Harmony Healthcare & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adaptive eating equipment was provided to 2 (R96 and R135) residents to facilitate self-feeding. This failure affected 2 (R96 and R135) of 2 residents reviewed for assistive device during mealtime in the sample of 33 residents. The findings include: R96's admission record documented admission date on 10/21/2023 with diagnoses not limited to Parkinson's disease without dyskinesia, Difficulty in walking, Alzheimer's disease, Unspecified dementia, Adult failure to thrive, Anemia, Presence of cardiac pacemaker. R135's admission record documented admission date on 6/7/2023 with diagnoses not limited to Huntington's disease, Adjustment disorder with depressed mood, Dysphagia, Anemia, Unspecified dementia. On 9/3/24 at 12:18 PM, During dining observation, R135 sitting up on wheelchair in the dining room. Lunch tray served with divider plate with rice, ground meat, mixed vegetables, juice, coffee. R135 observed with involuntary movements,…

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 implement fall precaution interventions for one (R2) resident identified as a fall risk out of three residents reviewed for fall precautions. Findings include: On 03/23/2024 at 9:02AM, surveyor observes a yellow star on R2's door next to R2's name. R2 observed lying in R2s' bed resting inside of R2s' room in a supine position with head of bed elevated at 45 degrees. R2s' floor mat was observed located in between two closet cabinets leaning against them in R2's room. R2's bed also observed to not be in the lowest position. On 03/23/2024 at 9:08AM, V5 (Agency Certified Nursing Assistant/CNA) states she works for an agency and this is the first time she has ever worked at the facility. V5 states she is the CNA responsible for caring for R2. V5 states she is aware that the yellow stars next to resident names indicate the resident is a fall risk. V5 states she was made aware by V4 (LPN) that V5 (Agency CNA) should watch those residents closely.…

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 maintain a resident's (R2) rights to privacy and confidentiality of personal and medical information for 1 of 3 residents reviewed for residents' rights. Findings include: On 02/16/2024 at 3:00 PM, V8 (R1's Power of Attorney for Healthcare) stated during R1's discharge, V9 put a bunch of medications in a bag and gave it to V8 without individually going through each medication blister pack. V8 did not realize R2's medications were also in the bag until a few days later. V8 received blister packs of R2's Escitalopram Oxalate 5 MG (milligram) and Levothyroxine 50 MCG (microgram). V8 stated the blister packs contain R2's name, doctor, medication name, dosage, and why R2 is on the medication - depression and hypothyroidism. V8 provided a picture of R2's medication label for Levothyroxine 50 MCG and Escitalopram 5 MG. Levothyroxine label documents in part prescription number, date of 11/22/2023, R2's previous room number, R2's name, medication name, dosage, frequency, and indication-hypothyroidism. Label also 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 interview and record review, the facility failed to ensure that resident belongings were returned after discharge for one (R2) of three residents reviewed for misappropriation of resident property. Findings include: R2's face sheet documents that R2 was discharged from the facility to a local psychiatric hospital on [DATE]. R2 is no longer at the facility. On 09/30/2023 at 12:05 PM, V8 (R2's family member) stated that approximately at the end of August 2023, she informed V3 (Social Services Director) and V4 (Social Services Coordinator) of R2's missing money totaling $49 dollars and R2's missing belongings. V8 stated that she had been in contact with V3 and V3 told her that R2 did not have any belongings at the facility. V8 stated she had been in contact with V4 and V4 stated that he would follow up with V8 regarding R2's missing belongings. V8 stated it had been weeks since she heard anything so she contacted V1 (Assistant Administrator) and told V1 about R2's missing belongings. V8 stated that 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 interview and record review, the facility failed to report and investigate misappropriation of property for one (R2) of three residents reviewed for misappropriation of resident property. Findings include: On 09/30/203 at 12:05 PM, V8 (R2's family member) stated that approximately at the end of August 2023, she informed V3 (Social Services Director) and V4 (Social Services Coordinator) of R2's missing money totaling $49 dollars and R2's missing belongings. V8 stated that she had been in contact with V3 and V3 told her that R2 did not have any belongings at the facility. V8 stated she had been in contact with V4 and V4 stated that he would follow up with V8 regarding R2's missing belongings. V8 stated it had been weeks since she heard anything so she contacted V1 (Assistant Administrator) and told V1 about R2's missing belongings. On 09/30/2023 at 3:35 PM, V1 (Assistant Administrator) stated she did not report allegations of theft to the state agency and was currently in the process of reporting to the state agency. V1 states she did not report this because the term theft…

