Continental Nursing & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of records, the facility failed to ensure that smoking was done in required designated area. These practices are not in accordance with their policy and State laws and can affect all 144 residents living in the facility as it pertains to their safety and comfort related to smoking effects. Findings include: On 06/17/2025, at 11:18 AM, R3 stated that residents are smoking inside their rooms, common restrooms, shower rooms and other areas not designated for smoking. R3 stated that it is a continuing problem that affects other residents when inhaling cigarettes strong odor. Inside another resident's room, R5 stated that he smelled strong cigarettes odor upon entering the common restroom on the floor. R6 who was outside of R5's room, stated that it is a continuing problem that needs to be addressed. R3 accompanied writer to the common restroom and showed the writer the wall filed with cigarettes marking. When R3 opened the door, a strong odor of cigarettes was smelled.…

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 record the facility failed to re-ordered medication on a timely manner for 1 out of 3 residents (R2) reviewed for pharmaceutical services. This practice is not in accordance with their policy and may affect 1 resident (R2) in ensuring pharmaceutical supplies are available to meet the needs of resident. Findings include: R2 is [AGE] years old, initially admitted on [DATE], with medical diagnosis of diabetes mellitus, multiple sclerosis and cerebral infarct. On 06/17/2025, at 10:52 AM, R2 was seen in her room alert and verbally able to express her thoughts well. R2 stated that she does not receive all her medications including eye drops and medication for diabetes. At the nurse's station with V5 (Registered Nurse) all of the medication for R2 in the medication cart was reviewed. After review, there were three (3) medicines that are not available: Glipizide (for diabetes), Metformin (for diabetes) and Trazodone (antidepressant). V5 stated that she just re-ordered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility policy for smoking safety and failed to ensure that residents are not smoking inside a shared residents' room near oxygen equipment where oxygen is in use which affected 5 residents (R2, R7, R8, R9 and R10) of 12 residents reviewed for odors from smoking within the facility. This failure resulted in R10, who uses nasal cannula oxygen from an oxygen tank, experiencing psychosocial harm from sharing a room with R4 who was found on 5/31/25 by staff with a lit, half smoked cigarette in their shared room with visible smoke in the air and on 6/1/25 when R10 smelled cigarette smoke in their shared room, alerted staff, and staff confiscated a box of 14 cigarettes from R4's dresser drawer. Subsequently, R10 was transferred to a different room on the floor. Findings include: On 6/4/25 at 11:00 AM, R10 observed laying in bed with oxygen infusing at 3 liters/minute (L/min) via nasal cannula from an oxygen tank positioned upright in a holder on…

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

Based on observations, interviews, and record reviews, the facility failed to a.) maintain sanitary kitchen conditions, b.) ensure proper working order of freezer, c.) ensure food items were properly labeled and dated, d.) maintain cleanliness of kitchen equipment. These failures have the potential to affect all 139 residents who receive food prepared in the kitchen. Findings include: On 05/27/25 at 9:28 AM, during initial kitchen tour observed a large amount of garbage and debris on the floor in tray line and food preparation area. Used discarded hairnets, empty plastic cups and particles of food were seen on the floor, the floor tiles had a greasy residue quality to them, the wall behind the oven had yellow/brown color splattered on the wall tile, and the oven had yellow colored food substance dried along the side of the oven. A large mop bucket filled with dirty gray colored water with a dirty looking mop head was observed. Next to the hand sink there was a very large gallon trash barrel with wheels. The lid of the trash barrel was propped open from all the garbage inside and had…

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 on multiple occasions medications were administered as scheduled per physician orders for one (R109) of four residents reviewed for medication administration. Findings Include: On 5/27/25 at 10:29 AM, R109 stated he does not get his Amlodipine on time on certain days. R109 stated for five days in the last twenty days, R109 did not receive his Amlodipine as scheduled in the morning. R109 remembers not getting it on time yesterday, Sunday, and other days but R109 does not remember exact days. R109 stated Amlodipine is ordered once a day to take in the morning. R109 stated some days the nurses don't give the medication to him until evening time. On 5/27/25 at 9:25 AM, V10 (Licensed Practical Nurse) stated that R109's Amlodipine is scheduled to be administered at 9:00 AM and nurses have two hours before and two hours after the scheduled time to administer medications to residents. V10 stated medications should be administered according…

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 (a) failed to properly discard multi-dose insulin pen on expiration date and to properly store unopened insulin pen for 1 resident (R10), (b) failed to label and date opened multi-dose inhalers for 2 residents (R121, R95), and (c) failed to discard house stock medication on expiration date from two of three medication carts inspected for medication storage and labeling. This failure had the potential to affect all 28 residents receiving medications from third floor medication cart one. Findings Include: On 5/27/25 at 9:29 AM, third floor team one medication cart was inspected with V10 (Licensed Practical Nurse) and found R121's opened Trelegy Ellipta inhaler without the date opened written on the label (label reads to discard 6 weeks), R10's opened Fiasp Flextouch (insulin aspart) with date opened 4/28/25 written on the label, R10's unopened Fiasp insulin pen with refrigerate until opened written on the label, and a bottle of house stock Zinc 50 mg medication with best by date 4/25 written on the label. V10 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 standardized pureed recipe during food preparation. This failure has the potential to affect eight residents (R11, R27, R53, R65, R72, R99, R102, R115) receiving pureed diets prepared in the facility's kitchen. Findings Include: On 05/28/25 at 11:10 AM, during pureed preparation observation V15 (Cook) stated he follows a recipe so that he know how to prepare the pureed food. V15 pointed to a recipe titled Pureed Beef Lasagna located in a binder near the prep area. V15 stated the consistency of the pureed should be smooth with no lumps and the consistency should be in between nectar and honey consistency. On 05/28/25 at 11:15 AM, V15 stated he needed to prepare eleven portions of pureed lasagna and was going to do the process in two batches. V15 measured out 5-eight ounce portions of beef lasagna into an industrial blender and then added a large unmeasured amount of water into the same blender. V15 stated he does not measure out the water, he just fills up the blender container halfway with water. V15…

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 standardized pureed recipe during food preparation. This failure has the potential to affect eight residents (R11, R27, R53, R65, R72, R99, R102, R115) receiving pureed diets prepared in the facility's kitchen based on list of residents receiving pureed diets dated 05/27/25. Findings Include: On 05/28/25 at 11:10 AM, during pureed preparation observation V15 (Cook) stated he follows a recipe so that he know how to prepare the pureed food. V15 pointed to a recipe titled Pureed Beef Lasagna located in a binder near the prep area. V15 stated the consistency of the pureed should be smooth with no lumps and the consistency should be in between nectar and honey consistency. On 05/28/25 at 11:15 AM, V15 stated he needed to prepare eleven portions of pureed lasagna and was going to do the process in two batches. V15 measured out 5-eight ounce portions of beef lasagna into an industrial blender and then added a large unmeasured amount of water into the same blender. V15 stated he does not measure out the water,…

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 obtain a physician order and to determine if self-administration of medication was appropriate for one (R117) out of one resident observed for safety on the total sample of 28. Findings Include: R117's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (12) indicates R117 is moderately cognitively intact. R117's Face sheet shows he is [AGE] years old, admitted to the facility on [DATE] with diagnosis not limited to Guillain-Barre syndrome, disorder of the autonomic nervous system, sixth nerve palsy right eye, pain in right knee, and pain in left knee. On [DATE] at 11:35 AM, R117 up in bed, working on the computer, surveyor and V6 (Registered Nurse/RN) observed a bottle of 15 Milliliter/ml of Opcon-A eye drop, a tube of expired 15 Gram/gm of Pevisone topical cream (written in foreign language), a bottle of vitamin B-12, 5000 microgram/mcg containing thirty-two pink with speckles lozenges, and he stated that he ordered 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 interviews and record reviews, the facility failed to follow their policy and procedure by not obtaining a physician's order for code status and develop a comprehensive person-centered care plan for one (R114) reviewed for advance directives on the total sample of 28. Findings Include: R114's face sheet shows an initial admission date of 11/12/24 and the advance directive section was blank. R114's minimum data set (MDS) dated [DATE] shows R114 is cognitively intact with BIMS (Brief Interview for Mental Status) of 114. R114's order summary report printed on 5/28/25 shows no physician order for R114's code status. R114's comprehensive care plan does not address R114's advance directive/code status. On 5/28/25 at 12:42 PM, V27 (Social Service Director) stated that upon admission, the resident or representative is asked for code status preference and is reviewed quarterly and with every significant change. The POLST (Physician Orders for Life-Sustaining Treatment) form is completed for DNR (Do Not…

