Elevate Care Windsor Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain a physician order for a code status for two (R10, and R12) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted she is moderately cognitively impaired. R10's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to type 2 diabetes mellitus without complications, dementia, obstructive and reflux uropathy, myocardial infarction, and chronic kidney disease. 2. R12's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R12's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to type 2 diabetes mellitus with neuropathy, heart failure, end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, cervicalgia, and adult failure to thrive. On 04/01/26…

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 a clinical contraindication for gradual dose reduction (GDR) for residents receiving psychotropic medications. This failure resulted in three residents (R3, R11, R70) not having a gradual dose reduction (GDR) attempted/completed for medications they receive. Findings include: 1. R3's electronic health record (EHR) documents in part a diagnosis of Dementia with Moderate Mood Disturbance, Schizophrenia, Bipolar Disorder, Brief Psychotic Disorder. R3's Minimum Data Set (MDS) dated [DATE] documents in part, R3 receives antipsychotic medications on a routine basis, a GDR has not been attempted, and the physician has not documented GDR as clinically contraindicated.R3's Order Summary Report review of physician orders documents in part, R3 has an active order for the following medications: Depakote 500 mg two times a day for agitation (start date 12/13/24), Haloperidol 10 mg give 0.5 tablet by mouth two times a day for bipolar (start date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to refer a resident (R11) who was later identified with a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents. Findings include:R11's Notice of PASRR Level I Screen Outcome dated 10/31/22 documents in part PASSR Level I Determination: No Level II Required - No SMI/ID/RC.R11's PASRR Outcome Explanation Notice of No PASRR Level II Required which documents in part, Your Level I screen does not show that you have a mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs.R11's admission Record documents in part an initial/original admit date of 11/04/22. It documents in part a diagnosis of Unspecified Psychosis (added 03/06/25).R11's admission Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a PASARR Level II Screen evaluation and determination with known mental illness for one (R35) out of eight residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35.Findings include:R35's electronic health records (EHR) indicate R35 was admitted to the facility on [DATE] with diagnosis including but not limited to Delusional Disorders upon admission.R35's Order Summary Report dated 04/01/26 includes but not limited to Seroquel 50 mg two times a day for delusional disorder.R35's MDS (Minimum Data Set) dated 03/09/26 documents in part, R97's active diagnoses include but not limited to Psychiatric/Mood Disorder including Psychotic Disorder.R35's Notice of PASRR I Screen Outcome dated 11/30/22 documents in part, PASRR Level I Determination: No Level II Required - No SMI/ID/RC.R35's PASRR Outcome Explanation Notice of No PASRR Level II Required…

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 nail care was provided for one (R126) resident who requires supervision in grooming reviewed for Activities of Daily Living (ADL) out of eight residents in total sample of thirty-five. Findings Include: R126's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R126 Electronic Health Record/EHR noted an active diagnosis of hemiplegia and hemiparesis affecting right dominant side, contracture of right hand, acquired absence of left leg below knee, acquired absence of other right toes, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy.R126's Minimum Data Set (MDS) dated [DATE] functional abilities assessment noted R126 requires partial/moderate assistance with personal hygiene.On 03/31/26 at 1:24 PM, R126 was observed up in a wheelchair in his room. R126's right hand was contracted with very long fingernails that overgrown the tips of his fingers. He also…

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 assist a resident (R78) out of bed for 1 out of a total sample of 35 residents reviewed for Activities of Daily Living (ADLs).Findings include: R78's admission Record documents in part diagnoses of pathological fracture of right femur, malignant neoplasm of prostate, secondary malignant neoplasm of bone, adult failure to thrive, hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) affecting the left non-dominant side, absolute glaucoma in the right eye, and history of falling. R78's 2/27/2026 MDS (Minimum Data Set) assessment documents in part that R78 is cognitively intact, has functional limitations to upper extremity on one side, and is dependent on staff to transfer from bed to chair. R78's Care Plan Report documents in part that R78 presents with functional deficit in bed mobility related to generalized weakness and musculoskeletal impairment (revised 10/14/2024). R78 has an ADL (Activities of Daily Living) self-care performance deficit related to impaired balance,…

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 controlled substances were counted and documented correctly in one of 4 medication carts reviewed during the medication storage and labeling observation.Findings Include:On 04/01/26 at 12:28 PM the third-floor medication cart 2 was reviewed with V25 (Licensed Practical Nurse). During review of the controlled substance a Controlled Substances Proof of Use sheet dated 03/19, amount received 15 ml (milliliter) was observed with no name documenting in part: Morphine Sulfate 100 mg (milligram) per 5 ml (milliliter). Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for shortness of breath. A box with R75's name was observed in the narcotic drawer. V25 stated the sheet has 15 ml but there is about 13 ml in the bottle. A Controlled Substances Proof of Use sheet, amount received 30 ml (milliliter) document in part: R75, Morphine Sulfate 20 mg/ml. Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for or every 1 hour as needed for SOB (Shortness of Breath). V25 stated 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 interview and record review, the facility failed to ensure a resident (R78) was up-to-date with their pneumonia vaccine series for 1 out of 5 residents reviewed for immunizations.Findings include: R78's admission Record documents in part multiple comorbidities including malignant neoplasm of prostate, secondary malignant neoplasm of bone, atrial fibrillation, high blood pressure with heart failure, adult failure to thrive, stroke, diabetes, and high cholesterol. R78's 2/27/2026 MDS (Minimum Data Set) assessment and care plan documents in part that R78 is cognitively intact. On 4/01/2026 at 10:09 AM, V2 (Director of Nursing) stated the facility has pneumonia immunization trackers in their electronic medical records. Facility is to run the reports and see which residents are due for vaccines. R78's View Immunization documents in part that R78 received the Pneumovax 23 (PPSV23) on 10/25/2024. R78's immunization records do not indicate any other pneumonia vaccine. Center for Disease Control and Prevention's PneumoRecs VaxAdvisor documents in part that for individuals older than…