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 provide their bed hold policy, upon discharge to hospital, for one (R2) of three resident reviewed. Findings include: R2's medical record (Face Sheet, MDS/Minimum Data Set, dated [DATE] documents R2 is a [AGE] year-old male who is cognitively intact with a BIMS/ Brief Interview for Mental Status score of 14/15. R2 has diagnoses not limited to: metabolic encephalopathy, dysphagia, schizoaffective disorders, major depressive disorder, atrial fibrillation, chronic kidney disease, and post-traumatic stress disorder. On 10/01/2023 at 9:21 AM V10 (admission Director) stated I sent out a bed hold notification to management and it's a template that I always follow when I send out the bed hold notifications. I send this template out via email every time a resident goes out to the hospital. I am not familiar with the bed hold policy but I do not send anything directly to the resident or their families, I only send it internally to V11 (Hospital Liaison) and 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 Basedonobservations interviews andrecordreviews thefacilityfailedtoensure that thelowairlossmattressissetonthe appropriatesettingfor4 residents(R0, R2, R4, andR36) reviewedforpressureulcerpreventioninthetotalsampleof57 residents Findingsinclude 1. On08/28/23 10:34 AM R2 waslyingonalowairlossmattresswithasettingbelow80lbs ThisobservationwaspointedouttoV4 (CertifiedNursingAssistant. V4 statedsettingisbelow80 andnormalpressure On08/28/23 10:53 AM V1 (WoundCareCoordinator statedI(V1) amcheckingthesettingofthelowairlossmattresses I(V1) startedatthe4thfloorgoingdownto2ndfloor V1 checkedR2'sweightonthesheetofpaperV1 washoldingontherequestofthesurveyorandstatedshe(R2) weighs157lbs V1 thencheckedR2'ssettingoflowairlossmattressandstateditsbelow80lbs Thesupportsurfaceismuchsofter thelowairlossmattressisnotusedtothefullextent On08/30/2023 at12:45 pm V11 statedifthe residentweighs157 pounds thesettingofthelowairlossmattressshouldnotbebelow80lbs Itistoolow…

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 review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications during shift change, failed to document dispensing of controlled medication, and failed to follow pharmacy instruction to refrigerate medications. These failures affected 4 residents (R27, R110, R140, and R141) reviewed for pharmacy services and records and have the potential to affect all 44 residents on 2nd floor Team 2 and 3rd floor Team 3. Findings include: The (08/31/2023) email correspondence with V1 (Administrator) documented that 2nd floor Team 2 include residents in rooms 214, 215-2, 217-229; and 3rd floor Team 3 include residents in rooms 303, 305, 306-312. The (08/28/2023) Daily Census documented that there were 27 residents in 2nd floor Team 2 and 17 residents in 3rd floor Team 3. On 08/29/2023 at 12:01 pm, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3, surveyor along with V19 (Registered Nurse) observed that R141's Morphine Sul (sulfate) Tab 30 mg ER (extended release)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure medication vials are contained in original packaging for 1 resident (R142), failed to discard expired flu vaccine, failed to check the temperature of vaccine refrigerator at a minimum of two times daily, and failed to ensure the refrigerator was within the required temperature. These failures have the potential to affect all the residents on 3rd floor. Findings include: On [DATE] at 11:48 am, on 3rd floor, during the medication storage and labeling task of the medication cart labeled as Team 3 along with V19 (Registered Nurse), surveyor observed 4 cyclosporin eye drop vials in the first drawer without labels and not contained in original packaging. This was pointed out to V19. V19 stated those are for (R142); they are not in original packaging. V19 opened the bottom drawer of the medication cart and showed this surveyor the original packaging of the cyclosporin eye drop vials. The original packaging had R142's identifier 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 provide required oxygenation assistance for one resident (R30). This failure has the potential to affect one resident R30 out a sample of 57. Findings: R30 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Benign Neoplasm of Cerebral Meninges, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Chronic Embolism and Thrombosis of unspecified Vein and Chronic Obstructive Pulmonary Disease with Acute Exacerbation. R30's Brief Interview for Mental Status is 07 that indicates moderately impaired. On 8/28/2023 at 10:55 am, surveyor observed R30 wearing a nasal cannula and the oxygen concentrator set at 0 liters. On 8/28/2023 at 10:56 am, V7 (RN) stated that R30's oxygen concentrator was on 2 liters, but it is on 0 liters now and he is not getting oxygen through his nasal cannula. On 8/30/2023 at 3:00 pm, V2 (DON) stated the expectation is for the nurses to carry out and implement the doctor's order. V2 stated that the oxygen concentrator should be set at the desired…