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

Based on interviews and record reviews, the facility failed to follow their policy and ensure the accuracy of three (R70, R81, R112) residents' MDS (Minimum Data Set) assessments for 3 of 28 residents reviewed for assessments. Findings include: 1. R70's 5/08/2025 Quarterly MDS assessment documents in part oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator use. V18 (Nurse) completed this section of the MDS (section O) on 5/06/2025. V19 (MDS Coordinator) verified R70's 5/08/2025 Quarterly MDS assessment completion on 5/13/2025. R70's admission Record and Order Summary Report do not document diagnoses or contain orders for oxygen therapy, suctioning, tracheostomy care, or ventilator use. Reviewed R70's progress notes during the 14-day look back period from the MDS Assessment Reference Date (ARD). No mention of oxygen, tracheostomy, or ventilator use. On 5/27/2025 at 12:39 PM, V10 (Nurse) stated no oxygen, tracheostomy or vent use for R70. On 5/27/2025 at 2:49 PM, R70 stated never been on ventilator while in the facility or had a tracheostomy stoma. R70…

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 professional standards of care for one (R117) resident out of a sample of 28 reviewed for medication administration. Findings Include: R117's Physician Order Sheet (POS) with active orders as of 5/27/25 shows Gabapentin oral capsule 300mg (milligrams), give 1 capsule by mouth three times a day for nerve pain, start date 4/19/25. On 5/27/25 at 11:35 AM, R117 was up in bed working on the computer, surveyor and V6 (Registered Nurse/RN) observed a medication bottle containing thirty-four yellow oblong capsules on R117's bed side table, and V6 acknowledged the capsules as being Gabapentin 300 milligram/mg that had been administered to him. R117 stated that he told the nurses he does not want the medication, and V6 stated that the nurses should have monitored him to ensure he swallowed the medication to achieve well-being. On 5/27/25 at 3:37 PM, V2 (Director of Nursing/DON) stated that it is his expectation that nurses will monitor resident during medication administration to ensure medication is swallowed…

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 coordinate services for a resident (R81) with diagnoses of chronic liver disease and Hepatitis C and failed to follow physician order and policy and procedure to ensure peripherally inserted central catheter (PICC) line dressing was changed weekly for R246. These failures affected 2 out of a total sample of 28 residents reviewed for quality of care. Findings include: 1. R81's admission Record documents in part diagnoses of hepatomegaly (enlarged liver) and viral Hepatitis C. R81's initial admission date was 1/25/2021. V28's (Physician) 5/22/2025 3:36 AM progress note for R81 documents in part: Hepatitis C - Chronic liver disease requiring careful monitoring of liver function and viral load. Plan: Monitor liver enzymes and viral load regularly. Coordinate with hepatology [doctor that specializes in treating liver diseases/conditions] for continued care and treatment recommendations. Continue to assess liver function and ensure that any…

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 fire hazard equipment was not located in a resident's room for one (R7) of one residents reviewed for accidents and hazards in a sample of 28 residents. Findings Include: R7's clinical records show an admission date of 2/11/25. R7's Minimum Data Set, dated [DATE] shows R7 is cognitively intact. On 5/27/25 at 10:48 AM, surveyor entered R7's room and noted two countertop microwaves at bedside. R7 stated [R7] uses them to warm up his food. On 5/27/25 at 12:59 PM, V1 (Administrator) stated residents cannot have microwave in their rooms because it is not safe and it's a fire hazard. V1 stated there's microwave available in the break room that the nurse can use to heat up residents' food. V1 stated will remove R7's microwaves from [R7's] room immediately. The facility's admission Agreement page 9 of 14 dated 11/24/23 documents in part: In an effort to make the Facility more homelike, residents may be allowed by Facility to bring in items…

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, facility failed to follow their policy to ensure residents received medications according to the physician order for 3 residents (R1, R2, R6) out of of 3 residents reviewed for medication administration in a total sample of 6. Findings include: On 5/6/2025, at 11:00 AM, surveyor observed R2 in her bedroom. R2 stated that sometimes the nurses take forever to administer medications. R2 stated that today she received her medications. R2 stated that she is not sure when. On 05/06/2025, at 11: 05 AM, surveyor asked V3 to show him the medication administration report for the 3rd floor residents. R1, R2, and R6's medication administration report (MAR) was marked red. Surveyor asked V3 what does it mean when residents' reports are marked 'Red'. V3 stated that if the medication administration report is 'red' that means the nurse has not documented that the medications were given. V3 stated that he is not sure if V4 (Registered Nurse) has administered all her medications yet. On 05/06/2025, at 11:14 AM, R1 stated that he has not received…

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 accurately document the dosage of one (R6) resident's antibiotic order. This failure has the potential to affect one (R6) resident out of six residents reviewed for professional standards. Findings include: R6's diagnoses include but are not limited to cerebral palsy; hydrocephalus; epilepsy; drug-induced systemic lupus; urinary tract infection; anxiety; and psychosis. R6's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 09 which indicates that R6's cognition is moderately impaired. R6's Order Summary Report, dated 4/9/25, documents, in part, Meropenem Intravenous Solution Reconstituted (Meropenem) Use 1 mg (milligram) intravenously three times a day for UTI (urinary tract infection) until 03/13/2025 23:59. R6's progress note, per dated 3/6/25 at 6:21 pm, documents, in part, Relayed the lab result urine culture to NP (nurse practitioner), per NP ordered Meropenem IV 1 mg (milligram) every 8…

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 sufficient dietary staff to carry out the functions of the food and nutrition service by not following posted mealtime schedule resulting in residents receiving their meals late for six (R4, R6, R7, R12, R13 and R17) residents reviewed for Dietary Services. These failures have the potential to affect all 141 residents receiving oral diets from the facility's kitchen. The findings include: On 3/25/25 At 11:24am Observed R7 lying in bed, on moderate high back rest, alert and oriented x 3, verbally responsive. She stated dinner tray was very late several times in the past few weeks. R7 said dinner is usually served around 5pm, but these couple of weeks dinner tray were served past 7pm. She said dietary is short staff, so meal tray is served so late. R7's admission record showed initial admit date on 4/18/2024 with diagnoses not limited to Quadriplegia, Epilepsy, Iron deficiency anemia, Chronic respiratory failure with hypoxia, Essential…

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 serve adequate food portions as documented on the recipes and spreadsheets. This failure has the potential to affect all 141 residents receiving food prepared in the facility's kitchen. Findings Include: On 03/25/25 at 12:10 PM, surveyor entered kitchen and observed lunch tray line in progress. V23 (Cook) stated the residents were receiving Country Fried Steak, Mashed Potatoes, Peas, and Vanilla Pudding for lunch today. Observed V24 (Cook) using the following serving utensils to serve food on the tray line including #10 scoop for Mashed Potatoes, #16 scoop for Pureed Country Fried Steak, #20 scoop for Ground Country Fried Steak. The Vanilla Pudding had already been pre-portioned into bowls. Portions of Mashed Potatoes, Pureed Country Fried Steak, Ground Country Fried Steak and Vanilla Pudding appeared smaller than standard portion size. On 03/25/25 at 12:25 PM, V25 (Dietary Aide) stated she is the one who portioned out the Vanilla Pudding for dessert and she used the #12 scoop. On 03/25/25 at 12:32 PM, V24…

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 meals as per posted mealtime schedule and to ensure there are no more than 14 hours between the evening meal and breakfast the following day with a substantial or nourishing bedtime snack available/offered to everyone for six (R4, R6, R7, R12, R13 and R17) residents reviewed for Dietary services. These failures have the potential to affect all 141 residents receiving oral diets from the facility's kitchen. The findings include: On 3/25/25 At 11:24am Observed R7 lying in bed, on moderate high back rest, Alert and oriented x 3, verbally responsive. She stated dinner tray was very late several times in the past few weeks. R7 said dinner is usually served around 5pm, but these couple of weeks dinner tray were served past 7pm. On 3/25/25 At 11:50AM R6 observed up on wheelchair, alert and oriented x 3, verbally responsive. He said at times, meal tray comes late. R6 said usually dinner is around 5pm. He said couple of times these past few…