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

Based on interview and record review, the facility failed to provide adequate nursing staff to ensure resident needs are being met in a timely manner and medications are being administered as ordered by the physician. This had the potential to affect residents assigned to V31 (Licensed Practical Nurse) on 03/21/26 and residents residing on the 2nd and 3rd floor on 03/21/26, residents residing on the 3rd floor on 03/22/26 and residents assigned to V46 (Licensed Practical Nurse) on 03/26/26.Findings include:On 03/24/26 at 10:46 AM, V31 (Licensed Practical Nurse) stated she has been working at the facility since January 2026 and has been a Licensed Practical Nurse (LPN) since 2019. V31 stated she works full time on the 7-3 and 3-11 shift, mostly on the 1st floor and works during the week and covers weekends sometimes. V31 stated the 1st floor is staffed with two nurses and four Certified Nursing Assistants. V31 stated the staffing is shorter on the weekend because they get more call outs. V31 stated she worked this past weekend on the 1st floor; she was asked to come in to cover the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders for administering medications to eight (R1, R6, R7, R10, R11, R12 R13, R14) of eight residents reviewed for Improper Nursing Care. Findings include: On 3/24/26 at 10:46 AM V31 (Licensed Practical Nurse/LPN) stated she worked this past weekend on the 1st floor; she was asked to come in to cover the 7-3 shift. V31 stated she arrived at the facility around 10:00 AM and had to administer all the medications on the 2nd set of room assignments. V31 stated some of the 9:00 AM medications were given late, meaning they were given after 10:00 AM. V31 stated if residents do not receive their medications on time, it may mean the residents' pain or blood pressure is not being well controlled. On 3/25/26 at 2:24 PM V30 (Registered Nurse/RN) stated on 3/21/26 she was the only nurse on the unit because the other nurse had called off. She stated one of the CNAs came to tell her that R12 was in a lot of pain, so V30 did a pain…

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 residents are free of any significant medication error for two (R12 and R13) of eight residents reviewed for improper nursing care. The findings include:On 3/25/26 at 2:24 PM V30 (Registered Nurse/RN) stated on 3/21/26 she was the only nurse on the unit because the other nurse had called off. She stated one of the CNAs (Certified Nursing Assistants) came to tell her that R12 was in a lot of pain, so V30 did a pain assessment on R12 and gave him his morning medications. V30 stated R12 had an order of Gabapentin at 9:00 AM and it was given around 11:15 AM. V30 stated 9:00 AM medications should be given between 8:00 AM-10:00 AM. V30 stated the potential problem with the residents receiving medication late is they could have a spike in their blood pressure, blood sugar, or pain level if they are receiving medications for those areas. On 3/25/26 at 2:45 PM Observed R12 sitting up in wheelchair at the side of his bed in his room. R12…

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 update a resident's (R1) care plan intervention post resident fall. This failure affected 1 of 3 residents reviewed for falls.Findings include: R1 has a diagnosis which includes but not limited to repeated falls and spinal stenosis. R1 has a Brief Interview for Mental Status (BIMS) dated 06/05/25 without a score of 10 which indicates that R1 has some cognitive impairments. During this survey R1 was able to answer surveyor questions appropriately. R1's progress note dated 06/11/25 at 7:40 pm, authored by V12 (Agency Licensed Practical Nurse/LPN) that documents, in part: Situation: Resident transferred to the local hospital per MD's (Medical Doctors) request following fall. No observable injuries noted per SN (Skilled Nurse) at this time other than redness on areas directly impacted from fall (sacral, right buttocks, lower central back.) Background: Resident fell in the hallway coming from dining area from standing position while pushing wheelchair to her room. Fall was unwitnessed. R1's progress note dated 06/11/25 at 6:59…

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 investigate a resident (R1's) fall. This failure affected 1 of 3 residents reviewed for fall accidents/incidents.Findings include: R1 has a diagnosis which includes but not limited to repeated falls and spinal stenosis. R1 has a Brief Interview for Mental Status (BIMS) dated 06/05/25 without a score of 10 which indicates that R1 has some cognitive impairments. During this survey R1 was able to answer Surveyors questions appropriately. R1's progress note dated 06/11/25 at 7:40 pm, authored by V12 (Agency Licensed Practical Nurse/LPN) that documents, in part: Situation: Resident transferred to the local hospital per MD's (Medical Doctors) request following fall. No observable injuries noted per SN (Skilled Nurse) at this time other than redness on areas directly impacted from fall (sacral, right buttocks, lower central back.) Background: Resident fell in the hallway coming from dining area from standing position while pushing wheelchair to her room. Fall was unwitnessed. R1's progress note dated 06/11/25 at 6:59 pm, authored…

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

Based on observation, interview and record review, the facility failed to (a) implement transmission-based precautions, (b) ensure staff wear proper PPE (Personal Protective Equipment), (c) post precaution sign to alert staff for instructions prior to entering the room, and (d) provide PPE supplies accessible to staff for 1 (R1) of 3 residents reviewed for improper nursing care. These failures have the potential to cross contaminate 15 residents assigned to V7 (Certified Nursing Assistant/CNA). The findings include: R1's admission record showed admit date on 5/12/2025 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, Essential (primary) hypertension, Aphasia following cerebral infarction, Dysphagia following cerebral infarction, Acute respiratory failure with hypoxia, Pneumonitis due to inhalation of food and vomit, Encounter for attention to gastrostomy, Pressure ulcer of sacral region unstageable. R1's MDS (Minimum Data Set) dated 5/20/2025 showed R1 was rarely or never understood. She needed total assistance or…

