Chalet Living & Rehab

Based on interview and record review the facility failed to initiate an investigate immediately of an allegation of Abuse for 1 (R44) resident reviewed for abuse in a sample of 35. Findings Include:R44 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Abnormalities of Gait and Mobility, Anxiety Disorders, Depressive Episodes, Other Psychoactive Substance Abuse, Essential (Primary) Hypertension and Other Recurrent Depressive Disorders. R44's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate impairment. R44's Care Plan document in part: Focus: History of Suspected Abuse/Neglect The resident's comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase his/her susceptibility to abuse/neglect. A history and/or personality that draws him/her into unhealthy, even abusive, relationships., Behavior that might be characterized as provoking, antagonizing, disrespectful, angry, insensitive, and/or annoying, Behavioral symptoms, Difficulty in adjustment 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.

Based on interviews and record reviews, the facility failed to refer a resident (R18) who was later identified with a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 resident. Findings include: R18's 7/17/2024 Notice of PASRR (Preadmission Screening and Resident Review) Level I Screen Outcome documents in part no level II required due to R18 not having a severe mental illness, intellectual disability or related condition. There was no mental health diagnosis known or suspected and no mental health medications during the assessment. R18's admission Record documents in part an initial/original admit date of 7/25/2024. It documents in part a diagnosis of schizoaffective disorder (onset 1/17/2025). V33's (Psychiatrist) 8/08/2024 12:57 PM progress note for R18 documents in part: Diagnosis: Schizoaffective [diagnosis], depressed type. Past Psychiatric History: Schizoaffective. V33 wrote historical medication to include lithium. V33 wrote to add…

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 a resident to the appropriate state-designated authority for a new Level II PASARR evaluation and determination with known mental illness for two (R11, R14) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35 residents reviewed. Findings include: R11's Facesheet documents that R11 was admitted to the facility on [DATE] with diagnoses not limited to bipolar disorder, current episode depressed, severe, with psychotic features, post-traumatic stress disorder, chronic R11's PASARR screening dated 06/09/2024 documents that R11 does not require a level II PASARR due to no SMI (severe mental illness)/ID (intellectual disability)/ RC (related concerns). R14's face sheet documents that R14 was admitted to the facility on [DATE] with admission diagnoses not limited to Schizoaffective Disorder, Bipolar Type, Other Recurrent Depressive Disorders, Mild Neurocognitive Disorder Due to Known Physiological Condition…

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 facility smoking protocol to ensure that smoking materials are not kept by the resident in their room. This failure has the potential to affect 1 (R109) resident reviewed for smoking in a total sample of 35.Findings include:On 01/06/2026 at 11:28 AM, observed R109 lying on his bed in his room. R109 said, I smoke cigars. R109 stated he does not keep a lighter in his room and that someone outside lights his cigars for him. R109 stated that he keeps his cigars in his coat pocket. On 01/06/2026 at 11:30 PM, observed R109 walk to his closet and remove his coat. R109 then reached into his coat pocket and pulled out a box filled with brown cigarettes/cigars. R109 then reached back into his coat pocket and pulled out an additional 8-10 brown cigarettes/cigars. On 01/07/26 at 1:45 PM, V22 (Activity Aide) stated cigarettes/cigars are stored at the front desk and the residents are only allowed to have smoking materials on them when they are out at smoke break. V22 stated they are not allowed to take them (smoking…