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 On 3/25/25 At 11:24am Observed R7 lying in bed, on moderate high back rest, alert and oriented x 3, verbally responsive. She stated food temperature is terrible, she was served with cold food instead of being warm / hot. R7's admission record showed initial admit date on 4/18/2024 with diagnoses not limited to Quadriplegia, Epilepsy, Iron deficiency anemia, Chronic respiratory failure with hypoxia, Essential (primary) hypertension. MDS (Minimum Data Set) dated 2/11/2025 showed R7's cognition was intact and needed total assistance with eating. R7's order summary report dated 3/26/25 showed order not limited to General diet, Regular texture, Thin Liquids consistency. Resident Council Meeting Minutes dated 02/26/25 documents in part, residents noted that meals and coffee are not consistently served hot. Facility provided policy titled, Resident Satisfaction dated 04/2017 which documents in part, the facility will serve foods that are palatable, attractive and at proper temperature to ensure resident satisfaction.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to follow their grievance policy. The facility [A] failed to immediately report all alleged lost or stolen items [B] failed to report missing items to administrator. The facility also failed to follow resident rights [C] failed to keep resident property from being lost or stolen. These failures affected one [R3] resident out of five reviewed for resident rights. Findings include, R3's clinical record indicates in part; R3 is a seventy-two-year-old admitted with limited to amenia, history of venous thrombosis, obesity, essential hypertension, lymphedema, delusional, schizophrenia, chronic ulcer, acute embolism right femoral vein. Minimum data set [MDS] Brief Interview Mental Status Score [13] Indicates R3 is cognitively intact. R3's care plan indicates in part: 3/12/25 R3 has shown a preference of wearing one outfit despites staff education and encouragement. R3's Progress Notes: 3/12/2025 18:00 V17 [Social Service Director] Note Note Text: Met with R3 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide safe and sanitary environment for one resident (R12) reviewed for Physical Environment. Findings include: On 03/25/25 at 10:08 AM, observed R12 lying in bed with a soft cast on her right hand/arm and a black eye. R12 stated she has been at the facility for approximately two weeks and has been in the same room the entire time. Observed sink in R12's bathroom with a garbage can underneath the sink filled approximately 25% with water. When surveyor turned on the cold water there was a steady stream of water dripping from the pipe under the sink and into the garbage bucket. No water was observed on the floor in the bathroom. On 03/25/25 at 10:10 AM, R12 stated her bathroom sink leaks and has been like that since she was admitted to the facility. R12 stated they keep a garbage can underneath to catch the water and dump out the water when it fills up. R12 stated she uses the bathroom sink to wash her face and brush her teeth but that she…

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 review of records, the facility failed to accommodate resident rights per facility policy pertaining to basic needs for clothing for one out of one resident (R12) for a total sample of 3 residents reviewed for resident rights. Findings include: R12 is [AGE] years old, initially admitted on [DATE]. R12 cognition is intact during conversation. R12 has a BIMS (Brief Interview of Mental Status) scored 13 dated 02/13/2025. On 03/5/2025, at 12:43 PM, R12 stated that she was not allowed to go to the store. R12 that is a big problem to her. R12 said, I don't have any clothes with me. V12 said that her clothes were lost in the facility. She asked to go to the store and was told by V10 (Activity Director) that she could go. But until now she was not able to go. V12 said, I do not tell them anymore because nothing happens. R12 was wearing brown jacket, light blue shirt, and gray sweatpants. Two housekeeping staff went inside the room to deliver clothes for R12. One of the housekeeping…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of records the facility failed to provide resident with a person-centered plan of care related to trachea infection and behavioral concern on suctioning of tracheostomy and care plan meeting for 1 out of 3 residents (R11) reviewed for interdisciplinary team care plan. Findings include: R11 is [AGE] years old, initially admitted in the facility on 10/31/2023. R11 medical diagnosis includes quadriplegia, seizure, respiratory failure with hypoxia, uses tracheostomy. R1 cognition is intact with brief interview of mental status of 15 dated 02/11/2025. On 03/05/2025, at 10:49 AM, R11 stated she got infected with MRSA in the tracheostomy at the end of January or the first week of February. R11 said, I got an antibiotic for MRSA. I was on a IV (intravenous) antibiotic. On 03/06/2025, at 10:02 AM, V2 (Director of Nursing) stated that possible cause of the trachea infection was due to R11 asking to be suctioned all the time. Even without secretions, R11 will ask to be suctioned. R11 will…

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 review of record, the facility failed provide an individual closet space for 1 out of 1 resident (R12) for a total sample of 3 residents reviewed for functional furniture to address residents' needs. Findings include: R12 is [AGE] years old, initially admitted on [DATE]. R12's cognition is intact during conversation. R12 has a BIMS (Brief Interview of Mental Status) scored 13 dated 02/13/2025. R12 is alert. On 03/5/2025, at 12:43 PM, R12 stated that she was not allowed to go to the store and that is a big problem to her. R12 said, I don't have no clothes with me. V12 said that her clothes were lost in the facility and she asked to go to the store. R12 was told by V10 (Activity Director) she could go. But until now she was not able to go. V12 said, I do not tell them anymore because nothing happens. R12 was wearing brown jacket, light blue shirt, and gray sweatpants. Two housekeeping staff went inside the room to deliver clothes for R16. One of the housekeeping staff stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of records the facility failed to follow it's policy on investigating incidents of abuse for 1 out of 3 residents (R5) reviewed for the right of every resident to be free from abuse. Findings include: On 02/11/2025 at 11:10 AM, R5 was initially seen in his room sleeping. R5 was unable to respond by calling his name multiple times. On 02/14/2025 at 09:44 AM, R5 was with V19 (Certified Nursing Assistant) was seen doing bedside care. R5 was on his bed awake but does not respond when his first name was called. R5 stares to the wall without reaction to any conversation. V19 stated that R5 does not talk and only respond to his name. V19 stated that R5 can walk if he wants to. And that R5 declines because he is now on hospice. V19 said, He does not understand and only respond to his name. R5 is [AGE] years old, initially admitted in facility on 12/28/2020. R5 medical diagnosis includes dementia / Alzheimer's disease, cognitive cognition deficit, brain disorder, behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing and nebulizer trach mask) and failed to properly contain oxygen equipment (nebulizer trach mask) per the facility policy. These failures affected one resident (R3) reviewed of oxygen care. Findings include: R3's face sheet shows that R3 has diagnoses which includes but not limited to quadriplegia, recurrent dislocation of right and left hip, asthma, epilepsy, tracheostomy, chronic respiratory failure with hypoxia, chronic embolism, and thrombosis. R3's Brief Interview for Mental Status (BIMS) dated 11/4/24 documents in part a BIMS score of 15. R3 is cognitively intact. On 2/10/25 at 1:35 pm, observation of R3's trach nebulizer mask lying in a grey basin with wound care cleaner and antifungal powder uncontained and not dated. Oxygen tubing not dated. On 2/11/25 at 10:36 am, observation of R3's trach nebulizer mask lying in a grey basin with wound care cleaner and antifungal powder uncontained…

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 supervision and monitoring of residents to prevent residents from smoking in the facility and ensure residents practice safe smoking in the designated area for two (R2 and R4) residents and has the potential to affect (R5, R6, and R7) residents reviewed for smoking safety on the sample list of nine. Findings include: On 01/18/2025, at 1:23 PM, R1 states R2 has been smoking in the facility unauthorized. R1 states he has never seen R2 smoking cigarettes in the facility, but he can smell cigarette smoke coming from R2s' room. R1 states a CNA/Certified Nursing Assistant staff member (identified as V14) also smelled smoke in the third-floor shower room while R2 was the only person inside the shower room. R1 states he reports his suspicion of R2 smoking in the facility to all the staff members, but they tell R1 they don't see it happening. R1 states there are several residents who are prescribed oxygen in the facility and the smoking affects them. On 01/18/2025, at 1:54 PM, surveyor enters R2s' room to…

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

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure the (3rd floor) medication cart was locked or attended by authorized staff. These failures have the potential to affect 48 (3rd floor) residents. Findings include: The 1/5/25 facility census includes 48 (3rd floor) residents. On 1/6/25 at 12:52pm, surveyor arrived on 3rd floor (via elevator) with V3 (Housekeeping) and entered the unit. Upon arrival, there were no staff present in the (3rd floor) hallway and/or Nursing station (except V3, who had just arrived) and the medication cart was noted to be unlocked and unattended. Surveyor inquired if staff were present at the Nursing station (where the unlocked medication cart was located) V3 stated No. Surveyor subsequently inquired if V3 could open drawer of the medication cart, V3 was hesitant to do so however was able to open the drawer. Surveyor inquired if the medication cart was locked at this time V3 responded It not locked. On 1/6/25 at 12:54pm, V4 (Licensed Practical Nurse) approached the (3rd floor)…