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

Based on interview and record review the facility failed to keep two residents (R2 and R5) free from abuse of three reviewed for abuse in a total sample of nine residents. Findings include: On 5/2/25 at 1:30 PM, R2 said R5 hit her in the head with an open milk carton and milk went everywhere. R2 said R5 and her popped each other. R2 was smoking a cigarette outside. R5 said R2 needs to do something with her hair and kept calling R2 big girl. R5 wouldn't leave R2 alone. R2 pushed R5's face, I muffed him. R5 threw an open milk carton in R2's face. R2 said there was no staff outside. V11 (Psychosocial Aide/Social Service Assistant) came outside after everything happened. R2 said R5 talks about her almost every day. R2 said they talk about her weight, hair, and how crazy she is. On 5/6/25 at 10:00 AM, V2 (Director of Nursing) stated the incident with R2 and R5 happened on the patio during smoking break. The police were not notified of the altercation between R2 and R5. R2 was sent out to the hospital. On 5/6/25 at 10:30 AM, R5 said the incident with R2 was during a smoke break. R5 and R2…

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

Based on observation, interview, and record review the facility failed to ensure foods in the refrigerator and freezer were labeled with a date indicating when the item was placed into the refrigerator/freezer and labeled with a use by date. These failures have the potential to affect all 194 residents in the facility who are receiving an oral diet. The findings include: On 03/03/2025 at 9:35am Walk-in Freezer #1 observation accompanied by V4(Director of Food Service). Observed four boxes of wild berry magic cup desserts which contained 48(4 fluid oz) cups in each box, the four boxes were not dated with a date the item was stored in the freezer, nor dated with a use by date. On 03/03/2025 at 9:45am Walk-in refrigerator observation accompanied by V4. Observed a package of yellow pasteurized process American cheese slices, not dated with a date the cheese was placed into the refrigerator, nor dated with a use by date. On 03/05/2025 at 11:45am V4 (Director of Food Service) stated all kitchen staff are responsible for labeling food items placed into the freezers and refrigerators with a…

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

Based on observation, interview and record review, the facility failed to ensure the outside trash dumpsters were not missing lids to cover the tops of the trash dumpsters. This failure has the potential to affect all 199 residents residing at the facility. Findings include: The (3/03/2025) facility census was 199 residents. On 03/04/2025 at 10:04am V38 (Dietary Aide) escorted surveyor to the outside dumpsters located behind the facility. The facility has 2 green colored outside trash dumpsters. Each dumpster has a black plastic lid divided into three parts covering the top of the trash dumpster. Observed the first part of the black plastic lid missing on both trash dumpsters. On 3/4/2025 at 10:08am V38(Dietary Aide) stated the trash disposal company comes to empty the outside dumpsters two to three times a week. V38 stated the lids are required so that the trash will not fly out of the trash dumpsters and to prevent animals from getting into the trash dumpsters. V38 stated I do not know who is responsible for maintaining the outside trash dumpsters. On 03/04/2025 at 10:10am…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a clean linen cart was not stored inside the restroom of a resident on Enhanced Barrier Precautions (EBP) and failed to ensure the plastic bag used for containment of soiled linen were securely tied prior to conveyance via a chute. These failures affected 2 (R7 and R89) reviewed for infection control and have the potential to affect all the residents residing at the facility. Findings include: #1 The (undated) Enhanced Barrier Precaution List include R89. On 03/04/2025 at 1:06pm, V26 (Infection Preventionist/LPN) stated residents on EBP are residents with indwelling cath, wound, trache, on dialysis, with colonized MDRO (multidrug-resistant organisms) and XDRO (extensively drug-resistant organisms). On 03/03/2025 at 11:25 AM, V8 (Assistant Director of Nursing) stated the orange sticker by the resident name identifier on the doorframe means the resident is on EBP (Enhanced Barrier Precautions). On 03/03/2025 at 12:03 PM, there 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.

Based on observation, interview and record review, the facility failed to conduct care plan conferences, allowing residents/their families exercise the right to participate in the development/implementation of their plan of care; failed to follow their comprehensive care planning policy. These failure affects 4 residents (R9, R58, R163, and R48). Findings include: Record review of R9's Minimum Data Set (dated 1/2/2025) documents in part a brief interview of mental status (BIMS) summary score of 12, indicating mild cognitive impairment. On 3/3/2025 at 10:27 AM, R9 stated wishes to discharge from the facility but did not know what R9's plan for discharge was within R9's care plan. R9 denied being asked to participate in the development of R9's plan of care, denied that R9's plan of care was reviewed with R9 and denied ever being invited to a care plan conference to discuss R9's plan of care. R9 affirmed that if there was a meeting about R9's plan of care, R9 would want to attend. Record review of Interdisciplinary Team Meeting (Care Plan Conference) (dated 6/18/2024) documents in part…

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 assistance with grooming. These failures affected 1 (R46) of 3 residents (R46, R73, R148,) reviewed for ADLs (activities of daily living) in a sample of 65. Findings Include: On 3/3/2025 at 12:04 pm, R46's fingernails were long and contained brown matter under all 10 fingernails. R46 stated that she did not like her nails long and wanted her nails trimmed. R46's Face Sheet dated March 4, 2025, shows R46 was admitted to the facility admitted to the facility on [DATE] with multiple diagnosis including but not limited to Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and anxiety, Altered Mental Status, Long Term Use of Anticoagulants, Hyperlipidemia, Essential Hypertension, Anemia, Contusion of Left Wrist, Syncope and Collapse, and Unspecified Psychosis Not Due TO Substance Or Known Physiological Condition. R46's Minimum Data Set (MDS) dated [DATE], shows R46 has a Brief Interview for…