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 accurate records of usage and accountability for controlled substances on 1 of 6 medication carts for two (R201, R154) out of seven residents reviewed for medication storage. Findings Include: On 1/6/26 at 10:21AM, during the narcotic reconciliation count with V14 (Licensed Practical Nurse/LPN) on team's one cart, R201's Controlled Drug Administration Record Sheet documented seven (7) tablets were available. R201's medication blister card had six (6) tablets of Lorazepam 2mg. R154's Controlled Drug Administration Record Sheet documented twenty-nine (29) tablets. R154's medication card had twenty-eight (28) tablets of clonazepam 1mg. On 1/6/26 at 10:33 AM, V14 (LPN) stated, I gave R201's medication around 7:45 AM or 8:00 AM, I am not sure of the exact time. I gave 154's medication around 8:15 AM. I was trying to hurry up and pass my morning medications. I know I was sign out the medication after I administered the narcotic. Om 1/6/26 at 11:10 AM, V5 (Assistant Director of Nursing) stated, After the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide nectar thickened water as ordered by the physician and failed to follow the meal ticket for one resident (R49) in a total sample of 35.Findings Include: On 01/06/2026 at 11:54 PM, during lunch meal rounds observed R49 sitting in bed eating from his lunch tray. R49 had already consumed the main entree and was in the process of beginning to eat the mashed potato and cooked cabbage. The cooked cabbage had various thickness of strands of cabbage surrounded by a thin liquid pooling around the outside edges of the cabbage. It appeared as if the liquid used in the cooking process had separated from the cabbage. The cooked cabbage was not pureed. Observed a closed container of nectar thick apple juice on R49's tray and next to his meal tray was a large pitcher filled 1/3 full of ice and water. Observed R49 continue to eat the mashed potato and the cooked cabbage. Then, observed R49 put down his fork, remove the lid from the nectar thick…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident positive with Covid-19 was quarantined for 10 days prior to cohorting with a non-positive Covid-19 resident to prevent the spread of Covid-19 virus. This failure affected 2 (R2 and R4) residents reviewed for infection control in the total sample of 4 residents. Findings include: R2's admission Record documented that R2's diagnoses (include but not limited to) attention-deficit hyperactivity disorder, generalized anxiety disorder, and secondary hypertensionR2's census list documented that R2 was in the current room since 02/23/2023. R4's admission Record documented that R4's diagnoses (include but not limited to) covid-19, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and vascular dementia. R4's census list documented that R4 was initially admitted on [DATE] and was moved to R2's room on 08/31/2025. R4's (08/27/2025) Hospital Record documented, in part Collection Time: 08/22/2025…

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 for storage and labeling of food. The facility also failed to ensure proper dishwashing machine sanitation temperatures to prevent the spread of food-borne illnesses. These failures have the potential to affect 186 residents who are receiving oral diets. Findings Includes: The Form CMS 671 The Long-Term Care Facility Application for Medicare and Medicaid dated 12/8/24 documents there are a total of 188 residents within the facility. Per V1 (Administrator), there are two residents that are not receiving oral diets from the kitchen. On 12/8/24 at 9:30 am, during the initial tour of the kitchen with V7 (Acting Dietary Supervisor/ADS), observed the following foods were found open in the walk-in freezer without preparation and expiration date labels: 1. 1 bag Garlic Toast 2. 1 bag Meatballs On 12/8/2024 at 9:35 am, observed the following foods in the walk-in refrigerator: 1. 1 Tuna Salad in a large silver container covered with saran wrap no preparation date and expiration date label. 2. 1 bag…

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 maintain an effective pest control program to ensure that the facility is free of roaches. This failure has the potential to affect all 188 residents in the facility. Findings include: The 12/08/24 resident census was 188. On 12/08/2024 at 11:33am, R398 requested surveyor come to his room to observe the room bathroom. On 12/08/2024 at 11:35am upon arrival to R398's room, observed one large cockroach crawling on R398's toilet seat and 4 small cockroaches crawling on the floor in R398's room bathroom. On 12/08/2024 at 11:37am R398 stated I have seen roaches in my room before. I don't like that the facility has roaches. On 12/08/2024 at 11:40 am surveyor requested maintenance staff come to the second floor. On 12/08/2024 at 11:53am V18 (Maintenance Assistant) arrived at R398's room. V18 observed the roaches in R398's bathroom and stated, We are fighting the roaches. V18 stated pest control does come to the facility. On 12/08/2024 at 11:54am surveyor observed V18 stepping on the roaches, picking the roaches up…