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 prevent resident to resident abuse. This failure resulted in R3 and R4 engaging in a verbal altercation that led to R3 hitting R4 while in the hallway. Findings Include: On 12/10/24 at 11:36 AM, R3 stated that R4 was cursing R3 in the hallway few weeks ago, and R3 used R3's foot to hit R4's jaw while R4 was sitting in wheelchair. On 12/11/24 at 10:04 AM, R4 received alert in bed, appeared weak. R4 stated that R4 was up in wheelchair in the hallway arguing with R3, and R3 hit R4 on the cheek. R4 stated that R4 did not hit R3. On 12/11/24 at 11:30 AM, V18 (CNA) stated that V18 worked 3PM-11PM shift with R3 and R4 on the date of the incident (11/01/24). V18 stated that V18 heard R3 and R4 arguing around 4 PM, and the argument turned to R3 fighting with R4, and R3 hit R4. V18 stated that hitting is a form of physical abuse. On 12/11/24 at 12:34 AM, V19 (Director of Social Services) stated that V19 heard that R3 and R4 were pushing and hitting each other in the hallway and staff immediately separated R3 and R4. V19 stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by involuntarily holding a resident in their room by blocking or holding the door closed with the use of a garbage bag. This failure affected 1 (R2) of 6 residents reviewed. Findings Include: R2 is a [AGE] year-old male. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is severely cognitively impaired and has a diagnosis of Unspecified Dementia, with other behavioral disturbance, other disorders of brain, Alzheimer's disease, Cognitive communication deficit, Type 2 diabetes mellitus, Essential hypertension, other abnormalities of gait and mobility, and need for assistance with personal care. On 12/10/24 at 11:54 AM, R2 was observed pacing in R2's room. R2 appeared to be confused. Surveyor asked R2 if staff has blocked R2's door with a bag and if staff has been physically abusive to R2? R2 was unable to remember, R2's cognition is severely impaired. On 12/11/24 at V11 (CNA) stated that V11 was only in this facility for six…

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 develop and implement a baseline care plan for falls upon admission and follow their incidents/accidents/falls policy to provide interventions for prevention of falls for 1 out of 3 residents (R6) with multiple falls. These failures affected 1 resident (R6) who had multiple falls in the facility without proper interventions and/or preventive measures. Findings include: R6 is [AGE] years old, initially admitted in the facility on 8/27/2024 with diagnosis that includes vascular dementia, cerebral infarction, and hemiplegia and hemiparesis. R6 cognition was moderately impaired with brief interview for mental status (BIMS) dated 10/4/2024 scored 8. R6's assessment on functional abilities dated 10/4/2024 documents that R6 has an impairment on both sides of his lower extremities. Progress notes of R6 related to fall: V19 (Registered Nurse) initial admission notes dated 8/28/2024, documents: Report from the hospital that R6 had history of multiple falls…

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 accommodations for a resident to easily get to the bathroom in the resident's room. This failure affects two residents (R1, R3) of the three residents reviewed for accommodations of needs. Findings include: R1's diagnosis include but are not limited to type 2 diabetes mellitus without complications, morbid (severe) obesity due to excess calories, acute pulmonary edema, unspecified asthma, uncomplicated, chronic respiratory failure with hypoxia, heart failure, unspecified, weakness, unsteadiness on feet, cellulitis of left lower limb, acute embolism and thrombosis of unspecified veins of right upper extremity, idiopathic gout, essential (primary) hypertension, hyperlipidemia, unspecified, hypothyroidism, unspecified, body mass index [bmi] 70 or greater, adult. R1's Brief Interview for Mental Status (BIMS) dated 10/09/2024 documents R1 has a BIMS score of 15 which indicates R1's cognition is intact. On 10/22/2024 at 11:47am observed a wide sized wheelchair in R1's room. On 10/22/2024 at 11:48am…

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

Based on observation, interview and record review the facility failed to ensure the kitchen equipment and preparation area was clean, follow cleaning schedule for the kitchen and equipment and label/ date stored food, and discard expired food. These deficient practices have the potential to affect all 139 residents receiving food prepared in the facility's kitchen. Findings include: On 10/9/24 at 9:28 AM, V18 [Cook] stated, We do not have a dietary manager, I am a cook, but I am not in charge, please speak to V15 [Cook], I think he is in charge of the kitchen. On 10/9/24 at 9:30AM, V15 stated, I am not in charge of the kitchen, I am just a cook. The administrator is over the kitchen. I only been working her for seven months; I do not know who is in charge. The dietary manager left a couple months ago. Surveyor and V15 observed on the clean dish racks, a bag, coffee cup, paper cutter, resident's meal tickets, and 3-tier metal file organizer, on the rack above the clean plant lids and coffee cups. On the clean plate lids, and coffee cups, noted small paper pieces all over the clean…

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 make arrangements for one [R7] of eight residents reviewed to attend religious services of their choice. Findings Include, R7's clinical record indicates in part; R7's medical diagnosis includes but not limited to cerebral infarction with hemiplegia/hemiparesis affecting left dominant side, type II diabetes, atherosclerotic heart disease, dementia, systemic lupus, nephrotic syndrome, anemia, chronic kidney disease, essential hypertension, thyrotoxicosis, atrial fibrillation. Dysphagia, need assistance with personal care, weakness, anxiety disorder, and bipolar disorder. R7's minimum data set brief interview mental status dated 8/7/24 indicate R7 is cognitively intact. R7's 2/11/22 [Latest Quarterly Activity Evaluation Completed] documents in part. R7 is oriented x2-3 and is able to make needs and wants known although, speech is sometimes hard to understand. R7 is non-ambulatory and is assisted by a wheelchair. R7 enjoys talking to staff and peers, participating in arm and mind strengthening work outs, listening to calm…

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 protect the resident's right to be free from physical abuse (R2) by another resident that has documented aggressive behavior (R4) for two (R2,R4) of four residents reviewed for abuse. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R2's Physical Aggression Received dated 09/29/24 document in part: This writer was sitting at the nurse's station when hollering could be heard coming from the dining room. When walking into the dining room…

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 thoroughly investigate an allegation of physical abuse for one (R2) of four residents who were reviewed for abuse. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R2's Physical Aggression Received dated 09/29/24 document in part: This writer was sitting at the nurse's station when hollering could be heard coming from the dining room. When walking into the dining room the two residents' (R2, R4) were seen near each other and one said he…

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 double portions as listed on the resident's meal ticket for 1 (R2) of 3 residents reviewed for nutrition. Findings Include: R2 has diagnosis not limited to Abnormalities of Gait and Mobility, Cognitive Communication Deficit, Essential (Primary) Hypertension, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Schizoaffective Disorder, Bipolar Type, Obstructive and Reflux Uropathy, Type 2 Diabetes Mellitus, Suicidal Ideations, Delusional Disorders, Polyosteoarthritis, Atherosclerotic Heart Disease of Native Coronary Artery, Peptic Ulcer and Contact with and (Suspected) Exposure to other Viral Communicable Diseases. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Wednesday 10/09/24 menu document in part: Lunch Breaded Pork Chop 3 ounces., Baked Sweet Potatoes with butter and brown sugar 1 potato, Mixed Vegetables 4 ounces, Peanut Butter Pie and 8-ounce beverage. R2's Lunch meal ticket that was observed on his meal tray 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 interviews and record reviews, the facility failed to follow physician's orders for therapy evaluation and treatment for one (R3) out of five residents reviewed for therapy services. Findings include: R3's admission Record and Order Summary Report document in part diagnoses of spinal stenosis (narrowing of the spaces inside the bones which can put pressure on the spinal cord), radiculopathy (pinched nerve), morbid obesity, osteoarthritis (degenerative joint disease), and muscle wasting and atrophy. R3's care plan contains a focus for spinal stenosis. Intervention includes PT (Physical Therapy)/OT (Occupational Therapy) eval and treatment as indicated (date initiated 5/28/2024). R3's care plan documents in part that R3 requires extensive to total assistance with most activities of daily living affecting all extremities (last revised 6/07/2024). It also documents in part that R3 has a self-care deficit with impaired dressing and grooming abilities (last revised 6/07/2024). R3's Order Summary Report documents in part an active order for PT, OT, ST (Speech Therapy) screen 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 interviews and record reviews, the facility failed to follow their policy and ensure a complete and accurate accounting of a resident's (R1) funds and ensure that R1 was not charged for services that were already covered under Medicaid for one out of three residents reviewed for personal funds. Findings include: R1's admission Record and Clinical Census document in part that R1 has Medicaid. R1 discharged from the facility on 8/26/2024. R1's Resident Statement Landscape documents in part Care Cost Auto [Withdrawal] of $757 on 7/03/2024. There was also a charge of $199.36 for Insurance Premiums on 7/11/2024. On 8/29/2024 at 10:55 AM, V1 (Administrator) stated R1 inquired about Trust Fund account sometime last week prior to discharge. V1 sent an email to V6 (Acting Business Office Manager) and V9 (Accounts Receivable) to review R1's account but has not heard back from V9 yet. Surveyor reviewed the e-mail thread between V1, V6 and V9. On 8/23/2024 V1 sent an e-mail to V6 regarding R1's trust fund account dispute. E-mail documents in part: Last month [R1] received $42.00. [R1]…

