V7 stated that again R157's immunization details should have been recorded in 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 use standard precautions and perform proper hand washing/hand hygiene while providing incontinence care to residents to prevent spread of infection or cross contamination. These failures could potentially affect 11 residents assigned to V4 as of census dated 7/21/24. The findings include: R1's face sheet documented admission date on 5/31/2023 with diagnoses not limited to Primary osteoarthritis right shoulder, Type 2 diabetes mellitus with unspecified complications, Heart failure, Anxiety disorder, Bilateral primary osteoarthritis of knee, Anemia, Enlarged lymph nodes, Gastro-esophageal reflux disease without esophagitis, Hypertensive heart disease with heart failure, Chronic embolism and thrombosis of unspecified vein, Obesity. R2's face sheet documented admission date on 12/3/2020 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, 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.

Based on observation, interview and record review, the facility failed to ensure incontinence care was provided in a timely manner for 2 (R1 and R2) residents who needed assistance with toileting. This failure affected 2 (R1 and R2) residents reviewed for improper nursing care in a sample of 4. The findings include: R2's face sheet documented admission date on 12/3/2020 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, Type 2 diabetes mellitus with unspecified complications, Epilepsy, Other muscle spasm, Hyperlipidemia, Hypertensive heart disease without heart failure, Constipation, Long term (current) use of oral hypoglycemic drugs, Vitamin d deficiency, , Muscle weakness (generalized), Unspecified sequelae of cerebral infarction, Other abnormalities of gait and mobility. R2's MDS (minimum data set) dated 5/19/2024 showed R2's cognition was intact. She (R2) needs partial / moderate assistance with eating; Dependent…

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 call light protocol to ensure residents always have accessibility to the call light for 6 [R1, R2, R3, R4, R5, R6,] of residents reviewed for call lights. Findings Include: R1 clinical record indicates in part; R1 was admitted with the following medical diagnoses of primary osteoarthritis, right shoulder, anxiety disorder, bilateral primary osteoarthritis of knee, hypertensive heart disease with heart failure, chronic embolism and thrombosis of unspecified vein, and obesity. R1's Minimum data set [MDS] indicates the following: section [C] dated 3/8/24- R1's cognition score [13] indicates R1 is cognitively intact, section [GG] dated 3/8/24- R1 is dependent (Staff does all the effort, resident does none of the effort to complete the activity, two or more helpers is required to complete the task. R1's care plan dated 6/1/23- R1's call light to be reach. On 6/29/24 at 10:20 AM, R1 stated, There are plenty of times whenever I 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy to ensure maintenance of skin integrity related to incontinence and failed to immediately report skin alterations that are identified to the nurse for further assessment. The facility also failed to address skin alterations in resident's plan of care. These failures could potentially affect 1 (R2) of 3 residents reviewed for improper nursing care. The findings include: R2's health record documented admission date of 5/31/2023 with diagnoses not limited to Primary osteoarthritis right shoulder, Type 2 diabetes mellitus with unspecified complications, Heart failure, Anxiety disorder, Bilateral primary osteoarthritis of knee, Anemia, Enlarged lymph nodes, Gastro-esophageal reflux disease without esophagitis, Hypertensive heart disease with heart failure, Chronic embolism and thrombosis of unspecified vein, Obesity. On 11/21/23 At 1:05 pm R2 was lying in bed, on moderate high back rest, alert, and oriented times/x 3,…

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 ensure that documentation of medication administration is recorded on the Medication Administration Record (MAR) and includes initials of the licensed nurse who administered the medication. This failure could potentially affect 3 (R2, R3, R4) residents reviewed for medication administration. The findings include: On 11/21/23 at 1:05 pm R2 lying in bed, on moderate high back rest, alert, and oriented x 3, verbally responsive. R2 stated that if agency staff is working, she doesn't get all her medications. V7 (Registered Nurse) said that she has been working in the facility for 15 years. R2 stated that facility is still using paper MAR (Medication Administration Record) and should be initialed after giving medications to resident. On 11/22/23 at 10:54 am V2 (Director of Nursing / DON) stated that nurses are supposed to give medications on time and follow doctor's order. V2 stated that facility is still using paper MAR (Medication Administration Record) and nurses need to sign the MAR after giving…

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

Based on observation, interview, and record review, the facility failed to ensure staff doffed potentially contaminated gloves prior to handling clean linens and failed to ensure staff clothing was not touching dirty and clean linens to prevent the spread of infectious microorganisms. These failures have the potential to affect all 197 residents in the facility. Findings include: On 07/10/2023 at 2:53pm, V3 (Assistant Administrator) and V23 (Laundry Aide) were in the laundry room. V23 was wearing gloves and placing dirty linens in the washing machine. V23's clothing was touching the dirty linens. After placing the dirty linens in the washing machine, V23 placed clean linens into dryer #2 without changing V23's gloves. The clean linens were touching V23's clothing. At this time, V3 was observed hinting to V23 to stop what V23 was doing with a hand gesture. V3 stated, V23 touched the dirty linens and clean linens with the same gloves and from dirty to clean linens is a cross contamination. V23 is also not wearing a gown and the dirty linens and clean linens touched V23's clothes. 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.