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 call light was within reach for one resident (R109) out of the 66 residents reviewed for call lights. Findings include: R109's Brief Interview for Mental Status (BIMS) dated 10/14/2024 Section C C0500 documents that R109 has a BIMS score of 09 which indicates that R109's cognition is moderately impaired. R109's diagnosis includes but are not limited to acute osteomyelitis, right ankle and foot, aftercare following surgery for neoplasm, age-related nuclear cataract, bilateral, hypertensive retinopathy, bilateral, essential (primary) hypertension, benign neoplasm of unspecified adrenal gland, other specified peripheral vascular diseases, and non-pressure chronic ulcer of other part of right foot limited to breakdown of skin. On 12/08/2024 at 10:35am R109 was asked where your call light is located. R109 responded I don't have a call light. Surveyor observed the red call light cord on the floor on the right side of R109's bed. On 12/08/2024 at 10:37am V16 (Certified Nursing Assistant/CNA) 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 observation, interview, and record review the facility failed to follow physician's orders regarding hand restraints. This failure affected one resident (R25) in the facility viewed for restraints in a sample size of 66. Findings include: R25's admission diagnoses include but not limited to Alzheimer's, bipolar, emphysema, anxiety, scoliosis and motor and sensory neuropathy. R25's Brief Interview of Mental Status (BIMS) score is blank. On 12/8/24 at 11:10 am, observed R25 in room lying in bed with hand mittens on the left and right hands. On 12/9/24 at 9:50 am, observed R25 lying in bed with a hand mitten on the left hand. On 12/10/24 at 9:56 am observed R25 lying in bed with hand mittens on the left and right hand. R25's Active Orders Summary Report as of (12/10/24) documents in part, may use hand mitten on right hand. On 12/10/24 at 10:00 am V33 (Restorative Aide) stated, I put the mittens on R25 today. I was told to put on both hands by the restorative director. She has the hand mittens for involuntary movement. On 12/10/24 at 10:34 am, Surveyor inquired to V34…

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 low air loss mattress was not layered with multiple linens. This failure affected 2 residents (R44 and R66) reviewed for pressure ulcer/injury prevention and treatment in a sample of 66 residents. Findings include: 1.) R44's admission diagnoses include but not limited to congestive heart failure, dementia, depression, venous insufficiency, chronic obstructive pulmonary disease, and pulmonary nodule. R44's Brief Interview of Mental Status (BIMS) score is 3. R44 has severe cognitive impairment. On 12/8/24 at 10:37 am, R44 was lying on a low air loss mattress with multiple layers between R44 and the low air loss mattress. The layers observed under R44 consisted of a flat sheet, a flat sheet folded multiple times, an incontinent pad, and an incontinent brief. R44's (12/11/24) Active Order Summary report documented in part, Air loss mattress alternating pressure for preventive measures. R44's Risk Assessment Profile dated 7/3/24 documents in part, R44's Braden Scale Score is a 14, indicating R44 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.

Based on observation, interview, and record review the facility failed to ensure one resident (R169) received equipment to assure that R169 maintains, and/or improves to the highest level of range of motion (ROM) and mobility. This failure affected one resident (R169). Findings include: R169 has a diagnosis of but not limited to Idiopathic Normal Pressure Hydrocephalus, Hypertension, Cognitive Communication Deficit, Bipolar Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. R169 has a Brief Interview of Mental Status score of 15, cognitively intact. R169's Order Summary Report with active orders as of 12/09/2024 documents, in part, may use Left hand splint/carrot. On 12/08/2024 at 9:45am surveyor observed R169 without a hand splint or carrot (assistive device) in R169's left hand. On 12/08/2024 at 9:46am R169 stated that staff has never place a rolled-up hand towel or carrot in his left hand to prevent his fingers from further contracture. On 12/08/2024 at 10:00am surveyor observed V20 (Restorative Aide) walk into R169's room with a…

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

Based on observation, interview and record review, the facility failed to properly contain oxygen equipment (nebulizer mask) for one resident (R133). This failure affected one residents (R133) reviewed for oxygen equipment, in a total sample of 66 residents. Findings include: R133's face sheet shows that R133 has a diagnosis which includes but not limited to atherosclerotic heart disease of native coronary artery with unstable angina pectoris, chronic obstructive pulmonary disease with acute exacerbation, venous insufficiency chronic peripheral and hypertensive heart disease with heart failure. R133's Brief Interview for Mental Status (BIMS) dated 10/10/24 documents that R133 has BIMS score of 15 which indicates that R133 is cognitively intact. On 12/08/24 at 10:53 am, R133 was observed in bed awake, alert, with R133's nebulizer mask uncontained in bed with R133. R133 stated that R133 uses R133's nebulizer mask daily for R133's nebulizer treatments. When R133 was asked how R133's nebulizer mask is stored when not in use R133 stated, I (R133) just keep it in bed with me. I don't 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 properly check and log a daily refrigerator temperature for three residents (R135, R145 and R113) with personal refrigerators. The facility also failed to provide a thermometer in one resident's refrigerator (R145) and failed to clean the personal refrigerator for one resident (R145). Findings include: 1.) On 12/08/2024 at 10:15 am observed a black personal refrigerator sitting on the floor next to R113's bed. Observed a temperature log on the front of R113's refrigerator door, the temperature log was for November (year not listed) and there was missing documentation for temperature readings on November 24th, 25th, 26th, 27th, 28th, and 29th. Upon R113 opening the refrigerator door, observed a carton containing 6 eggs and a clear locked box containing six insulin pens. R113 stated I have an order to keep my insulin pens in my refrigerator. R113 stated my refrigerator door has a lock on it and I check the temperature in my personal refrigerator every day. R113 stated I did leave the facility on November 24th,…