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

Based on Observation, interview, and record review, the facility failed to ensure that residents' Low Air Loss Mattresses (LALM) for pressure ulcer prevention are set at the correct weight settings. This failure affected five residents (R38, R40, R113, R148, R170) out of nine residents reviewed for pressure ulcer prevention and treatment in a sample of 33 residents. Findings include: Facility presented a list of 33 residents on low air loss mattress with the corresponding weight taken on 3/3/2025. R40's Face sheet dated March 4, 2025, documents that R40 was admitted to facility on November 19,2024 with diagnosis including Pressure Ulcer of Sacral region Stage 4, Pressure Ulcer of Right Hip Stage 4, Non- Pressure Chronic Ulcer of Right Heel and Midfoot with Unspecified Severity, Pressure Ulcer of Head Stage 3. R40's MDS (Minimum Data Set) dated February 21,2025, shows R40 has a score of 3 which means R40 is has severe cognitive impairment. R40's care plan dated August 2,2024 shows that R40 has a Pressure injury to left ear, sacrum, right hip, left hip and left thigh back, is at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the personal refrigerator temperatures were monitored daily, failed to ensure expired food items were discarded, and failed to ensure personal refrigerator has temperature log form in an effort to prevent foodborne illnesses. These failures affected 5 (R7, R71, R77, R124, and R145) residents reviewed for personal refrigerator in a total sample of 65 residents. Findings include: On 03/03/2025 at 12:09pm with V10 (Licensed Practice Nurse-LPN) inside R7's room. There was a personal refrigerator by R7's bedside. V10 was requested to check for the temperature log. V10 looked on the sides of R7's refrigerator and stated there is no temp log. There should be a log and we should be checking the refrigerator temperature every night. On 03/03/2025 at 11:50 AM with V7 (Certified Nursing Assistant). R71's personal refrigerator Fridge/Freezer log was from 12/2024. This surveyor requested V7 to check the food items inside R71's personal…

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

Based on observation, interview, and record review, the facility failed to ensure that residents' call lights are functional and in good working order. This failure has the potential to affect 4 residents, R32, R97, R645, and R646, reviewed for functioning call lights, in a total sample of 65 residents. Findings include: On 3/03/25 11:50 AM, R32 was observed in bed and stated that no staff responded to his call light for the past few days, and he sometimes had to yell out if he sees someone in the hallway. The surveyor asked R32 to push the call button and the call light was not functional. V19(CNA/Certified Nurse Assistant) tried the call light, and the light still did not come on. V19 stated that she (V19) would notify Maintenance. On 3/03/25 11:58 AM, R645's and R646's bathroom call light was observed to be non-functional. V19(CNA) went into the bathroom and pulled the light and stated that it was not working. V11(LPN/Licensed Practical Nurse) was notified. The surveyor asked V11 about Maintenance logbook at the nursing station; V11 stated that they do not use a logbook and that…

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

Based on interview and record review, the facility failed to obtain informed consent for psychotropic medication. This failure affects 1 resident (R58) in a sample of 65. Findings include: Record review of R58's physician orders documents in part that R58 has an active order for QUEtiapine Fumarate (Seroquel) 25 mg tablet, give 0.5 tablet (total dose=12.5 mg) by mouth at bedtime for dementia with behavioral disturbance. This order began on 9/17/2023. Record review of R58's informed consent for psychotropic medication use (dated 1/11/2024) documents in part that R58 is consenting to take Seroquel 25 mg q hs (at bedtime). Diagnosis, benefits, targeted behaviors and alternatives to this medication are not noted on the consent as reviewed with the resident. No other psychotropic medication consent forms for R58 were provided during the survey. On 3/05/2025 at 1:39 PM, V20 (Nursing Supervisor, Licensed Practical Nurse) affirmed that V20 oversees the psychotropic medication program in the facility. V20 reviewed R58's physician order and affirmed that the total dosage for QUEtiapine…

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 store a bottle of lorazepam in accordance to manufacturer's instructions. This failure affects 1 resident (R32) in a sample of 65. Findings include: Record review of R32's physician orders documents in an order for Lorazepam 2mg/mL concentrate that was discontinued on 12/20/2024. On 3/4/2025 at 12:18 PM, observed V42 (Licensed Practical Nurse) withdraw R32's bottle of lorazepam from the team 1 medication cart narcotics drawer. On the bottle of the lorazepam, a sticker was observed indicating that the medication should be stored in the refrigerator. V42 observed the sticker and affirmed that the bottle of lorazepam should have been stored in the fridge. Record review of manufacturers' instructions for Lorazepam Oral Concentrate documents in part, .PROTECT FROM LIGHT STORE AT 2 (degrees) to 8 (degrees) C (Celsius) (36 (degrees) to 46 (degrees) F (Fahrenheit)) . Record review of facility policy titled, STORAGE OF MEDICATIONS (dated 5/1/2018) documents in part, Policy Medications and biologicals are stored safely,…

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 residents with a home-like environment, clean and sanitary shower rooms. This failure has the potential to affect 195 residents residing in the facility. Findings include: On 11/8/2024 at 11:36am, V3 (LPN) stated, generally residents get showers 2 times a week or more if requested or if we see the resident needs an additional shower. There are 2 shower rooms on each floor and all the shower rooms are being used by residents. I have not heard shower rooms are not functioning. CNAs give showers and stand by assistance is given to residents that needs minimum assistance, more assistance is given to cognitive residents. On 11/8/024 at 11:39am, surveyor observed first floor SPA (shower) room with wet used towels on the floor, first shower stall with open bottle of soap on the floor, broken floor tiles, shower bed sitting in middle of the floor, middle shower stall with no shower fixture, water gauge station with missing tile, third…

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 availability of adequate clean bed linen due to inadequate supply of new bed linens and laundry equipment malfunction. This has the potential to affect all 197 residents who reside in the facility. Findings include: On 7/9/24 10 AM the 3rd floor was observed with no bed linens on 2 clean linen carts located in the corridor. 3rd floor clean linen room was observed with no sheets stocked on shelves. On 7/9/24 10:20AM the 2nd floor was observed with no linens on 3 clean linen carts. The 2nd floor clean linen room had no sheets. On 7/9/24 10:30AM the 1st floor was observed with no linens on 2 clean linen carts. On 7/9/24 at 11:44AM the basement supply storage room used to store new bed linens was observed with no new bed linen. On 7/9/24 at 11:50AM the laundry machine room was observed with 3 washing machines. One washing machine was not functioning and there were no clean bed sheets observed in the laundry area. On 7/9/24 10:15AM V17 (3rd floor CNA) stated we usually have linens on floor however they…

