Kensington Place Nrsg & Rehab

Based on interview and record review, the facility failed to complete an accurate facility assessment. This failure has the potential to affect all 127 residents that reside within the facility. Findings include: The facility provided census (4/28/2025) documents 127 residents reside in the facility. The facility assessment (4/25/25) documents the following inaccuracies, including but not limited to: 1) No staff, resident, or family names that participated in the development of the facility assessment (pg. 6) 2) 803 residents with Heart/Circulation conditions (pg. 8) 3) 447 residents with metabolic conditions (pg. 8) 4) 252 residents that have > 252 diseases (pg. 8) 5) 383 residents were in the facility from 3/1/2025 to 4/1/2025 (pg. 8) 6) (Facility) is unable to care for and/or accept residents with a primary diagnosis of mental illness (pg. 8) when page 7 identifies that the facility has a long term/Psych unit 7) Acuity (Pg. 9) lists the facility as (Another Facility) 8) Identifies that 95% of the facility population has care needs related to urinary incontinence/indwelling…

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 wear personal protective equipment (PPE) while performing gastrotomy (G-tube) care for one resident (R104) on enhanced barrier precautions (EBP). This failure affected one resident (R104) in a total sample size of 54 residents. The facility also failed to do hand hygiene while performing laundry duties. This failure has the potential to affect all 127 residents residing in the facility. Findings include: 1. On 4/28/25 at 10:28 am, R104 observed in bed with a tube feeding pump hanging on a pole with a piston syringe for a G-tube. R104 stated that R104 went back to the hospital recently to have R104's G-tube replaced, and R104 pointed to R104's covered stomach saying that the G-tube is clamped now. An Enhanced Barrier Precautions (EBP) sign is observed visibly posted on R104's room door. On 4/29/25 at 10:41 am, R104 observed in bed with a tube feeding pump hanging on a pole with a piston syringe for a G-tube, and R104's G-tube is clamped. 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 and interview the facility failed to clean the lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 127 residents that reside in the facility. Findings include: On 04/29/25 at 11:07am, a large amount of lint is observed in all three of the dryers covering the lint trap catcher and the base of the dryers located in the facility's laundry area. Also observed a large amount of lint on the floor surrounding the three dryers. On 04/29/25 at 11:07am V11 (Housekeeping Supervisor) stated that he cleans the lint traps every three days. V11 stated that there is a loose wire in one of the dryers and the repair guy is coming to fix the wire. V11 stated that he is unable to physically move the dryers to clean around them and will do so when the repair guy comes to fix the dryer. V11 stated that it is important to clean the dryer's lint traps and surrounding areas because they are fire hazards and could cause a fire. On 05/01/25 at 12:56pm V1 (Assistant Administrator) sent an email that stating, There is 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.