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 an Enhanced Barrier Precaution (EBP) sign was posted for a resident on EBP in an effort to prevent the spread of multi-drug resistant organism at the facility. This failure affected 1 (R70) resident reviewed for infection control. Findings include: The (12/07/2024) midnight census documented that there were 61 residents on the fourth floor. On 12/08/24 at 10:46 AM on the 4th floor, inquiring about the acuity of the floor. V4 (Registered Nurse) stated this is the dementia floor. (R70) has a g-tube (gastric feeding tube). On 12/08/24 at 11:02am, there was no EBP sign posted by R70's room/door. This was pointed out to V8 (Wound Care Coordinator/Registered Nurse). V8 stated she (R70) has a g-tube. She is on EBP. There is no EBP sign posted. The sign is supposed to be posted but I don't want to give you wrong information. I called the Infection Preventionist. On 12/08/24 at 11:08am, V2 (Director of Nursing/Infection Preventionist) brought an EBP sign and posted it by R70's door. V2 stated our policy is, if…

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, interviews, and review of records, the facility failed to ensure that all elevators were timely inspected, the required parts that need repaired or replacement were addressed, maintain a clean environment, and ensure all elevator parts were functioning properly per city regulation. These failures have the potential to affect all residents, staff and/or visitors that uses any of the elevator in the facility. Findings include: On 8/28/2024 at 11:28 AM, on the first floor there were two (2) elevators that were used by residents, staff, and visitors. When in front of both elevators, the left elevator has a post that has a written marker that reads: Out of Order. Upon entering the right elevator, R6 was present and agreed to have a conversation inside his room. R6 stated that elevator availability is and was a problem due to on and off not functioning. At 11:53 AM, R2 stated that she is currently the president of resident council and just had a meeting today. R2 stated that elevator was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of record, facility failed to follow their policy to ensure residents would be free from abuse and mistreatment for two (R2 and R3) out of three residents reviewed for abuse. R2 expressed feelings of hurt and frustration. Findings include: R2's Face sheet documents in part: R2's diagnosis are traumatic brain injury, anoxic brain damage, generalized epilepsy, and epileptic syndrome, MERRF (Myoclonic epilepsy with ragged red fibers) syndrome, schizoaffective disorders, bipolar disorder, cerebellar ataxia. R2's MDS (minimum data set) section C (05/22/2024) documents in part: R2's BIMS (Brief Interview for Mental Status) score is 15 which means R2 is cognitively intact. R3's MDS Section C documents in part: R3's BIMS score is a 15 which means R3 is cognitively intact. On 06/12/2024 at 11:52 AM, surveyor saw R2 sitting in his room in a wheelchair. R2 had mild tremors and would have difficulty formulating his words. Surveyor observed a CNA (Certified Nursing Assistant) feeding R2. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, failed to follow their policy to report an allegation of abuse to the administrator or administrator's designee for two residents (R2 and R3) out of three residents reviewed for abuse. Findings include: R2's Face sheet documents in part: R2's diagnosis are traumatic brain injury, anoxic brain damage, generalized epilepsy, and epileptic syndrome, MERRF (Myoclonic epilepsy with ragged red fibers) syndrome, schizoaffective disorders, bipolar disorder, cerebellar ataxia. R2's MDS (minimum data set) section C (05/22/2024) documents in part: R2's BIMS (Brief Interview for Mental Status) score is 15 which means R2 is cognitively intact. R3's MDS Section C documents in part: R3's BIMS score is a 15 which means R3 is cognitively intact. On 06/12/2024 at 11:52 AM, surveyor saw R2 sitting in his room in a wheelchair. R2 had mild tremors and would have difficulty formulating his words. Surveyor observed a CNA (Certified Nursing Assistant) feeding R2. R2 stated he needs help feeding…