A. Based on observation, interview and record review, the facility failed to ensure the circuit breaker boxes were locked, and failed to ensure the padlocks used to lock the circuit breaker boxes were functioning to provide a safe environment to the residents. This failure has the potential to affect all 197 residents who reside in the facility. B. Based on observation, interview and record review, the facility failed to ensure the drying machines lint screens were free of lint debris build-up. This failure has the potential to affect all 197 residents who reside in the facility. Findings include: a. On 07/10/2023 at 2:30pm, three circuit breaker boxes close to the Kitchen Main door were not locked. The circuit breaker boxes on the left and in the middle have padlocks but were not locked and the circuit breaker box on the right had no padlock. On 07/10/2023 at 2:36pm, V24, Maintenance Supervisor stated, these are circuit breakers (pointing to the three circuit breaker boxes), and their purpose is to prevent fire and electrical shortages. V24 stated V25, Maintenance is fixing…

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

Based on interview and record review, the facility failed to perform nurse shift to shift counts of controlled substances which has the potential to affect 55 residents residing on the second floor when reviewed for medication labeling and storage. Findings include: On 7/10/23 at 1:22 pm, V22 (Agency Licensed Practical Nurse, LPN) completed a controlled substance audit. Upon reviewing the current Shift Change Accountability Record for Controlled Substances, V22 verified the record as the current record for the month of July 2023 with the last entry on Day 10 (7/10/23) on the 7:00 am to 3:00 pm shift. This record documents the following: 7/3/23 with empty space on 7:00 am to 3:00 pm shift off going nurse (only one nurse initials signature); 7/4/23 with empty space on 7:00 am to 3:00 pm shift and 11:00 pm to 7:00 am shift off going nurses (only one nurse initials signature); 7/8/23 with empty space on 7:00 am to 3:00 pm shift off going nurse (only one nurse initials signature); 7/9/23 with empty space on 7:00 am to 3:00 pm shift off going nurse (only one nurse initials signature). 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 store an oral antibiotic medication with a pharmacy label; failed to lock medication cabinets storing emergency medications; failed to maintain an emergency medication box with a seal; and failed to store an emergency intravenous fluids (IV) medication box that was not expired. These failures have the potential to affect all 55 residents residing on the 2nd floor when reviewed for medication labeling and storage. Findings include: On [DATE] at 1:22 pm, V22 (Agency Licensed Practical Nurse, LPN) observed with the medication cart keys on V22's person. V22 stated, there is one medication cart for the 2nd floor. V22 opened medication cart for review for this surveyor, and this surveyor observed the following: Top drawer of 2nd floor medication cart: 3 capsules of Cephalexin 250 mg in manufacturer packaging with no packaging (plastic bag) or no labeling from the pharmacy. When asked V22 who does this Cephalexin 3 capsules belong to, V22 stated…

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

Based on interview and record review the facility failed to document the code status for one resident (R59) in the electronic and paper chart. This failure has the potential to affect one resident (R59) out of a sample size of 54. Findings include: R59 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Paranoid Schizophrenia, and Anxiety Disorder. On 7/09/2023 at 1:09pm R59's profile screen and Physician's orders in R59's electronic medical record were reviewed and did not list R59's code status or Advance Directive. On 07/11/23 at about 11:00am R59's paper face sheet and Physician's Order Sheet that was blank were reviewed and did not indicate the R59's code status. On 7/10/2023 at 10:23am V29 Licensed Practical Nurse (LPN) stated, she (V29) checks the computer for the resident's Code Status and that it should be listed on the face sheet. On 7/10/2023 at 10:25am V3 (Assistant Administrator) stated, there is a Do Not Resuscitate (DNR) binder for each floor and if a resident is a DNR there would be an orange sticker on the outside of the chart…