Based on interview and record review, the facility failed to ensure all staff were trained on Quality Assurance (QA)and Performance Improvement (QAPI). This failure affects all 127 residents that reside within the facility. Findings include: Record review of facility provided census (4/28/2025) documents that 127 residents reside in the facility. On 4/28/2025 at 10:52 AM, V44 (Housekeeper) stated that V44 did not know what QAPI was and had never received training on QAPI. On 4/28/2025 at 11:14, V26 (Registered Nurse) stated that V26 was unsure what QAPI or QA was. V26 could not recall when the last time V26 was in-serviced on QAPI. On 4/29/2025 at 12:11, V1 (Assistant Administrator) stated, we do train on QAPI, like we just got done training everyone on handwashing. The line staff get training on hire. When asked if the floor staff get trained on QAPI, V1 replied they don't participate in the QAPI meeting. V43 (Nurse Consultant) and V1 (Administrator) were unsure if it was a requirement that all staff receive QAPI training. V43 stated, I will have to check on that. On 4/30/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure preadmission screening assessments were completed as needed for residents identified to have a mental illness. This failure affects 4 residents (R10, R33, R40, and R46) reviewed for pre-admission screening in the sample list of 54 residents. Findings include: 1. R10's face sheet documents, in part, admit date : [DATE] 05:15 PM (latest return); 09/21/2015 06:47 PM (current). R10's face sheet documents R10's diagnoses that include but are not limited to schizophrenia (date diagnosed 10/01/15). R10's active order, start date 1/7/24, documents, in part, risperidone (antipsychotic) 2mg (milligram) orally twice a day. Review of R10's health records do not show that a Level I Pre-admission Screening and Resident Review (PASARR) was completed for R10. 2. R33's face sheet documents, in part, admit date : [DATE] 06:53 PM (latest return); 07/07/2010 12:01 AM (current). R33's face sheet documents R33's diagnoses that include but are not limited 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 two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 4 out of 18 residents who are prescribed controlled substances from the second-floor long hall medication cart. Findings include: On 04/29/2025 at 1:26 pm, review of the 2nd Floor long hall medication cart with V15 (RN/Registered Nurse) surveyor observed the Controlled Substances Check Form for April 2025. The Nurse's Initials On box was left blank for April 17, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 17, 2025(11-7 shift). The Nurse's Initials Off box was left blank for April 20, 2025 (11-7 shift). The Nurse's Initials On box was left blank for April 21, 2025 (3-11 shift). The Nurse's Initials On box was left blank for April 23, 2025(3-11 shift). The Nurse's Initials On box was left blank for April 26, 2025 (3-11 shift). The Nurse's Initials Off box was left blank for April 26, 2025 (11-7 shift). The Nurse's Initials On box 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 interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 9 residents (R21, R25, R33, R39, R64, R68, R69, R102, R115) sampled in a total sample size of 54 and has the potential to affect all eligible residents that reside at the facility. Findings include: Review of records for R21, R25, R33, R39, R64, R68, R69, R102, and R115 from admission dates to 04/30/25 have no findings of documentation of pneumococcal vaccine offering or education of the vaccine. Review of physician orders for R21, R25, R33, R39, R64, R68, R69, R102 and R115 from admission to 04/30/25 show no orders for pneumococcal vaccination. Immunization records for R21, R25, R33, R39, R64, R68, R69, R102 and R115 has no current pneumococcal…

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

Based on observation, interviews and record review, the facility failed to maintain confidentiality of personal and medical information for two residents (R225 and R69) out of the 54 residents reviewed for privacy and confidentiality of records. Findings include: 1. On 4/28/2025 at 10:05am R225 observed in room, lying in the bed. R225 stated I came to this facility on Thursday (4/24/2025) from the hospital. Observed a white band on R225 's left wrist. R225 stated this is the band I had at the hospital. R225 stated none of the staff have asked me if I wanted the band removed. Observed the following information documented on R225 's white wrist band: MRN# (medical record number), AD (admission date): 04/13/2025, and R225's date of birth . R225's Face sheet which documents in part, last qualifying hospital stay: 04/13/2025-04/24/2025. 2. On 4/28/2025 at 10:35am R69 observed lying in bed watching television. Observed a white band on R69's right wrist. R69 stated I went to the hospital about two months ago. R69 stated this is the band I got in the hospital. Observed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident was free of confinement to bed with all four side rails up. This failure has the potential to affect 1 resident (R40) of 1 resident reviewed in a sample size of 54 residents. Findings include: R40 Face Sheet documents a diagnosis of Hypertension, Psychotic Disturbance, Schizophrenia, and Gastro-esophageal reflux disease. On 4/28/2025 at 11:09 AM, R40 was noted lying in bed with all four side rails up. R40's Physician Order Sheet dated 3/29/2025 -4/29/2025 does not document an active order for a restraint. R40's Physician Order Sheet dated 3/29/25 - 4/29/25 documents an active order with a start date of 11/25/2024 with an end date of Open Ended, documents Half Side Rails to bed for mobility. Special Instructions: half side rails x 2 as a enable for mobility and repositioning while in bed. R40's Minimum Data Set, dated [DATE], Section C documents in part, A Brief Interview Mental Status (BIMS) score of 6 out of 15 which is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer residents with possible serious mental disorders for Screening and Resident Review to the appropriate state-designated authority for further assessment as required. This failure affects 2 residents (R106 and R110) reviewed for pre-admission screening in the sample list of 54 residents. Findings include: 1. R106's face sheet documents, in part, admit date : [DATE] 01:48 PM (latest return); 05/11/2023 02:34 PM (current). R106's face sheet documents R106's diagnoses that include but are not limited to schizophrenia (date diagnosed 7/05/24). R106's care plan, edited date 3/31/25, documents, in part, (R106) has displayed aggression and was recently involved in an incident with another peer where he was NOT the aggressor. This may be potentially related to his mental health issues of Delusional Disorder and Personality Disorder. [NAME] can also at times exhibit verbally inappropriate behaviors towards staff/peers. Review of R106's Notice of PASRR…