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 update a resident's care plan that was high risk for falls to include fall prevention interventions after a fall for one resident (R1) out of 3 residents reviewed for fall prevention. Findings include: R1's face sheet documents that R1 has the following medical diagnosis including but not limited to other lack of coordination, chronic obstructive pulmonary disease with (acute) exacerbation, plantar fascial fibromatosis, corns and callosities, generalized anxiety disorder, and post-traumatic stress disorder. R1's Minimum Data Set (MDS) dated [DATE] shows that R1 has a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R1 is cognitively intact. On 05/06/24 at 12:14 pm, R1 was observed ambulating in R1's room into the hallway without assistance and with an unsteady gait. R1 stated, I (R1) keep falling at the facility and nothing is being done about it. R1 would not stop to speak with Surveyor and Surveyor was not able…

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 follow bed hold policy requirement in giving proper written notice for 1 out of 3 residents (R2) for the total sample of 3 residents reviewed for bed hold, admissions, transfers, and discharges rights. This failure affected 1 resident (R2) rights to be informed of the right to and exercise the right to bed hold under the regulation. Findings include: R2 was [AGE] years old, initially admitted on [DATE] for cerebral infarction, and aphasia following cerebral infraction. Per R2's progress notes dated 3/2/2024 by V25 (Registered Nurse/Agency) documents that R2 was transferred and was admitted in the hospital for Cerebrovascular Accident and aggressive behavior. On 3/12/2024 at 11:10 AM, V22 (Spouse of R2) stated that initially facility did not accept his husband (R2) because of his behavior due to brain damage. V22 said that facility did not inform her, instead hospital needed to inform her that the facility does not want to accept her husband (R2). V22…

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 interviews the facility failed to provide a person-centered care plan addressing necessary care for nutrition for 1 (R1) out of 3 residents reviewed for care plan. These failures have the potential to affect 1 resident (R1) nutritional services. Finding includes: R1 was [AGE] years old male resident, initially admitted on [DATE]. R1 medical diagnosis includes the following Pancytopenia and acute kidney failure. Per R1's record he was discharged on 2/23/2024. Weight Summary record of R1 documents multiple significant weight loss: R1's recorded weight documents significant weight loss on the following dates: R1's weight dated 5/16/2023 - 114.8 LBS compared to 5/24/2023 there was a decrease of -20.2 LBS or -17.6% weight loss for a period of 8 days. Weights on 7/7/2023 to 8/7/2023 comparison there was a decrease of -8.0 LBS or 7.2% weight loss for a period of 30 days. And weights on 2/9/2024 to 2/16/2024 comparison there was a decrease of -11.6 LBS or -10.92% weight for a period of 7…

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

Based on observation, interview, and record review the facility failed to provide food at a safe and appetizing temperature. This failure affects 202 residents receiving food in the facility. Findings include: On 02/20/2024 at 11:40AM R81 was observed sitting on the bed in R81's room eating his lunch meal. R81 states sometimes hot foods are served cold, and the staff will have to reheat resident meals. On 02/21/2024 at approximately 9:30AM, V16 (Food Service Supervisor) informs surveyor that the spinach vegetable for lunch will be replaced with collard greens and all residents have been made aware. On 02/21/2024 at 12:50PM, V16 (Food Service Supervisor) states food temperatures are checked twice during meal preparation; first, when food comes out of the oven and second, when food is placed on the steam table right before plating. V16 states food temperatures were last taken at 11:00AM on the steam table and are as follows: Meat loaf- 186 degrees Fahrenheit Beef steak-195 degrees Fahrenheit Mashed potatoes- 197 degrees Fahrenheit Vegetables/collard greens- 200 degrees Fahrenheit 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 proper sanitation and food storage practices. The facility failed to properly label food. The facility failed to properly store food. The facility also failed to adequately sanitize equipment used for food preparation. These deficient practices have the potential to affect all 202 residents receiving food prepared in the facility kitchen. Findings include: On 02/20/2024 at 9:11 AM during initial kitchen tour with V16 (Food Service Supervisor), the following food items were found in the walk-in cooler: 1. 3 boxes of blueberries with a receive date of 02/16/2024, 1 box of blueberries with a receive date of 02/13/2024, no expiration or use by date. 2. 1 box of oranges, no receive date, no expiration or use by date. 3. 1 box of spinach greens with receive date of 01/30/2024, no expiration or use by date. 4. 1 spray bottle with a pink colored liquid inside the spray bottle sitting on the second food storage shelf located in between the box of spinach greens and tomatoes. On 02/20/2024 at 9:18AM, V16 states…