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 label and date oxygen tubing per the facility policy. This failure affected one resident (R90) reviewed for oxygen equipment, in a total sample of 57 residents. Findings include: On 08/29/23 at 10:30 am, surveyor observed R90 in bed awake and alert. R90 was observed with 2 liters oxygen via nasal cannula with tubing in place unlabeled and not dated. When R90 was asked regarding R90's nasal cannula oxygen tubing, R90 stated, You would do better by asking the nurse when the oxygen tubing was last changed, I really do not pay attention when the nurse comes in to change the oxygen tubing. On 08/29/23 at 10:43 am, V17 (LPN/Licensed Practical Nurse) stated I don't see a label dated with a date that the oxygen tubing was changed. V17 stated the nurse should put a label on the oxygen tubing indicating the date the tubing was changed. V17 stated placing a date on the oxygen tubing avoids the tubing being in place too long and the resident getting an infection. V17 stated the nurse is responsible for changing the oxygen…

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 records review, the facility failed to follow their policy on sanitation and food safety by failing to date open food items with open date and use by date. This failure has the potential to affect 151 residents who are on an oral diet. Findings include: On 11/01/2022 at 9:53 am, in the kitchen freezer, surveyor and V4 (Dietary Manger) observed the following open food items with no opened by date and no use by date: Carrots in a plastic bag, noted bag on the bottom shelf on top of a box. No open or use by date. Chocolate vanilla/strawberry ice-cream, No open on date or use by date. Chicken legs in a knotted plastic bag, placed in a tin pan. The chicken legs were observed to have a lot of ice inside the plastic bag. No open on date or use by date. Beef sausages in a knotted plastic bag. No open date or use by date. In the fridge was observed: 4 small containers of facility made salad dressing with use by date of 10/29/2022. In the dry food section was observed: An open bag of potato chips, no open on date or use by date. Open 50lb bag of dry…