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 a Low Air Loss Mattress was implemented according to manufacturer recommendations for two (R22, R398) residents reviewed for prevention and treatment of pressure injury/ulcer in the sample of 54 residents. Findings include: 1. R22's Medical Record document R22's diagnoses including of Chronic Obstructive Pulmonary Disease, Hypertension, Depression, Atherosclerotic Heart Disease, Schizoaffective Disorder, Anxiety, and Dementia. On 7/9/23 at 11:00 am, R22 was laying on a low air loss mattress with multiple layers of linen between R22 and the low air loss mattress including a fitted sheet, a folded bath blanket, an incontinent pad, and an incontinent brief. On 7/11/23 at 11:30am R22 was laying on a low air loss mattress with multiple layers that consisted of a fitted sheet, a folded bath blanket, a folded flat sheet, an incontinent pad, and an incontinent brief. On 7/11/12 at 11:40 am, V21 RN (Registered Nurse) in R22's room stated, R22 should just have a flat sheet on the air loss mattress. The purpose…

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 a written consent was obtained for a psychotropic medication prior to its administration. This failure affects one resident (R60) in the sample of 54 residents. Findings include: R60's admission Record documents, diagnoses including, Major Depressive Disorder, Bipolar Disorder, Schizophrenia, Insomnia, Unspecified Psychosis, and Delusion Disorders. R60's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R60 is cognitively intact. In Section N of R60's MDS, Medications Received: for antidepressant medications is documented as 7 days a week. R60's Physicians Order Sheet (POS) documents an active order with start date of 09/29/22 for Trazodone 50 mg (milligrams) one tablet by mouth every day at bedtime. On 7/11/23, V2 (Director of Nursing, DON) provided R60's psychotropic medication consent for Trazodone 50 mg QHS (at bedtime) signed by R60 and with a date of 02/29/23. 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 policy related to the following: label and date food stored in bins, follow first-in-first out on cans on the shelves and removed dented can products out of Dry Storage Room; Failed to cover, label and date onions, carrots, cabbages, and lettuce in walk-in cooler; Failed to discard expired dairy product inside walk-in cooler; Failed to date multiple bread to determine when it still good for consumption; Failed to maintain dishwasher on working condition. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet. Findings include: On 05/31/2022 at 10:55 AM. With V11 (Dietary Director) near walk-in cooler there are 2 shelves full of bread mostly loaves. None of the bread was labeled and dated as to receive and best of date. V11 stated that she has knowledge that some of the bread was delivered yesterday. And dietary staff should know which bread to use first. When asked how staff should determine which bread should be used first based on delivery date. 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 observation, interview and record review the facility failed to maintain garbage disposal contained in designated containers. Leaving trash or garbage overflowing on the floor and other areas of the Garbage Room. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet. Findings include: On 05/31/2022 at 10:55 AM. With V11 (Dietary Director), facility have a Garbage Room that has a chute with 2 dumpster-like garbage containers/receptacles placed together directly receiving garbage from the chute. In the containers were full of garbage some contained inside the bags, and some are not. Both containers were overflowing with garbage because it cannot accommodate due to its capacity. A lot of garbage was seen on the floor and all over the areas inside the room. V11 said, I don't know why it is overflowing with garbage. But I know it attracts pest if it is not inside the container. This are just the garbage for breakfast. And I don't know how lunch garbage will fit in that container. All floors disposed their garbage on that chute…

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 record review and interview the facility failed to follow Influenza and Pneumococcal Immunization policy related to determining and providing education for 6 out of 8 residents for Influenza Vaccination (R442, R191, R441, R192, R178, and R11) and 6 out 8 for Pneumococcal Vaccination (R191, R441, R192, R178, R177 and R11) reviewed for Influenza and Pneumococcal Immunization. These failures have the potential to affect 6 out of 8 residents for Influenza Vaccination (R442, R191, R441, R192, R178, and R11) and 6 out 8 for Pneumococcal Vaccination (R191, R441, R192, R178, R177 and R11) to have opportunity to receive benefits of Influenza and Pneumococcal Vaccinations. Findings include: Sample residents were selected for review of immunizations (Covid-19, Influenza and Pneumococcal). R442 received pneumococcal vaccination on 5/3/2018 and Covid-19 on 1/1/2021 and 2/8/2021, no influenza vaccinations on record: R191 immunization report no data R441 immunization report no data R192 immunization report no data R178 immunization report no data Sample was extended for 3 more residents:…