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 a.) handle linen to prevent contamination, b.) ensure a resident on Droplet/Contact Precaution door was closed to prevent the spread of infection and c.) failed to handle and distribute food items in a sanitary manner. These failures have the potential to affect 204 residents residing in the facility. Findings Include: 1.) On 02/20/24 at 09:24 AM surveyor asked during the entrance were there any positive COVID-19 cases in the facility. V1 (Administrator) responded that there was one resident and that (R29) is no longer on COVID precautions. R29 has diagnosis not limited to Alzheimer's Disease, Adult Failure to Thrive, Hypokalemia, Insomnia, Generalized Anxiety Disorder, Forms of Scoliosis, Lumbar Region, Bipolar Disorder, Elevated [NAME] Blood Cell Count, Hereditary Motor and Sensory Neuropathy, Lack of Coordination, Need for Assistance with Personal Care, Dysphagia, Oropharyngeal Phase, Abnormal Posture, Pneumonia, Unspecified Organism.…

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 call light was within reach for 6 (R99, R159, R163, R178, R255, R256) residents reviewed for accommodation of needs in a sample of 36. Findings Include: 1.) R255 has diagnosis not limited to Aphasia Following Cerebral Infarction, Obstructive Sleep Apnea, Psoriasis, Type 2 Diabetes Mellitus, Local Infection of the Skin and Subcutaneous Tissue, Lack of Coordination and Gastrostomy. Care Plan document in part: Focus: R255 is at risk for falls related to Current medication use, Poor safety awareness, Unsteady gait. Date Initiated: 11/02/23. Intervention: Keep call light within reach when in bedroom or bathroom Date Initiated: 11/02/23. Focus: is at risk for falls related to unsteady gait Date Initiated: 11/03/23. Intervention: Ensure that I will be able to use the call light. If the light is difficult to press, consider giving me a foam pad call light or other adaptive call lights Date Initiated: 11/03/23. On 02/20/24 at 10:40 AM R255 door was observed to be closed. Upon surveyor knocking on R255 door…

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 reviews the facility failed to refer four (R5, R48, R64, R175) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review in a sample of 59 residents. Findings include: On 02/21/2024 at approximately 10:30AM, V12 (Social Services Director) states she does not deal with the Pre-admission Screening and Resident Review (PASARR) process and refers surveyor to V13 (Admissions Director) for further information. On 02/21/2024 at 11:01AM, V13 (Admissions Director) states he has been working at the facility for 9 months. V13 states he works with the facility's hospital liaison to get the DON/determination of needs screening and Level 1 screening because it is performed prior to being admitted to the facility. V13 states once he obtains the DON score, he is then able to go into the facility's PASARR screening system to go to obtain the Level 1 screening. V13 states once he obtains the Level 1 screening, V13 uploads it into 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 properly dispose of unused medications and expired medications during one observation of medication disposal and review of 2 of 4 medication carts. Findings include: On 02/20/2024 at 9:13 AM, V5 (Licensed Practical Nurse/LPN) prepared R152's medications. V5 took out two tablets of Tylenol 325 MG (milligram) and one tablet of Ascorbic Acid 500 MG and placed them in a medicine cup. R96 approached V5's medication cart. After speaking with R96, V5 stated [V5] will start medication preparation over again. V5 took the medicine cup and tossed the pills in the opening of the sharps' container. V5 did not close/push the lid leaving the pills sticking out and sitting on the lid. 2/20/24 at 9:29 AM, V5 stated there were two residents with dementia on the unit and a lot of residents that walk about independently. 2/20/24 at 9:33 AM, V5 walked away from the medication cart to the nurses' station. Medication cart was in front of room XXX. 2/20/24 at 9:37 AM, V5 was preparing medications for R101. At 9:40 AM, V5 donned…