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

Based on observation, interview and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by failing to place a resident with a pressure wound on EBP to prevent the potential spread of multidrug resistant organisms. This failure affects one resident (R5) and the potential to affect three additional residents (R9, R10, R11) on the sample list of 11. Findings include: The (07/08/2024) list of residents seen by V4 (Occupational Therapist) after seeing R5 include R9, R10 and R11. On 07/08/2024 at 11:46am, R5 stated I (R5) have a wound on my butt. This surveyor double checked R5's doorway. There was no EBP sign posted or Personal Protective Equipment (PPE) available outside of R5's room. On 07/08/2024 at 11:50am, V4 (Occupational Therapy) brought a rolling walker inside R5's room. V4 was wearing a mask, placed the rolling walker by R5's doorway and donned gloves. V4 walked towards R5, opened R5's milk carton, raised R5's bedside table, and repositioned R5 on bed. V4 removed V4's gloves and donned another pair of gloves. V4 then…

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 low air loss mattress was set appropriately for one (R7) resident reviewed for pressure ulcer/injury treatment in the total sample of 11 residents. Findings include: On 07/08/2024 at 12:54pm, R7 was lying on a low air loss mattress, setting at 280 lbs (pounds), pulse, static off. On 07/08/2024 at 12:59pm, requested V7 (Certified Nursing Assistant) to check R7's setting of low air loss mattress and stated setting is at 280 lbs. On 07/08/2024 at 1:02pm, requested V3 (Agency RN) to check the setting of R7's low air loss mattress. V3 stated setting of low air loss mattress is at 280 lbs, pulse. On 07/08/2024 at 2:01pm, V10 (Wound Care Nurse) stated preventive measure for pressure ulcer or pressure injury are repositioning, supplement, low air loss mattress, pillow like equipment, and suspension boots. On 07/08/2024 at 2:02pm, V10 stated the setting of the low air loss mattress depends on the resident's weight. If the setting did not indicate the weight of the resident, we could set the low air loss mattress…

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 nurse call system was properly working for four of eight residents (R5, R6, R7, R8) reviewed for call lights on the sample list of eight. Findings include: R5 is [AGE] year old with diagnosis including but not limited to: Limitation of activities due to disability, Abnormalities of gait and mobility, dementia, pain in left shoulder, repeated falls and hypertension. R5's Functional Abilities and Goals section of MDS (Minimum Data Set) documents the following: R5 requires substantial/maximal assistance with toileting, dressing, eating, personal hygiene and transferring. R6 is [AGE] year old with diagnosis including but not limited to: Acquired absence of right leg below knee, Peripheral vascular disease, pain in right foot, chronic obstructive pulmonary disease and hypertension. R6's Functional Abilities and Goals section of MDS (Minimum Data Set) documents the following: R6 requires substantial/maximal assistance with dressing…

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 records review, the facility failed to investigate, and report alleged mental abuse for one (R1) of three residents reviewed. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to; pain in left shoulder, chronic obstructive pulmonary disease with (acute) exacerbation, other lack of coordination, hyperlipidemia, unspecified, type 2 diabetes mellitus without complications. R's MDS (Minimum Data Set) section C-Cognitive function dated 2/2/24 documents R1's BIMS(Brief Interview for Mental Status as 15/15, meaning R1 has intact cognitive function, and R1's section D-Behavior, documents R1 has bad feelings about self. On 4/7/2024 at 10:10am, R1 said V8 (Restorative aide/CNA) was mean to her when V8 come to answer R1's call light and R1 asked her for help cleaning the back of her body because she cannot reach it. R1 said V8 told R1 that R1's CNA (Certified Nursing assistant[no name provided]) was in another…

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.) ensure food items were properly labeled, dated, and stored, b.) kitchen staff wearing hair/beard coverings These failures have the potential to affect all 181 residents receiving food prepared in the facility's kitchen. Findings include: On 01/16/24 at 9:24 AM, V3 (Dietary Manager) stated all food items in the walk-in refrigerator should be labeled with a delivery date, open date and use by date. V3 pointed to a posted sign outside the walk-in refrigerator which listed expiration dates by the products. On 01/16/24 at 9:32 AM, during initial kitchen tour observed opened one gallon of Thousand Island Dressing in the walk-in refrigerator labeled with delivery date 10/31/23 and opened date 11/07/23. V3 unscrewed the bottle of Thousand Island Dressing which showed that the seal of the dressing had been broken and the product had been used. At 9:34 AM, V3 stated you cannot tell the use-by-date, it must have rubbed off. V3 stated the use-by-date for this item would be 30 days from the opened date. V3 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 dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 185 residents who reside in the facility. Findings include: On 01/16/24 at 11:00 AM, a member of the survey team observed dumpsters with opened lids. On 01/17/24 at 11:17 AM, with V3 (Dietary Manager) and V21 (Housekeeper) observed two large dumpsters outside the building. One dumpster was overflowing with trash bags and the lids were not fully closed because they were propped open with the trash bags. The second dumpster had 2 of the 3 lids wide opened. Debris could be seen on the ground outside the dumpster including disposable plastic gloves. V3 stated the kitchen and the housekeeping staff both use the dumpsters. V21 stated the dumpster lids are supposed to be closed to keep debris inside and keep pests from getting inside the dumpster. V21 usually stated the dumpster lids are closed and that there is usually not that much trash in the dumpsters…

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

Based on observation, interviews, and review of records the facility failed to ensure all policies related to infection control were reviewed in a timely manner. And failed to follow policy on handling clean linen to avoid contamination. These failures have the potential to affect all 185 residents using linens and ensuring that facility policies and procedures are updated to address present infection related concerns. Findings include: On 1/16/2024 Infection Control policies and procedures were reviewed. The following policies and/or procedures are out of date: - Infection Prevention and Control Program effective date 11/28/2012 with revision date of 11/28/2017. Reviewed and approved date left blank. - Antibiotic / Antimicrobial Stewardship Program effective date 11/28/2017 without revision date. Reviewed and approved date is without a date. - Influenza and Pneumococcal Immunizations effective date 11/28/2012 with revision date 4/21/2022. Reviewed and approved date is without a date. - Outbreak Investigation and Reporting - Infection Control effective date 11/28/2012 with revision…