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 record review and interview the facility failed to Covid-19 Vaccination policy related to determining and providing education for 4 out of 8 residents (R191, R441, R192 and R178) reviewed for Covid-19 Immunization. These failures have the potential to affect 4 residents (R191, R441, R192 and R178) to have opportunity to receive benefits of Covid-19 Vaccination. Findings include: Sample residents was picked for review of immunizations (Covid-19, Influenza and Pneumococcal). R442 received pneumococcal vaccination on 5/3/2018 and Covid-19 on 1/1/2021 and 2/8/2021, no influenza vaccinations on record R191 immunization report no data R441 immunization report no data R192 immunization report no data R178 immunization report no data Sample was extended for 3 more residents: R177 received influenza vaccination on 9/18/21 and completed Covid-19 vaccination, no pneumococcal vaccination on record R83 received influenza vaccination on 10/04/2021, pneumococcal vaccination on 8/17/2016 and Covid-19 vaccination 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, facility failed to follow their call light policy to ensure call lights are placed within reach for w residents (R106, R119) reviewed for call lights in a final sample of 35. Findings include: On 05/31/2022 at 12:38 PM, surveyor observed R119's call light was hanging off side table few feet away from the bed. R109 stated he cannot reach the call light. On 05/31/2022 at 1:41 PM, V6 (1st Floor Charge Nurse) stated hourly rounding is done every two hours. Call light should be placed within reach of the resident. If the call light is not within reach, they cannot call for anything. On 05/31/2022 at 1:45 PM, surveyor and V6 went into R106's room. Surveyor asked V6, Can R106 reach his call light? V6 said no. V6 then moved the side table out of the way and then placed the call light in R109's hands. On 05/31/2022 at 1:50 PM, surveyor observed R119's call light behind his (R119) bed and on the floor. On 06/01/2022 at 1:55 PM, V2 (Director of Nursing) stated, hourly rounding is done every two hours. As soon as they see a call light, 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 follow Fall Prevention Policy related to supervision and/or assistance and maintaining environment free of clutter to 1 of 1 resident (R81) for a total sample of 35 residents reviewed. These failures have the potential to affect 1 resident (R81) recurrent of fall. Findings include: R81 was [AGE] years old, medical diagnosis includes unsteadiness of feet, abnormalities of gait and mobility and weakness. On 05/31/2022 at 10:47 AM. R81 was found inside the restroom without any supervision or assistant. Bed was without any cover, television lying flat screen facing up was turned on due to picture was showing with distortion, cane left on the bed, shoes and socks and folded walker on the floor at the right side of the bed blocking where R81 pass by accessing the bed. V4 (Licensed Practical Nurse) was informed and came to R81's room. V4 said, We don't use bed cover on R81's bed because he will just take it out. His (R81) room is always full of…

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

Based on observations, interviews and record reviews, the facility failed to follow their policy and procedure for Controlled Substances labelling and storage for 3 residents (R37, R100, R121) receiving medications from 1 of 2 medication carts reviewed. Findings include: On 5/31/22 11:09 AM, inspected medication cart on 1st floor with V4 (Licensed Practical Nurse-LPN) and noted facility's CONTROLLED DRUG RECEIPT RECORD/DISPOSION FORM had multiple empty spaces with no nurses' initials for R37, R121and R100. Dates missing nurse's initials on R37's Controlled medication form were: 5/24/2022-5pm, 5/28/2022-5pm, 5/29/2022-9am and 5pm. R37's medication missing initials was Vimpat Sol 10mg/Ml. R121's Controlled medication form for medication Pregabalin 50mg capsule was missing nurses initial for 5/30/2022-9am. Review of R100's Controlled medication form for medication Pregabalin 50mg capsule was missing nurse's initials 5/30/2022-9am. On 5/31/2022 at 11:34am, V4 (LPN) said that if the Controlled medication form is not signed, then the medication was not given, and can affect the residents…

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, facility failed to follow their policy to accurately test 3 newly admitted residents (R441, R191, and R178) for COVID-19 in a sample of 5. Findings include: Facility's COVID-19 Testing Policy documents in part: Conduct testing at the time of admission to the facility. New admissions or readmissions, when community transmission levels are substantial or high, asymptomatic new admissions and readmissions, regardless of vaccination status must be tested on admission if not tested in the past 72 hours. If negative, test again 5-7 days after admission Reviewed R441's medical record. R441 was admitted on [DATE]. Facility's COVID-19 Antigen Test (Rapid) test for R441: date unable to determine. Result: negative. Facility's COVID-19 Antigen Test (Rapid) test for R441 (5/30/2022): Result: negative. Reviewed R191's medical record. R191 was admitted on [DATE]. Facility's COVID-19 Antigen Test (Rapid) test for R191 done on 5/5/2022: Result is negative. Facility's COVID-19 Antigen Test…

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.