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, interview, and record reviews, the facility failed to maintain a resident's (R184) dignity during breakfast for 1 out of a total sample of 36 residents. Findings include: R184's face sheet documents in part medical diagnoses including but not limited to multiple sclerosis, adult failure to thrive, and personal history of traumatic brain injury. R184's comprehensive care plan documents in part that R184 requires assistance with Activities of Daily Living (ADL) care including eating. Facility initiated the focus on 07/18/2023 and revised it on 02/19/2024. R184's physician orders document in part that R184 requires one-to-one assist with feeding with every meal and as needed. On 02/21/2024 at 8:40 AM, R184 was in bed with head of the bed elevated. R184's bed was close to the floor. V47 (Certified Nursing Assistant/CNA) stood on R184's right side and fed R184. V47 was standing on the floor mat and not at eye level with the resident. At 8:48 AM, V46 (CNA) stood on R184's left side and V47 stood on R184's right side. Both continued to provide feeding assistance…

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 follow their policies and procedures to consistently follow the Preadmission Screening and Annual Resident Review (PASARR) process for 2 (R68, R194) out of 22 residents with mental illness reviewed for a Level 2 PASARR Screening for MD and ID in a total sample of 36. Findings Include: 1.) R68's Minimum Data Set (MDS) dated [DATE] shows R68 is cognitively intact. According to the admission Record, R68 is [AGE] years old, R68 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder. There is no documentation to show that R68 was referred to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. On 2/22/24 at 1:10 PM, the surveyor asked V2 (Assistant Administrator) for a Level 2 PASARR screening for R68. V2 provided the surveyor with a Level 1 PASARR screening dated 4/20/15 for R68. V2 was unable to provide a Level 2 PASARR screening for R68. V2 stated that V2 has no Level 2 PASARR…

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 reviews and interviews the facility failed to follow care plan policy on person-centered care plan for a resident who has diagnosis for schizophrenia and bipolar disorder with psychotropic medication orders to 1 out of 36 residents (R405) for a total 36 residents reviewed for care plan. Findings include: R405 is [AGE] years old, initially admitted on [DATE] with diagnosis of schizophrenia and bipolar disorder. Per medication list of ordered by physician, R405 has the following psychotropic medications: -Sertraline Hydrochloride (antidepressant) 25 MG tablet with once daily order date 2/5/2024, -Fluphenazine Decanoate (antipsychotic) 25 MG per ML every 3 weeks with order date 2/16/2024, -Fluphenazine Hydrochloride (antipsychotic) 5 MG tablet once daily with order date 2/16/2024, -Haloperidol Lactate (antipsychotic) 2 MG per ML injection to be given for agitation with order date 2/16/2024, -Haloperidol (antipsychotic) 2 MG tablet to be given for agitation with order date 2/16/2024, -Trazodone…

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 update a resident's (R162) comprehensive care plan and follow physician orders for one-to-one feeding for a dependent resident (R162) for 1 out of a total sample of 36 residents. Findings include: V36's (Registered Dietician) progress note dated 01/30/2024 12:46 PM for R162 documents in part that R162 had significant weight loss. Recommendations included to continue meal set-up assistance to maximize oral intake at mealtimes. R162's physician orders document in part a new order on 02/19/2024 for one-to-one assist with feeding for every meal and as needed. R162's comprehensive care plan did not reflect this change. On 02/20/2024 at 12:53 PM, R162 was in the dining room eating lunch. R162 was confused and only oriented to self. R162 was pushing food around in meal tray and not focused on eating. V8 (Wound Care Nurse) went in and out of the dining room and cued R162 to eat. No staff sitting one-to-one assisting R162 with the meal. At 1:10 PM, R162 stated [R162] was done eating. R162's lunch tray was placed 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 observations, interviews, and record reviews, the facility failed to have a person-centered care plan that included R74's hearing needs and ensure R74 received an assistive device to maintain hearing abilities for one out of a total sample of 36 residents. Findings include: R74's face sheet documents in part an admission date of 08/29/2014. R74's Minimum Data Set assessment dated [DATE] documents in part that R74 is cognitively intact. On 02/20/2024 at 10:09 AM, R74 was alert and oriented to person, place, and time. R74's television was on a high volume which was heard from the hallway. R74 stated difficulty hearing and stated the left ear was worse than the right. R74 pointed to the right ear and instructed surveyor to speak to [R74's] right ear. R74 stated [R74] does not have hearing aids and cannot recall the last time an ear doctor evaluated [R74]. R74's physician orders from 06/19/2023 document in part that R74 may see an audiologist as needed. R74's comprehensive care plan did not include a focus…