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

Based on interview and record review, the facility failed to follow their policy to develop a comprehensive person-centered care plan that directs the care team, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This failure affects 7 (R20, R45, R61, R91, R125, R129, R136) residents reviewed for comprehensive care plan in a sample of 35. The findings include: R61's health record documented admission date of 7/6/23 with diagnoses not limited to Type 2 diabetes mellitus with hyperglycemia, Epilepsy, Diverticulosis of intestine, Aphasia following cerebral infarction, Unspecified dementia, Anxiety, Depression, Benign prostatic hyperplasia without lower urinary tract symptoms, Personal history of other venous thrombosis and embolism, Complex regional pain syndrome, Malignant neoplasm of prostate, Essential (primary) hypertension, Hyperlipidemia, Heart failure. On 1/16/24 at 2:34 pm, R61's POS (Physician order sheet) included active order not limited to FULL CODE. No care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to follow their policy and procedure for medication storage and labeling to ensure medication was secured in a locked storage area for 1 (R182) resident and failed to properly date opened multi-dose inhalers and insulins for 6 residents (R144, R104, R123, R18, R76, R48) from two of four medication carts inspected for medication storage and labeling. Findings Include: On 1/16/24 at 10:17 AM, 2nd floor medication cart 2 was inspected with V33 (Licensed Practical Nurse). The following were noted: - R144's opened Tiotropium 18MCG inhaler without the date opened written on the label. - R104's opened Symbicort inhaler without the date opened written on the label. - R123's two opened Lispro insulin pen without the date opened written on the label. - R18's opened Basaglar insulin pen without the date opened written on the label. - R76's opened Lantus insulin vial without the date opened written on the label. V33 stated that all inhalers and…

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

Based on observation, interview, and record review the facility failed to follow the pureed menu spreadsheets for five residents (R16, R21, R77, R87, R101) out of 8 residents receiving pureed diets in a total sample of 35 residents. Findings include: On 01/16/23 during lunch round observations observed residents on pureed diets receiving pureed spaghetti w/meat sauce, pureed green vegetable (broccoli), applesauce, beverage. No pureed garlic bread was served. Items listed on the Diet Spreadsheet provided by V3 (Dietary Manager) listed the following items on fall/winter 23-24 week, 4 day 24 - Tuesday: pureed spaghetti w/meat sauce, pureed broccoli, pureed fruit crisp, pureed garlic bread, beverage. On 01/17/23 at 10:44 AM, during pureed meal preparation observations V19 (Dietary Cook) stated V19 follows the spreadsheets so V19 knows what food must be prepared. V19 stated V19 was the cook on duty 01/16/24. V19 reviewed the spreadsheets from 01/16/24 and stated, no, I didn't make the pureed garlic bread yesterday. I forgot. On 01/17/24 during tray line observations resident on pureed…

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

Based on record review and interview the facility failed to follow policy on documenting influenza and pneumococcal vaccination on residents record for 5 out of 10 residents (R531, R233, R24, R182, and R181) reviewed for vaccination / immunization. Findings include: On 1/16/2024 five (5) residents were at randomly selected for Pneumococcal and Influenza vaccination / immunization review. Under immunization on their electronic health record, five (5) residents selected has the following recorded immunization: - R531 does not have any immunization recorded. - R233 influenza was recorded as completed. No other immunization was recorded. - R24 influenza was recorded as refused. No other immunization was recorded. - R182 influenza was recorded as refused. No other immunization was recorded. - R181 influenza was recorded as refused. No other immunization was recorded. On 01/17/2024 at 01:08 PM, V41 (Infection Control Preventionist / Registered Nurse) stated that all immunizations including influenza and pneumococcal vaccinations should be recorded in the immunization tab in resident's…

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

Based on review of records and interviews the facility failed to show documentation of 5 out of 10 residents (R531, R233, R24, R182, and R181) Covid-19 vaccination status. Failed to provide staff documentation that Covid-19 was screened and offered and failed to provide Covid-19 vaccination policy for both residents and staff. This also affects 5 residents (R531, R233, R24, R182, and R181) determination of Covid-19 vaccination and to avail the benefit of Covid-19 vaccine. Findings include: On 1/16/2024 five (5) residents were at randomly selected for Covid-19 vaccination / immunization review. Under immunization on their electronic health record, five (5) residents selected has the following recorded immunization: - R531 does not have Covid-19 record. - R233 does not have Covid-19 record. - R24 does not have Covid-19 record. - R182 does not have Covid-19 record. - R181 does not have Covid-19 record. On 01/17/2024 at 01:08 PM, V41 (Infection Control Preventionist / Registered Nurse) stated that all immunizations including Covid-19 vaccinations should be recorded in the immunization…

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

Based on observation, interview, and review of records the facility failed to follow their policy on feeding and assisting residents to eat. Failures include facility staff was standing and not giving attention to 3 out of 3 residents (R2, R101, R16) during mealtime. These failures affects 3 residents (R2, R101, R16) socializing experience during mealtime. Findings include: On 01/16/2024 at 12:19 PM, at the dining room, three (3) residents were located on the same table. R2 being fed with V37 (Certified Nursing Assistant), R101 fed by V10 (Certified Nursing Assistant, and R16 fed by V39 (Certified Nursing Assistant). V37, V10 and V39 were standing and focused on talking to each other while feeding the residents. R2 was coughing and refusing food. R2 was transferred to his room instructed by V24 (Registered Nurse/Unit Manager) because of discomfort and was not able to tolerate the feeding. R101 was observed to be coughing while being fed. V39 said that they are use to feeding the resident while standing, but admitted that it is a good idea to feed residents while sitting because it…