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 store potentially hazardous food, ensure that the walk-in freezer remained securely closed, maintain a clean walk-in freezer and oven, cover prepared food, and serve milk that was not spoiled. This has the potential to affect all residents that receive their nutritional needs from the kitchen. Findings include: On 8/13/2024 at 10:00 AM, surveyor conducted an initial kitchen tour with V4 (Dietary Director). In the walk-in refrigerator there was a silver pan of unsealed, thawed chicken. There was a torn piece of foil on top of the pan with the date of 8/6. The pan was sitting on top of more thawed chicken in a plastic wrap. V4 stated facility was not serving chicken as the main dish for lunch but facility has a resident that consumes mostly chicken. V4 grabbed the pan and placed it on a metal shelf next to a pan of unsealed, sliced turkey. It had a plastic wrap that was pealed back. Date on the clear, plastic wrap was 8/10. At 10:05 AM, surveyor and V4 went to the walk-in freezer. Walk-in freezer…

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 have adequate staffing to ensure one [R9] resident's ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all 44 residents residing on the 4th floor. Findings Include: During the facility tour from 9AM to 11 AM, noted the fourth floor there was offensive odors, and residents in bed and not dressed. On 8/13/24 at 11:22 AM, V41 [R9's Family Member] waved surveyor into the R9's room. Entering R9's room, noted strong offensive odors. R9 was resting in bed lying on his left side. V41 stated, Please help me, R9 smells like feces and urine, I need someone to check him to see if R9 needs changing. Surveyor went into the hallway and asked V9 [Registered Nurse] for assistance. V9 stated, I am R9's nurse and I can check to see if R9 needs to be changed. On 8/13/24 at 11:30 AM, V41 and R9 gave surveyor permission to observe incontinence care. V9 detached R9's under brief, surveyor, V9, and V41 observed and half of the under brief was inside R9's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician medication orders were followed as written and medications were administered as ordered by the physician for 1 (R1) of 3 residents reviewed for physician orders. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Anxiety Disorder, Encephalopathy, Insomnia, Nutritional Anemia, Anorexia, Hyperosmolality and Hypernatremia, Disease of Esophagus, , Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Attention-Deficit Hyperactivity Disorder, Epilepsy, Vitamin D Deficiency, Gastrostomy Status, Adult Failure to Thrive, Esophageal Obstruction, Disorders of Electrolyte and Fluid Balance, Severe Protein-Calorie Malnutrition, Cellulitis of Abdominal Wall and Conversion Disorder with Seizures or Convulsions. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 13 indicating intact cognitive response. Physician Orders: document in part: Flush enteral tube with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide timely incontinence care and assistance with turning and repositioning for one [R9] resident who requires assistance with activities of daily living in a total sample of 15 residents. Findings include: R9 clinical record indicates in part: R9 is a [AGE] year-old, with the following medical diagnosis includes but not limited to need for assistance with personal care, dementia, essential (primary) hypertension, weakness, legal blindness, cognitive communication deficit, and unsteadiness on feet. R9's Minimum Data Set (MDS) section [C] dated 7/2/24 score of [6] indicates R9 is moderately impaired. R9s' MDS section [GG] indicates R9 is total dependent for all of his activities of daily living such eating, oral hygiene, shower, bathing, upper and lower body dressing, putting on and off footwear, personal hygiene, rolling left and right, toileting, sit to stand, and transfers. R9's care plan dated 7/14/24: R9 is incontinent of bladder…

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 adequate staffing to ensure two resident's (R8, R9) ADL (Activities of Daily Living) needs were met in a timely manner. The facility's short staffing has the potential to affect all 137 residents residing in the facility as of the census dated 08/06/24. Findings include: On 08/06/24 at 10:05 AM, observed V10 (Certified Nursing Assistant) enter R8's room and ask R8 if R8 needed to be changed. R8 stated R8 was wet. On 08/06/24 at 10:08 AM, R8 stated R8 is dependent on the staff for most things including toileting care. R8 stated the staff changed R8's brief early this morning around 5:00 AM. R8 stated R8 is wet and has been wet since 8:00 AM. R8 stated R8 does not like sitting in a wet diaper. R8 stated I don't say anything because I know they are busy, and I don't want to hear them tell me You have to wait or we are short staffed. R8 stated, this is typical and I'm used to it. R8 stated there is less staff now to get the help R8…

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 sufficient dietary staffing resulting in meals being delivered late, outside of posted meal schedule. These failures have the potential to affect all 135 residents receiving food prepared in the facility's kitchen. Findings include: On 08/06/24 at 11:33 AM, V4 (Dietary Director) stated, we are in the process of hiring. We are short two evening Dietary Aides. V4 stated the kitchen has been short staffed for approximately 1 month. V4 stated full staff means one [NAME] and two Dietary Aides for the morning shift (6AM-2PM) and one [NAME] and two Dietary Aides for evening shift (12PM-8PM). V4 stated the mealtimes are: breakfast 7:15-7:45 AM, lunch 11:30-12:15 PM, and dinner 4:40-5:30 PM and each unit has a specific time frame for delivery within those time frames. V4 stated there have been no changes in the meal delivery schedule since V4 has been working at the facility five months ago. V4 stated there has been no issues with…

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

Based on observation, interview, and record review the facility failed to ensure food was served at a palatable temperature and appetizing taste. This deficient practice has the potential to affect all 135 residents receiving food prepared in the facility's kitchen. Findings include: On 8/6/24 at 10:48 AM, R11 stated that the food in the facility is not good. R11 stated, Sometimes the meat is not cooked, and the veggies are hard. Like the eggs it's runny. Sometimes I ask for substitute I don't get it. Sometimes I don't get what's on the menu. I have been complaining about food a lot of times. They are not addressing it. On 8/6/24 at 10:54 AM, Surveyor asked R12 about the food in the facility and stated, The food be cold. Whatever it says on the menu they be lying, and they don't give it to us. Sometimes the food is not cooked. When we go down to the kitchen to complain they ignore us. On 8/6/24 at 11:09 AM, R10 stated R10 has concerns with the food in the facility. R10 stated, Sometimes I don't get the food on the menu. They are giving us too much red meat. I'm not a picky eater but…

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 diet spreadsheet was followed for 4 (R19, R20, R21, R22) out of 4 residents who were receiving mechanical and pureed diets. This failure has the potential to affect all 29 residents receiving mechanical and pureed diets in the facility's kitchen. Findings Include: On 8/7/24 at 9:50 AM, Surveyor observed menu posted in the kitchen. Lunch menu showed Herbed Pork Roast, [NAME] Pilaf, Steamed Broccoli, Cinnamon Scalloped Peaches, Dinner Roll/Margarine, and Beverage. At approximately 10:02 AM, V15 (Cook) was preparing mashed potato using powdered mix from a package. Surveyor asked V15 if that will be served that day to the residents for lunch or dinner. V15 answered that it will be served for lunch that day for residents who are on mechanical and pureed diets. On 8/7/24 at 12:28 PM, lunch observation conducted on 2nd floor west wing. No signage for substitute on the menu posted on 2nd floor west wing. Lunch menu showed Herbed Pork…

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 Activities of Daily Living (ADL) care was provided for dependent residents who required assistance with bladder and bowel incontinence for two residents (R8, R9) reviewed for ADL care. Findings include: On 08/06/24 at 10:05 AM, observed V10 (Certified Nursing Assistant) enter R8's room and asked R8 if R8 needed to be changed. R8 stated R8 was wet. On 08/06/24 at 10:08 AM, R8 stated R8 is dependent on the staff for most things including toileting care. R8 stated the staff changed R8's brief early this morning around 5:00 AM and that this is the first time someone has asked R8 since then if R8 needed to be changed. R8 stated R8 knows when R8 is wet or soiled. R8 stated R8 was not wet in the morning at 7:00 AM but that V10 did not ask R8 if R8 was wet at that time. R8 stated R8 has been wet since 8:00 AM. R8 stated R8 does not like sitting in a wet diaper. R8 stated I don't say anything because I know they are busy, and I don't want to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physician order for G-tube (Gastrostomy) feeding, flushing, and dressing change for 2 (R5 and R6) of 3 residents reviewed for enteral feeding. The findings include: R5's face sheet showed initial admission date on 11/9/23 with diagnoses not limited to Encephalopathy, Chronic obstructive pulmonary disease, Unspecified severe protein-calorie malnutrition, Unspecified sequelae of cerebral infarction, Anxiety disorder, Gastro-esophageal reflux disease, Epilepsy, Insomnia, Nutritional anemia, Major depressive disorder, Post-traumatic stress disorder, Vitamin d deficiency, Gastrostomy status, Conversion disorder with seizures or convulsions, Cellulitis of abdominal wall, Borderline personality disorder, Patient's noncompliance with other medical treatment and regimen due to unspecified reason, Emotional lability, Poisoning by unspecified drugs, medicaments and biological substances intentional self-harm, Bell's palsy, Esophageal…