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.) staff donned the appropriate PPE (Personal Protective Equipment) prior to entering Transmission Base Precaution Rooms and b.) failed to ensure linen was stored on the linen cart to prevent contamination. This deficient practice has to potential to affect all residents residing on the 3rd floor of the facility. Third floor census= 52 residents. Finding Include: On 11/01/2022 at 12:23 pm, V13 (Agency CNA) observed standing inside of R9 and R107's room (identified as a contact isolation room). V13 observed wearing an N95 mask and face shield only while standing inside of R9 and R107's room. V13 states I am supposed to be wearing a gown and gloves while inside of R9 and R107s' room. If I am not wearing proper PPE then I can spread an infection. V14 (CNA) observed walking into R9 and R107's room with a meal tray and briefly walking back out with the same meal tray. Isolation cart with gowns and gloves inside of cart observed located outside of R9 and R107s' room. Contact isolation signs documenting 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 answer a call light in a timely manner for 1 (R309) of 4 residents reviewed for call lights. Findings include: On 11/01/2022 at approximately 10:25 am, surveyor located outside of R309's room. Surveyor observed V28 (R309's family) standing in the doorway of R309's room with the door open. Surveyor observed that R309 was lying in bed with the call light audibly alarming and illuminating, indicating that R309's call light was turned on. V28 stated R309 turned the call light on about 5 minutes ago and no one has come to answer it yet. I went to the nurses station to inform V9 (Agency LPN #1) that R309 needs assistance. V9 told me that V14 (CNA) is the assigned CNA for R309 and V9 just sat back down at the nurses station. R309 has to use the bathroom. On 11/01/2022 at 10:26 am, surveyor now located inside of R309's room interviewing R309 and V28 (R309's family). Surveyor remained in R309's room for approximately 10 minutes while R309's call light continued to alarm. Surveyor observed that no one came into R309'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 obtain a physician order for oxygen therapy for one resident (R210). The facility also failed to properly label oxygen tubing with a date for six residents (R3, R310, R64, R312, R313, R127). The facility failed (a) to follow their policy and procedure and comprehensive care plan to ensure the correct oxygen flow rate was received as ordered by the physician for one resident (R123), and (b) to follow their policy and procedure to ensure humidifier bottle had at least an inch of water and was properly labeled for 1 (R123) of 8 residents reviewed for respiratory care. Findings include: On 11/01/22 during the facility tour R210 was observed in bed receiving oxygen at 5 liters per nasal canula. R210 asked the surveyor what is the oxygen set on and the surveyor responded 5 liters. On 11/01/22 at 10:25 AM, observed R123 sitting up in chair alert and able to verbalize needs. Observed R123's using her (R123) oxygen concentrator and was set to 3…

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

Based on observations, interviews and record reviews, the facility failed to (a) properly date opened multi-dose inhalers for 4 residents (R35, R76, R73, R159); (b) properly discard multi-dose insulin pen after 28 days of opening for 1 resident (R104); and properly discard expired house stock medications on expiration date that could potentially affect all 20 residents residing on 4th floor team 1 from three of four medication carts inspected for medication storage and labeling. Findings include: On 11/01/2022 at 10:50 AM, inspected 4th floor medication cart team 2 with V17 (Registered Nurse). The following were noted: - R35's Symbicort inhaler without the date opened on the label. - R104's Novolog insulin pen with date opened 10/3/22 written on the label. On 11/01/2022 at 11:49 AM, inspected 4th floor medication cart team 1 with V3 (Licensed Practical Nurse). The following was noted: - 1 bottle of house stock Omeprazole 20mg medications with expiration date on the bottle that reads, 5/2022. V3 stated that expired medications should be discarded and not kept in the medication cart…

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

Based on observation, interview, and record review, the facility failed to assess/monitor one resident (R38) for self-administration of medication out of a sample of 31 residents reviewed. Findings include: On 11/01/2022 at 10:50 am, surveyor observed R38 located sitting in a wheelchair inside of R38's room next to R38's bedside table. Surveyor observed 4 unidentified oblong shaped pills inside of a medication cup on R38's bedside table. R38 stated V9 (Agency LPN #1) left my pills here because V9 knew that I was going to take my medication when I came back in my room. On 11/01/2022 at 10:53 am, V9 located inside of R38's room and observed R38's medication on R38s' bedside table. V9 stated I just sat those pills there because I knew that R38 was going to take them later. R38 always take R38's pills later, R38 takes R38's own time to take R38's medication, that's just how R38 is. On 11/03/2022 at 10:03 am, V2 (Director of Nursing) stated In order for a resident to be able to self-medicate, first the resident should be alert and oriented x3. Then the resident is visually observed 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 observation, interviews and record reviews, the facility failed to follow their policy and procedure and the comprehensive care plan to ensure incontinence care was provided for a dependent incontinent resident in a timely manner for 1 (R71) of 4 residents reviewed for ADL (Activities of Daily Living) care in a sample of 31. Findings include: On 11/01/22 at 11:16 AM, R71 was observed lying in bed on her (R71) night gown. Noted with bilateral upper extremities contractures. Alert and able to verbalize needs. R71 stated, I'm really really wet. I need to be changed. The last time they changed my diaper was at 1:00 AM. Nobody has checked on me since then. Surveyor immediately asked V18 (Memory Care Director) to get assistance for R71. At 11:20 AM, V18 and V19 (Certified Nursing Assistant) entered R71's room to assist her (R71) with incontinence care. Observed R71's incontinence brief and underpad saturated with stool and urine. R71 stated, I'm wet all over. At 11:28 AM, an interview conducted with V19. V19…