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

Based on observation, interview, and record review, the facility failed to follow their policy to ensure that call light was within easy accessibility to resident at the bedside and failed to monitor defective and/or non-functioning call light. These failures affect 2 (R114 and R531) residents to call for assistance and receive care in a sample of 35. The findings include: 1. R114's health record documented admission date of 9/25/20 with diagnoses not limited to Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, Other pulmonary embolism without acute cor pulmonale, Aphasia following cerebral infarction, Wrist drop right wrist, Hyperlipidemia, Repeated falls, Essential (primary) hypertension, Schizophrenia, Cerebrovascular disease, Subsequent non-st elevation (nstemi) myocardial infarction, Contracture right hand. On 1/16/24 at 11:03 am, R114 observed lying in bed, alert and responsive with splint on right hand. Observed call light on the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a Physician's order with the code status for 1 (R24) of 6 residents reviewed for Advance Directives in a sample of 35. Findings Include: R24 was admitted to the facility on [DATE] with diagnosis not limited to Peripheral Vascular Disease, Seizures, Essential (Primary) Hypertension, Polyneuropathy, Major Depressive Disorder, Anemia, Gastritis, Gastro-Esophageal Reflux Disease, Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Generalized Epilepsy and Epileptic Syndromes, Altered Mental Status, Extended Spectrum Beta Lactamase (ESBL) Resistance. Review of R24 Physician orders, Progress Notes and Care Plan has no orders or documentation for Advance Directives. On [DATE] at 11:39 AM, R24 was observed sitting in a wheelchair in his room in no distress. On [DATE] at 10:11 AM, V11 (Social Service Director) stated Advance Directives are uploaded in PCC (Point Click Care) and a POLST (Physician Order Life Sustaining Treatment)…

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 obtain a resident's blood glucose as ordered, this failure affected 1 resident (R42) in a sample of 35 residents. On 1/16/24 at 11:55 AM, R42 was sitting on R42's wheelchair in R42's room. R42 was alert and able to verbalize needs. R42 stated that R42 receives insulin injections, but the staff has not checked R42's blood glucose since Friday. R42 stated that R42 is diabetic, and no one checked R42's blood glucose this morning either. At 12:01 PM, Surveyor checked R42's electronic health record (EHR) with V5 (Registered Nurse/3rd Floor Unit Manager). R42's current physician order sheet (POS) shows an order for blood glucose monitoring two times a day scheduled at 9:00 AM and 6:00 PM. R42's blood glucose results show R42's blood glucose was last taken on 12/12/23 at 4:40 PM with a result of 331 mg/dl. At 12:12 PM, V15 (Agency Licensed Practical Nurse) stated that V15 is assigned to R42 and did not check R42's blood glucose this morning. Surveyor and V15 checked R42's medication administration record (MAR) in R42's EHR and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy to ensure that intervention was documented or initialed in the electronic treatment administration record (ETAR) for 1 (R94) resident with presence of pressure ulcer in a sample of 35. The findings include: R94's health record showed initial admission date of 9/18/19 with diagnoses not limited to Type 2 diabetes mellitus, Major depressive disorder, Pressure ulcer of sacral region stage 4, Heart failure, Dysphagia, Hyperlipidemia, Atherosclerotic heart disease of native coronary artery without angina pectoris, Peripheral vascular disease, Hypothyroidism, Essential (primary) hypertension. On 1/16/24 at 11:09 am, R94 Observed lying in bed on moderate high back rest, alert and verbally responsive, stated that she has a wound on her buttocks. Observed with wound vaccum and air mattress in place. On 1/17/23 at 2:38 pm, V18 (Wound Care Nurse, Licensed Practical Nurse/LPN) stated that wound care team is doing treatment for 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 a.) failed to provide services to treat and prevent a decline of Range of Motion (ROM) for a resident with contractures to the left hand, b.) failed to assess a resident with contractures and c.) failed to implement a care plan to address the resident contractures. This deficient practice was identified for 2 (R70, R172) of 2 residents reviewed for ROM in a sample of 35. Findings Include: 1. R172 was admitted to the facility on [DATE] with diagnosis not limited to Adult Failure to Thrive, Single Subsegmental Pulmonary Embolism Without Acute Cor Pulmonale, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side, Essential (Primary) Hypertension, Paraplegia, Hyperlipidemia, Emphysema, Long Term (Current) use of Anticoagulants, Abnormalities of Gait and Mobility, Weakness and Lack of Coordination. R172's Progress note dated 01/17/24 19:40 document in part: Nurse Practitioner Progress Notes Text: History of Present Illness:…

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

Based on observation, interview, and record review, the facility failed to follow their policies and procedures to ensure a resident received the correct oxygen flow rate as ordered by the physician and to ensure oxygen tubing was properly labeled when it was changed for 1 (R65) of 2 residents receiving oxygen therapy in a sample of 35 residents reviewed for respiratory care. Findings Include: On 1/16/24 at 12:38 PM, R65 was sitting in R65's geriatric chair alert and awake but unable to answer surveyor's questions. R65 was noted receiving oxygen (O2) via nasal cannula that was set to 4 liters per minute (LPM). R65's O2 tubing was also noted with no date labeled when it was last changed. On 1/18/24 at 9:54 AM, V2 (Director of Nursing) stated that a resident's oxygen should be administered per physician's order. V2 stated that the nurses are responsible in monitoring and making sure that the resident is receiving the correct oxygen order. V2 also stated that O2 tubing should be changed weekly and should be labeled with the date when it was last changed. R65's clinical records show an…