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 complete pre-employment screening of a potential employee for one of three (V6 Certified Nursing Assistant) reviewed for health care worker background checks. Findings include: On 4/18/2024 11:56 AM, V3 (Human Resources) said, regarding V6 (Certified Nursing Assistant), I think there was a missed communication. She initially applied around the end of January 2024. I ran her background check; she looked good on paper. We wanted to hire her. I sent her an email regarding her onboarding. I set up an orientation date, she never completing onboarding, never showed up for orientation. V3 said, she (V6) came in again the beginning of March. She filled out a new application on 3/19/24. She returned the next day, I had someone at the front desk call someone to interview her. They called V4 (Scheduler). instead of interviewing her, they discussed a schedule. Per V4, V6 told V4 she completed the onboarding. I found out that she was on the floor, I told (V4) to remove her from the floor. I ran the background check a second time; she…

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 prepared by methods that conserve palatability, and at a safe and appetizing temperature. This failure affects 139 residents who receive food from facility kitchen. Findings include: On 04/02/24 at 11:59AM, R111 states the food is cold when it is served to the residents. R111 states staff tells her that they do not have a microwave to heat the food up and she has to eat her meals cold. On 04/03/2024 at 10:51AM, surveyor located inside of the kitchen observing the tray line service. V11 (Cook) observed preparing resident food and plating resident meals for lunch service. V11 observed preparing baked chicken, spaghetti pasta, spaghetti meat sauce, and mixed vegetables. Surveyor did not observe V11 perform temperature reading checks of resident food prepared in the kitchen by V11. After V11 plated five resident meal trays and placed them on the meal cart for transportation to residents, V11 was asked about temperature readings for the resident's lunch meal that V11 prepared. V11 did not perform…

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 by food not properly labeled, food not properly stored, equipment used for food preparation not adequately sanitized. These deficient practices have the potential to affect all 139 residents receiving food prepared in the facility kitchen. Findings include: On 04/02/2024 at 9:49 AM during initial kitchen tour with V6 (Director of Dietary), the following food items were found in the walk-in cooler: 1. 1 box of open bacon with a receive date of 03/28/2024, no expiration or use by date. 2. 1 pan covered with aluminum foil with cooked chicken inside, no food identification label, no expiration or use by date. 3. 1 package of ham meat placed inside of a white tub container, no food identification label, no receive date. 4. 1 box of open lettuce, no expiration or use by date. 5. 3 packages of open cheese slices wrapped in plastic wrap, no food identification label, no expiration or use by date. 6. 1 box of open tomatoes, no expiration or use by date. 7. 1 box 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 observation, interview and record review, the facility failed to lock one medication cart while unattended, label unsealed medications, and discard expired medications in four out of six carts reviewed for medication labeling and storage. These failures have the potential to affect ninety-one residents receiving medication from the third and fourth floors medication carts. Findings include: On 04/02/2024 at 9:44am, surveyor observed V17 (Registered Nurse) leave medication cart open while taking R71 his medications. After V17 gave R71 medications, (V17) proceeded down the east end of hall leaving cart unlocked to go borrow a blood pressure cuff from V18. On 04/02/2024 at 9:45am surveyor observed V17 leave medication cart unattended and unlocked on the west hall of the unit. On 04/02/2024 at 9:46am V17 (Registered Nurse) states, keeping the medication cart locked is important. It's a safety issue. Medication can come up missing or residents can get in the cart which, is not safe. On 04/02/2024 at 10:20am V18 (Registered Nurse) states, it is very important to keep 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 maintain a sanitary and homelike environment for one (R118) out of 33 residents reviewed for environment in the sample of 33 residents. Findings include: On 04/02/24 at 11:28AM, R118 lying in bed, asleep, in the corner of the room nearest to his bed, were multiple green and pink linen pads on the floor, bundled up. R118's Physician Order Sheet dated 04/03/2024 documents: Enhanced Barrier Precautions: Wounds. R118's current face sheet documents R118 is a [AGE] year-old individual admitted to the facility on [DATE], medical diagnosis includes but not limited to: Paraplegia, Anemia, Pressure Ulcer of Sacral Region. R118's Minimum Data Set (01/10/2024) documented, in part Cognitive Patterns: BIMS (Brief Interview for Mental Status) Summary Score: 13 out of 15 Indicating R118's mental status as cognitively intact. On 04/02/2024 at 11:36AM V3 (Certified Nursing Assistant/CNA) stated that she has been working for the facility for six years. V3…

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 develop and/or implement a discharge care plan for one (R45) resident who had expressed a desire to discharge from the facility of 3 reviewed for discharge in the total sample of 33 residents. Findings include: On 04/02/24 10:59 AM, observed R45 sitting up in his bed, in no respiratory distress. R45 states that he has been in the facility for a while now, R45 states that he wants to discharge, and that social services staff change frequently. R45 states that he has informed different social workers that R45 is interested in leaving the facility. R45 states that he would like to move to Puerto Rico eventually, but he is interested in leaving from the facility, but he is not allowed to. Observed R45 standing and walking around R45's room with a cane. R45 states that he uses oxygen therapy as needed. R45's Minimum Data Set, dated [DATE] documented, in part : BIMS (Brief Interview for Mental Status) Summary Score: 12/15. Indicating R45's mental status 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, interviews and records review, the facility failed to follow its oxygen tubing policy by failing to date the tubing for one (R59) of three residents reviewed for oxygen in a sample of 33. Findings include: On 4/1/2024 at 11:34am, R59 was observed in his room siting on his bed and was alert and oriented to person, place, time, and was observed wearing his nasal cannula on his nose, with his oxygen running at 5LPM (liters per minute) V59's nasal cannula tubing was not labeled with date when it was changed. V59 stated he also uses his C-Pap machine when he sleeps even during the day. R59's current face sheet document R1's medical conditions to include but not limited to acute and chronic respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, acute pulmonary edema, obstructive sleep apnea, and R59's Brief Interview for Mental Status (BIMS), dated [DATE], documents R59's BIMS as 15/15, indicating he has intact cognitive function. On 04/02/2024 at 12:13am, with V4…

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 prevent a resident from eating other resident's unfinished food during meal time for one resident (R139) out of five residents reviewed for infection control in a sample of 33. Findings include: R139's current face sheet documents R139 is a [AGE] year-old individual with medical diagnosis includes but not limited to: type 2 diabetes mellitus without complications, narcissistic personality disorder, schizoaffective disorder, bipolar type, liver disease, unspecified. R139's MDS (Minimum Data Set) section C-Cognitive functions document R139's BIMS (Brief Interview for Mental Status) dated 2/7/2024 documents R139's BIMS as 13/15, indicating R139 has intact cognition. On 04/01/2024 at 11:55am, V3 (Certified Nursing Assistant -CNA) was observed talking to R139 and taking the empty food tray from him. V3 stated the food tray was not for R139, and R139 ate his breakfast earlier, and V3 does not know what was on the tray that R139 was eating from,…

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

Based on observation, interview, and record review the facility failed to provide adequate supervision for five of six residents (R3, R11, R12, R13, and R14) in the sample reviewed for supervision and falls. This failure affected R3, R11, R12, R13, and R14 who were observed in the dining room without visual staff supervision. Findings include: On 03/11/24 at 11:05am, R3, R11, R12, R13, and R14 were observed in the dining room without any visual staff supervision and no activity going on. R3 was observed trying to hold on to the dining table and move into the regular chair in front of the wheelchair. R3 was observed to be unable to move freely and was about to fall. R11 observed in wheelchair struggling to get some documents from the floor including social security card and nearly falling off the wheelchair. The surveyor then called on V12 CNA (Certified Nurse Aide) who was sitting at the nurse's station desk to come into the dining room and assist these residents. V12 stated that she is supposed to sit in the dining room watching the residents, but she was busy charting on the…

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

Based on observation, interview, and record review the facility failed to ensure that medications were not left at the resident's bedside without physician order for one (R4) of 16 residents reviewed for safety. Findings include: On 03/11/24 at 10:43am, R4 was observed in bed in the room, and on R4's over the bed table was noted a plastic medication administration cup with two pink tablets. R4 stated those are given to me by my nurse. R4 stated they are Benadryl pills for itching and I (R4) will use them later. Albuterol sulfate HFA inhaler with no name and not in the manufacturer's box and Budesonide and Formoterol fumarate Dihydrate inhaler was also noted in a wash basin on top of the side table drawer. This observation was brought to V9's attention, was shown the medications and asked about the facility policy/protocol for medication storage and standard of profession in medication administration. V9 stated I gave the Benadryl to R4 thinking R4 had taken them. V9 stated that R4 is not on any self-medication program. At 10:53am, after checking R4's electronic medical record MAR…