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 nursing services and care to ensure continuity of care for 1 resident (R309) out of a sample of 31 residents reviewed. Finding include: On 11/01/2022 at 10:35 am, R309 stated I was admitted to the facility last night around 6:30 pm. On 11/01/2022 at 12:44 pm, surveyor asked V9 (Agency LPN #1) who is the nurse that is assigned to care for R309 residing in room [ROOM NUMBER]. V9 then stated There are no residents residing in room [ROOM NUMBER]. I am assigned to care for the residents residing in rooms 305-312. On 11/01/2022 at 12:45 pm, V10 (Agency LPN #2) stated I am assigned to care for the residents residing in rooms 301, 302-1, and 324-329. On 11/01/2022 at 12:47 pm, V11 (Agency LPN #3) states When I first started my shift today, the supervisor did not tell me that I am assigned to care for R309 in room [ROOM NUMBER]. According to my census, there are no residents located in room [ROOM NUMBER]. V11 then shows surveyor a facility…

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 assess/document a blood pressure assessment and failed to ensure medications were administered as ordered by the residents' physician for one (R309) resident out of a sample of 31 residents reviewed. Findings Include: On 11/01/2022 at 10:35 am, R309 stated I have not received my morning medication and it is almost 11 o'clock. On 11/01/2022 at 12:42 pm, V28 (R309s' family) stated R309 still has not received any medications. On 11/01/2022 at 1:07 pm, V9 (Agency LPN #1) located at the 3rd floor nurses station accessing the electronic medication administration record (eMAR) via computer. Surveyor observed residents' eMARs on V9s' computer and observed R309s' eMAR was red in color. On 11/01/2022 at 1:14 pm, V2 (Director of Nursing/DON) located on the 3rd floor of the facility at the nurses station. Surveyor informed V2 that R309 has not received prescribed medications. On 11/01/2022 at 1:14 pm, V2 states to V9 R309 is your assigned resident to care for. You need to follow your eMAR because R309s' medication is assigned to your…

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, interview and records review, the facility failed to follow their policy of diets & diet orders and failed to follow their food menu/mechanical soft diet for one resident (R20) reviewed for diets & diet orders in a sample of 6 residents. Findings include: R20 is an [AGE] year-old individual admitted to the facility on [DATE]. R20 has medical diagnosis including but not limited to: Dysphagia, oropharyngeal phase. R20 is on Mechanical soft diet. On 11/01/2022 at 12:20 pm, R20 was observed in the dining room eating lunch. R20 was observed eating a toasted slice of garlic bread and R20 was observed trying to bite the bread. At 12:42 pm, R20 was observed coughing as R20 was eating toasted garlic bread. On 11/01/2022 at 12:35 pm, V7 (Activity aide) said that staff passing residents trays should check the food on resident tray to make sure what is on the resident tray matches the resident diet. V7 said V7 did not know which staff served R20's lunch. V7 was observed going to V7 and patting R20 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.

Based on observation, interview and record review the facility failed to follow their policy of food from outside for one of six residents (R62) reviewed for food from outside labeling in a sample of 6 residents. Findings include: On 11/02/2022 at 12:25 pm, R62 was observed in R62's room eating lunch. In R62's room was observed a small black fridge placed on a table next to the window. R62 said That is my food that my wife brings for me from home. R62 gave surveyor and V30 (Certified Nursing Assistant-CNA) permission to check what was in R62's Fridge. On 11/02/2022 at 12:30 pm, V30 opened R62's fridge and inside R62's fridge was observed : o 1 black container with cooked oatmeal. No date when oatmeal was brought to R62, or when food should be eaten by. o 1 black container with cooked white rice. No date when rice was brought to R62, or when rice should be eaten by. o I clear cup with pineapple. No date when pineapple was brought to R62, or when pineapple should be eaten by. o Three cups pink lemonade. No date when lemonade was brought to R62, or when lemonade should be drank by. o 1…

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.