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

Based on observation, interview and record review the facility failed to follow facility policy for personal refrigerators by not labeling food items with a date and discarding expired food items from resident's personal refrigerators for 1 (R45) resident reviewed in the sample of 7 for safe personal food storage. Findings include: On 01/16/24 at 11:36 AM, observed a personal refrigerator in R45's room. Inside the refrigerator there were a lot of food items not labeled with dates or use by dates. Items included a biscuit, roll and piece of fried chicken in a plastic bag, a piece of cherry cake in a plastic pie box, large piece of cake partially covered in aluminum foil, soup in a reusable plastic container, a takeout container with crackers and strong smell of fish inside surrounded by liquid, and a large piece of apple pie with three black fuzzy circles covering it. None of the items were labeled or dated. On 01/16/24 at 11:40 AM, R45 stated that her family brings her in food and puts it into the refrigerator. R45 does not remember the last time family put food inside 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 call lights are within reach for 9 residents (R2, R3, R4, R5, R6, R10, R11, R12, and R13) reviewed for call lights in the sample. Findings include: On 11/15/23 at 9:55 am, R2 and R3 were observed in bed with call light not within reach noted under the bed. At 10:02 am, V15 CNA (Certified Nurse Aide) stated the call light should be placed where the resident can reach it attached to the bed. At 10:03 am, R10's call light noted on the floor not placed within the reach of the resident. At 10:08 am, R5 noted in bed with call light not within reach and was behind the bed headboard on the floor. R5 stated I want water, they don't care. When asked to use call light she stated, they don't care. At 10:09 am, R6 noted in bed with call light not placed within reach. It was on the floor under wheelchair extending to under the bed. R6 stated the call light should be on the pillow but I can't find it. At 10:10 am, R4 noted in bed with call light on the floor and not within reach. On 11/15/23 at 10:15 am, V4 LPN…

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 beverages were served in sanitary way to prevent contamination and prevent the spread of food borne illnesses. This failure has the potential to affect all 69 residents on the 3rd floor of the facility. Findings include: On 11/20/23 at 12:14 pm, on the 3rd floor of the facility, V24 CNA was observed pouring beverage into plastic cups and serving it on the lunch tray of the residents with fingers dipped into the plastic cup. When approached and asked about sanitary way of serving beverage or sanitary way of picking up the clean cup. V24 stated, Sorry I know I should pick it up around the cup without dipping my fingers into the cup. On 11/20/23 at 4:10 pm, V19 (Dietary Manager) stated that the cups for serving beverages and juice should be handled by staff on the sides and the coffee mugs by the handle. It is unsanitary to dip hand/fingers in the cups. At 4:13 pm V19 stated that this can cause cross-contamination of germs and that can make the resident sick. Facility Food Safety Requirements Guidance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident room TV's are in good working condition for two residents (R1 and R15) in the sample reviewed for homelike environment. Findings include: R1's medical record showed that R1 was admitted to the facility on [DATE] with diagnosis that includes but not limited to unspecified Dementia, Unspecified severity without behavioral disturbances, Psychotic disturbances, Mood disturbances, Chronic fatigue, Osteoarthritis of knee, and Other Specified Glaucoma. R15's medical record admission record showed that R15 was admitted to the facility on [DATE] with diagnosis that includes but not limited to Aphasia following Unspecified Cerebrovascular Disease, Hemiplegia and Hemiparesis following Cerebral Infraction Affecting Right Dominant side, other lack of coordination, Dysphagia oral phase, Type 2 Diabetes Mellitus without complications and weakness. On 11/15/23 at 10:00 am, R1's TV was noted to be off in the room and not plugged to…

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

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accidental hazards by not leaving sharp items, disposable shaving razor that could harm the residents. This failure affected R3 who had a disposable shaving razor stored on the over bed side table visible to the hallway unsupervised and has the potential to affect all 69 residents residing on the 3rd floor of the facility. Findings include: On 11/15/23 V3 ADON (Assistant Director of Nurses) identified the 3rd floor as a floor residing residents that have diagnosis of either Dementia or Alzheimer's. On 11/15/23 at 9:59 am, R3 was noted sitting in bed in the room. One used disposable shaving razor noted on the over bed side table visible from the hallway. At 10:01 am, when shown to V15 CNA (Certified Nurse Aide), V15 picked up the used disposable shaving razor and disposed it in the regular garbage container in R3's room. The surveyor then asked about the facility policy/protocol on sharps disposal and infection control. V15 stated, I'm sorry, it should 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 ensure that inhaler medication was stored in a locked medication cart when not in use and not in visual proximity of the nurse for two residents (R8 and R18) in the sample reviewed for medication storage. Findings include: 1. 11/15/23 at 10:25 am, R8 was observed in bed and two inhaler vials were noted on the table with no pharmacy label, no name, not in manufacturers container. 1st inhaler Symbicort 160/4.5 (busonide160mcg/formoterol fumarate dihydrate 4.5 inhalation Aerosol). 2nd inhaler Symbicort 80/4.5 (busonide80mcg/formoterol fumarate dihydrate 4.5 inhalation Aerosol). R8 stated the inhalers are for (R8). When shown to V5 RN (Registered Nurse) who identified self as the third-floor manager, V5 stated, I (V5) will have to ask the nurse about it. V5 identified V6 (LPN). -At 10:27 am, V5 and V6 after checking R8's physician orders stated R8 has no order for R8 to keep any medication at the bedside and was not on a self-administration program. -At 10:37 am, V6 LPN (Licensed Practical Nurse) stated she 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 interviews and record reviews the facility failed to provide on-site social worker coverage on a full-time basis for 12 days, resulted in [R1] to discharge home without the durable medical equipment needed for safe mobility. This failure has the potential to affect all 195 residing in the facility. Findings include: R1's clinical record document in part: R1 is an [AGE] year-old admitted on [DATE] and discharged on 9/16/23, with the medical diagnosis of displaced fracture of base of neck of right femur encounter for closed fracture with routine healing, history of falling, Alzheimer disease, dementia, syncope and collapse, kidney failure, long term use of anticoagulant, abnormalities of gait and mobility, weakness, and lack of coordination. R1's minimum data set [MDS] Brief Interview Mental Status Score Indicates R10 is mildly cognitively impaired. On 10/5/23 at 9:47 AM, V3 [R1's Family Member] stated, R1 lived at home on her own, until R1's memory and cognition started to decrease. R1 then was moved 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.