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 and interview, the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment related to offensive odors, unclean floors, and walls in resident rooms. This failure affects R1, R4, R5, R6, R7, R8, R9, R10 and R11 and has the potential to affect all 44 residents residing on the third floor. Findings Include, During the survey dates of 1/2/24 and 1/3/24, surveyor noted offensive odor on the third floor, hallway floors, bedrooms floors, walls, and resident's personal bathrooms floors, and walls, bed side tables were not clean, swept, or mopped. On 1/2/24 at 12:02 PM, R1 stated, I lived on the third floor then moved to the second floor. The third floor always smelled terrible. Now when I go up to the third floor to play bingo, the odor is so offensive. It smells like urine and feces during bingo. On 1/2/24 at 11:57 AM, R4 stated, I been living on the third floor for a while. There is an odor on this floor, because I think more men live on this floor…

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 nursing staff properly documented on the medication administration record. This failure affected one resident (R1) in the sample of 3 residents reviewed for improper nursing care. Findings include: R1's diagnosis includes, but are not limited to, encephalopathy, unspecified, chronic obstructive pulmonary disease, unspecified, unspecified severe protein-calorie malnutrition, unspecified sequelae of cerebral infarction, anxiety disorder, unspecified, gastro-esophageal reflux disease without esophagitis, epilepsy, unspecified, not intractable, without status epilepticus, insomnia, unspecified, nutritional anemia, unspecified, major depressive disorder, single episode, unspecified, difficulty in walking, not elsewhere classified, unsteadiness on feet, need for assistance with personal care, weakness, post-traumatic stress disorder, unspecified, vitamin d deficiency, unspecified, adult failure to thrive, gastrostomy status, borderline personality disorder, patient's noncompliance with medical treatment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure continuity of care after discharge for one resident (R4) by not setting up home health services. Findings include: According to R4 face sheet printed 11/30/23, R4 is [AGE] years old with diagnoses not limited to multiple sclerosis, type 2 diabetes mellitus, peripheral vascular disease, hyperlipidemia, cellulitis, muscle weakness, abnormalities of gait and mobility. MDS, 10/14/23, Brief Interview for Mental Status scores R4 at 15 indicating cognitively intact. MDS, 10/14/23 indicates R4 required partial/moderate assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene. R4 required setup or clean-up assistance with eating, oral hygiene. On 11/29/23 at 1:25 PM, V6 (Social Service Coordinator) stated R4 was discharged to V14's home. R4 told me R4 would be discharging home with V14 and gave me V14 contact information. The first time I talked to V14 was 9/25/23 about…

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 the appropriate discharge information, discharge date and time, for one resident (R4) was communicated to the receiving resident representative or Power of Attorney. Findings include: According to R4 face sheet printed 11/30/23, R4 is [AGE] years old with diagnoses not limited to multiple sclerosis, type 2 diabetes mellitus, peripheral vascular disease, hyperlipidemia, cellulitis, muscle weakness, abnormalities of gait and mobility. MDS, 10/14/23, Brief Interview for Mental Status scores R4 at 15 indicating cognitively intact. MDS, 10/14/23 indicates R4 required partial/moderate assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene. R4 required setup or clean-up assistance with eating, oral hygiene. On 11/29/23 at 1:25 PM, V6 (Social Service Coordinator) stated R4 was discharged to V14's home in Peoria, IL. R4 told me R4 would be discharging home with V14 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one resident (R4). Findings include: According to R4 face sheet printed 11/30/23, R4 is [AGE] years old with diagnoses not limited to multiple sclerosis, type 2 diabetes mellitus, peripheral vascular disease, hyperlipidemia, cellulitis, muscle weakness, abnormalities of gait and mobility. MDS, 10/14/23, Brief Interview for Mental Status scores R4 at 15 indicating cognitively intact. MDS, 10/14/23 indicates R4 required partial/moderate assistance with toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene. R4 required setup or clean-up assistance with eating, oral hygiene. On 11/29/23 at 1:25 PM, V6 (Social Service Coordinator) stated R4 was discharged to V14's home in Peoria, IL. R4 told me R4 would be discharging home with V14 and gave me V14 contact information. The first time I talked to V14 was 9/25/23 about discharge. V14 gave…

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 monitor and supervise residents; failed to implement post fall, fall prevention interventions and update a resident's care plan; failed to implement their policy to immediately report a resident found on the floor and assess a resident found on the floor for 2 of 3 residents (R2 and R4) reviewed for accidents and hazards on the sample list of four. These failures resulted in R2 falling and sustaining a left eyebrow laceration requiring repair at a local emergency room. Findings include: 1. R2 is [AGE] years old, initially admitted on [DATE] with medical diagnoses of dementia, major depressive disorder, anxiety disorder, bipolar disorder, and repeated falls. R2's Brief Interview of Mental Status (BIMS) dated 06/19/2023 scored 0. Per R2's MDS (Minimum Data Set) means that R2 is rarely or never understood. On 10/10/2023 at 11:43 AM, R2 was seen sleeping in her bed with upper side rails up and guards on bilateral sides. R2's bed height was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to appropriately assess for pain and failed to monitor the effectiveness after pain medication administration. These failures apply to 1 of 3 residents (R3) reviewed for pain management on the sample list of four. Findings include: R3 is [AGE] years old, initially admitted on [DATE] in the facility. R3 has a BIMS (brief interview for mental status) dated 07/18/2023 score of 12 which means R3's cognition is intact. R3's medical diagnoses include fracture of left femur. On 10/10/2023 at 12:38 PM, V4 (Registered Nurse) and V5 (Licensed Practical Nurse) at the Nurse's Station. V4 stated that R3 always asked for his Norco (Hydrocodone / APAP (Acetaminophen) 5-325 MG) narcotic medication that is supposed to be given every 8 hours only when needed. V4 showed R3's Norco (Hydrocodone / APAP 5-325 MG) Controlled Drug Receipt/Disposition Form from 9/22/2023 to 10/10/2023. On the record, R3 was receiving Norco every day from 9/22/2023 to 10/10/2023. V4…

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 psychotropic consent form was filled out with the correct diagnosis and classification related to the prescribed antipsychotic medication was documented on the consent form for 1 of 3 residents (R1) reviewed for unnecessary medications on the sample list of four. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's medical diagnoses include dementia, schizophrenia, depressive disorder, and anxiety disorder. On 10/11/2023 at 1:52 PM, V13 (Licensed Practical Nurse) said that his task is to make sure that psychotropic medication is being reviewed by the pharmacy and recommendation is relayed to the psychiatric doctor or his nurse practitioner. V13 presented the following documentation: - R1's psychotropic and sedative/hypnotic review by the pharmacy for July, August, and September 2023. It documents that R1 was receiving Loxapine Succinate capsule 10 MG which was categorized as antipsychotic. And Trazodone Hydrochloride 50…

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 resident received adequate supervision to prevent accidents in 1 of 3 residents (R6) reviewed for falls on the sample list of 14. Findings include: R6 is a [AGE] year-old female with a diagnosis including End Stage Renal Disease, Hemiplegia and Hemiparesis Right Dominant Side, Dementia, Psychotic Disorder, Respiratory Disorder and Seizures. R6 was admitted to the facility on [DATE]. R6 has had two falls since admission, one on 5/16/23 and one fall on 7/29/23. Facility incident report dated 7/29/23 states on 7/29/23 R6 was found in her room on the floor on her right side. R6 had an open area to her right brow area. There was no loss of consciousness, first aid was applied and 911 was called. R6 was transferred to the hospital. It was concluded that R6 fell from bed. R6 was unable to explain what happened. Review of hospital record dated 7/29/23 shows CT scan complete with no acute hemorrhage or masses noted. R6 was diagnosed with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a sanitary environment for two of 12 residents (R4, R9) on the sample list of 14. Findings include: On 8/21/23 at 10AM, room [ROOM NUMBER] was observed with floor heavily soiled from liquid spills food and unidentifiable debris on entire floor surface. On 8/22/23 at 10:30AM, room [ROOM NUMBER] was observed with floor heavily soiled from liquid spills, food and unidentifiable debris on entire floor surface. The bathroom was observed with urine on the floor. The floor was also littered with debris of trash and brown unidentifiable substance. On 8/23/23 at 10:25AM R9 stated the floor is a mess. Last night I tripped and dumped my food tray all over the floor. On 8/23/23 at 1:10PM V14 (Housekeeping Supervisor) stated I only have one housekeeper per floor. The housekeeper starts at one end and goes to the other end of the floor. We do the best we can. Housekeeping policy was requested but not provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Low Air Loss Mattresses were set based on the residents' weight and failed to ensure the Low Air Loss Mattresses were layered with linens per facility policy. These failures affected 4 (R9, R107, R117, and R123) residents reviewed for pressure ulcer/injury prevention and treatment in a sample of 51 residents. Findings include: R107 has an admission diagnosis of but not limited to encephalopathy, diabetes, seizures, depression, bipolar disorder, and thrombocytopenia. R107's Minimum Data Set (MDS), dated [DATE] documents, in part, Brief Interview of Mental Status (BIMS) score is 10. Functional status for Activities of Daily Living (ADL) for Bed Mobility -how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture is documented, in part, for Self- Performance coded as 3, requires extensive assistance and for support is coded as 3, requires two-person physical…