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 low air loss mattress was on the correct setting for 2 (R31, R163) of 2 residents reviewed for pressure ulcers in a sample of 36. Findings include: 1.) R31 has diagnosis not limited to Fibromyalgia, Type 2 Diabetes Mellitus with Foot Ulcer, Radiculopathy, Lumbar Region, Gastro-Esophageal Reflux Disease, Secondary Hypertension, Human Immunodeficiency Virus [HIV] Disease, Chronic Osteomyelitis, Right Ankle and Foot, Bipolar Disorder, Chronic Kidney Disease, Stage 3, Abnormalities of Gait and Mobility. Treatment Administration Record document in part: Sacral-Coccyx wound: Cleanse with NSS gently pat dry apply Triple antibiotic ointment cover with dry dressing change QOD and PRN until healed. every day shift every other day -Start Date- 02/07/24. Care Plan document in part: R31 admitted with the following wounds, Left heel stage 3 pressure injury. Right heel stage 4 pressure injury. Right gluteal stage 3 pressure injury. Coccyx stage 2 pressure injury. R31 readmitted with the following wounds: Right heel…

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

Based on observations, interviews, and record reviews, the facility failed to follow physician orders and assess for the removal of a urinary catheter for one (R101) out of a total sample of 36 residents. Findings include: R101's face sheet documents an admission date of 01/29/2024. Listed medical diagnoses do not include urinary retention or bladder issues. On 02/20/2024 at 11:07 AM, R101 was alert and oriented to person, place, time, and situation. R101 stated admitted from the hospital with an indwelling catheter. R101 did not know why R101 continued to have it. R101 stated no bladder issues and no sacral pressure ulcers. R101 stated facility has not attempted to remove the urinary catheter. R101's physician orders contain an order dated 01/29/2024 that documents in part to discontinue indwelling catheter if without acceptable indication (pressure ulcers 3 and 4 at sacral areas, urinary retention secondary to certain diagnoses). R101's comprehensive care plan contained a focus created on 1/30/2024 for the indwelling urinary catheter but it did not list the indication for it. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their oxygen therapy and administration policy to ensure adequate oxygenation to 1 (R19) of 3 oxygen dependent residents in the sample of 36. Findings Include: R19's clinical record documents in part: R19 is a [AGE] year-old with the medical diagnosis of chronic obstructive pulmonary disease, asthma, metabolic encephalopathy, need for assistance with personal care, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, adult failure to thrive, retention of urine, pleural effusion, myocardial infarction, fracture of nasal bones, subsequent encounter for fracture with routine healing, fall, subsequent encounter, secondary hypertension, chronic obstructive pulmonary disease, chronic kidney disease, stage 3a, retinopathy of prematurity, stage 2, unspecified eye, schizoaffective disorder, bipolar type, bipolar disorder, current episode mixed, moderate, major depressive disorder, spinal stenosis, schizophrenia,…

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 offer and provide education to the residents or their Representatives for the Pneumococcal and Influenza Vaccine for 2 (R29, R255) of 5 residents reviewed for immunizations in a sample of 36. Findings Include: 1.) R29 was admitted to the facility on [DATE]. R29 has no documentation of the pneumococcal of Influenza vaccination or education. Progress note dated 02/21/24 1:45pm document in part: General Progress Note Text: Spoke to R29 daughter to remind her about pending consents for flu, pneumococcal and COVID vaccines, she gave consent to have her mom get the flu vaccine but refused the pneumococcal. Resident schedule to get flu vaccine as consented by daughter. 2.) R255 was admitted to the facility on [DATE]. R255 has no documentation of the pneumococcal of Influenza vaccination or education. Progress note dated 02/21/24 1:45pm document in part: General Progress Note Text: Spoke to R255 wife (to remind her about pending consents for flu, pneumococcal,…

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.