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

Based on observation, interview and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change. This failure has the potential to affect all 20 residents on the 4E unit of the facility. Findings include: The (06/25/2023) Daily Census documented that there were 20 residents at 4East. On 06/27/2023 at 2:05pm, during the Medication Storage and Labeling Task with V21 (Registered Nurse), the (06/2023) 4-East Narcotic Count Verification had missing signatures on shift 7pm - 7am Nurses In/Signature and Nurse Out/Signature on days 4, 8, 15, 17, and 22; and on shift 7am-7pm Nurses In/Signature and Nurse Out/Signature on day 12. This observation was pointed out to V21. V21 stated, the incoming nurse should count the controlled medications with the outgoing nurse. Both nurses have to sign; the outgoing nurse has to sign out and the incoming nurse has to sign in to make sure an accurate number of narcotics and to make sure no controlled medication is missing. On 06/28/2023 at 1:50pm, V2 (Director of Nursing) stated,…

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

Based on observation, interview and record review the facility failed to ensure 4 East medication cart was free of loose pills which has the potential to affect all 20 residents in 4East and failed to ensure staff food item was not stored at the 4th floor's medication storage room refrigerator which has the potential to affect all 44 residents residing in 4th floor. Findings include: On 06/27/2023 at 2:04pm, during the medication storage and labeling task with V21 (Registered Nurse), there were loose pills in the medication cart labeled 4E. V21 counted the loose pills, per this surveyor's request and stated there were 35 loose pills in the cart. On 06/27/2023 at 2:11pm, there was a bottle of coke inside the medication storage refrigerator. This observation was pointed out to V21. V21 stated, the staff kept it there. It is not expected for staff to keep the bottle of coke in the resident's medication refrigerator. It is only for the resident's medication. On 06/28/2023 at 1:57pm, V2 (Director of Nursing) stated, the medication cart should be cleaned by the nurse at the end of each…

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 device was within reach of the 2 residents (R56 and R80). This failure affected 2 residents out of the sample of 51. Findings include: R80 has a diagnosis of but not limited to Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Dehiscence of Amputation Stump, and Hypertension. R80's Brief Interview of Mental Status is 6 that indicates severely impaired. On 6/26/2023 at 12:43pm surveyor observed R80's call light hanging from wall not within reach of R80. Surveyor asked R80 if she could reach her call light. R80 stated, she could not reach the call light. R80 stated, she yells to get the attention of whoever is walking by when she needs something. On 6/26/2023 at 12:45pm V25 (CNA) stated, R80's call light should be close to R80. On 6/27/2023 at 2:36pm V2 (DON) stated, the call light should be within reach of the resident. R80's care plan focus on Falls dated 4/26/2023 documents I would like staff to provide me with a safe environment with a working and reachable call light. Findings…

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 one resident's room (R123) provides a homelike environment free of odors. This failure affected one resident out of a sample of 51. Findings include: R123 has a diagnosis of but not limited to Morbid Obesity, Chronic Obstructive Pulmonary Disease, Edema, Colostomy, Depression and Necrotizing Fasciitis. R123's Brief Interview of Mental Status is 6 that indicates severely impaired, but R123 answered all questions appropriately. On 6/26/2023 at 11:15am surveyor observed a clear canister for the suction machine with a white kind of substance caked on the inside of the cannister on the bedside table in R123's room. Surveyor also noticed a strong odor inside of R123's room. On 6/26/2023 at 11:16am R123 stated that the staff only changes the cannister every two months and it is only emptied and never cleaned out. R123 stated that it is depressing to have her room smell of urine. On 6/26/2023 at 11:20am V26 (Restorative Nurse/LPN) [NAME],…

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 primed a new insulin pen to give the right initial dose of insulin during administration and failed to ensure staff administer dose of insulin per physician's order. These failures affected one resident (R80) reviewed for quality of care in a total sample of 51 residents. Findings include: R80's admission Record documented that R80's diagnoses include but not limited to Metabolic encephalopathy, Type 2 Diabetes Mellitus, hypoglycemia, gastro-esophageal reflux disease, severe protein-calorie malnutrition and encounter for attention to gastrostomy. R80's (Active Order as of: 06/28/2023) Order Summary Report documented, in part Insulin Aspart Injection Solution 100 unit/ml inject 7 units subcutaneously with meals. Novolog Injection Solutionminject as per sliding scale. For Blood sugar > (greater than) 400 = 10 units. R80's (05/30/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R80's mental status…

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 g-tube placement was checked prior to flushing the g-tube and prior to administration of medication via a g-tube. This failure affected 1 of 4 (R80) residents reviewed for administration of medications in a total sample of 51 residents. Findings include: R80's admission Record documented that R80's diagnoses include but not limited to Metabolic encephalopathy, Type 2 Diabetes Mellitus, hypoglycemia, gastro-esophageal reflux disease, severe protein-calorie malnutrition and encounter for attention to gastrostomy. R80's (05/30/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R80's mental status as severely impaired. Section K. Swallowing/Nutritional Status. K0510. Nutritional Approaches. B. Feeding tube: while a resident. On 06/27/2023 at 11:13am, V19 (Licensed Practice Nurse) flushed R80 g-tube and administered Sodium Chloride 1 gram without checking for the placement of R80's g-tube. On 06/27/2023 at…

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

Based on observation, interview and record review the facility failed to ensure that oxygen tubing is labeled when it is changed for 3 residents (R107, R111, R123). This failure has the potential to affect 3 residents (R107, R111, R123) out of a sample of 51 residents. Findings include: R123 has a diagnosis of but not limited to Morbid Obesity, Chronic Obstructive Pulmonary Disease, Edema, Colostomy, Depression and Necrotizing Fasciitis. R123's Brief Interview of Mental Status is 6 that indicates severely impaired but answers all questions appropriately. Physician Order Summary with an active date of 06/29/2023 documents to change oxygen tubing and bottle weekly on Sunday every night shift. On 6/26/2023 at 11:02am surveyor observed R123's oxygen tubing with no date. R123 stated, the tubing had been changed on Saturday (June 24th). On 6/26/2023 at 11:17am R123 stated, she (R123) asked staff to change her oxygen tubing and that it is not changed weekly. On 6/29/2023 via email V2 (DON) stated, oxygen tubing should be changed weekly and PRN (as needed) and should be labeled with the…

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

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5% for 3 out of 4 (R26, R80, and R110) residents reviewed for medication administration. There were 25 opportunities and 5 errors resulting in 20% medication administration error rate. Findings include: R26's (Active Order as of 06/28/2023) Order Summary Report documented that R26's diagnoses include but not limited to chronic obstructive pulmonary disease and rheumatoid arthritis. On 06/27/2023 at 9:11am, V17 (Licensed Practice Nurse) dispensed R26's medications including Vit D3 (cholecalciferol) 10mcg (400IU). Error 1. On 06/27/2023 at 9:23am, V17 (Licensed Practice Nurse) administered R26's medications including Vit D3 (cholecalciferol) 10mcg (400IU). This is an error. R26's (Active as of: 06/28/2023) Order Summary Report documented in part Cholecalciferol Tablet 1000unit give 1 tablet by mouth one time a day. Order Date: 05/22/2023. R110's (Active Order as of: 06/28/2023) Order Summary Report documented that R110's diagnoses include but not…

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

Based on observation, interview and record review the facility failed to maintain safe refrigerated food storage (refrigerator not defrosted) for one resident (R51); and failed to properly log refrigerator temperatures for three residents (R29, R51, and R104,). These failures have the potential to affect all 51 residents in the sample. Findings include: R104's face sheet documents that R104 has diagnosis which include but are not limited to: Vitamin D, dysphagia oral phase, gastro-esophageal reflux disease without esophagitis, and calculus of gallbladder without cholecystitis without obstruction. R104's Brief Interview for Mental Status (BIMS) dated 04/27/23 Section C C0500 documents that R104 has a BIMS score of 00 which indicates that R104 has some cognitive impairments. On 06/26/23 at 11:31 am, Surveyor observed R104's refrigerator without a temperature thermometer and without a temperature log sheet. Surveyor observed R104's refrigerator with spilled food stored inside R104's refrigerator that was both dried and moist in consistency and adhered to the bottom of R104's…

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