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 and interview, the facility failed to have signage posted identifying a resident who has oxygen in use in the resident's room to prevent a possible hazard. This affected one resident (R69) in a total sample of 54 residents. Findings include: On 04/28/2025 at 10:355am observed nasal cannula in R69's nares, with tubing leading to an oxygen concentrator machine next to R69's bed. The oxygen concentrator machine was set to deliver oxygen at two liters per minute. R69 stated I have been on oxygen for three months now. There was no Oxygen in Use sign posted on the outside of R69's door indicating that oxygen was in use in R69's room. On 4/28/2025 at 10:45am V15 (RN/Registered Nurse) stated R69 is on as needed oxygen. V15 was asked what would indicate that R69 was receiving oxygen. V15 stated when you enter the room you see the concentrator machine. V15 stated a sign would be on R69' s door before entering the room. V15 stated the sign is missing from R69's door. V15 stated the purpose of the sign is for safety reasons. V15 stated IP (infection preventionist) is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents remain free of abuse for one of three residents (R5) reviewed for abuse in the sample of eight. Findings include: Facility's final incident report dated (3/21/2025) documents in part, on 3/16/2025, staff observed (R4) acted inappropriately towards (R5). Staff immediately intervened and both residents were separated. (R5) indicated (R4) walked up in a conversation he was having with another peer at the end of the 3rd floor hallway. (R5) alleged that (R4) began to use profanity towards him and touched him inappropriately across his eyes with an open hand. Peer (R6) that was speaking to (R5) indicated that (R4) walked up and stated, I'm tired of your stuff and acted inappropriately towards R5. He (R6) stated it was unprovoked. On 4/16/2025, at 10:26 AM, V4 (Assistant Director of Social Service) said it was reported that R4 and R5 were in the long hall on third floor. R5 said R4 walked up to R5 while R4 was having conversation with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to post the required information for [NAME] Program information in areas where it is easily accessible to the residents. This failure has the potential affect all the 125-residents residing in the facility. Findings include: On 02/18/2025 at 10:40am, on the 3rd floor of the facility the surveyor observed no required posting of [NAME] Program information poster on any area of the floor that is accessible to the residents. On 02/18/2025 at 11:20am V7 SSD (Social Service Director) stated that I don't post anything, I (V7) have never posted it personally and I don't know where it is posted. We tell them about it, and the agency sends their representatives (referring to [NAME] Program staff) to come and educate the residents. At 11:22am, V7 stated that I have never been given any poster and did not know that it should be posted on the floors. During the same observation rounds between 11:22am to 11:30am with V7 on the 1st and the 2nd there was 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 ensure the facility temperature in residents' rooms, common area hallways, and dining area on the 1st, 2nd, and 3rd floor meet the required temperature of 71-degree Fahrenheit to 80-degree Fahrenheit. This failure has the potential all the 120-resident residing in the facility. The facility aslo failed to ensure that residents sinks were functioning properly for two (R1 and R3) of five residents reviewed for physical environment. Finding include: 1. On 02/18/25 the following observation were made: Temperatures on the 3rd floor selected rooms and hallways did not meet the required 71 to 80-degree Fahrenheit. South hallway = 63.9 degrees Fahrenheit, room [ROOM NUMBER] =68.2 degrees Fahrenheit, room [ROOM NUMBER]=62.6 degrees Fahrenheit room [ROOM NUMBER]= 67.3 degrees Fahrenheit room [ROOM NUMBER]= 66.9 degrees Fahrenheit room [ROOM NUMBER]=57.2 degrees Fahrenheit room [ROOM NUMBER]= 64.8 degrees Fahrenheit Residents observed in the dining…

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 that residents were free from physical abuse from fellow residents. This failure affected two residents R3(who was physically abused by R2) and R5(who was physically abused by R4), that were reviewed for resident versus resident physical abuse. Findings include: R2's diagnoses include but are not limited to Schizophrenia, Delusional Disorders, Schizoaffective Disorders, Psychotic Disorder with Delusions, and Anxiety. BIMS (Basic Interview for Mental Status) score dated 10/7/24 is 15(Cognitively Intact). R3's diagnoses include but are not limited to Schizophrenia and Bipolar disorder. BIMS score dated 11/14/24 is 10(Moderate Cognitive Impairment). R4's diagnoses include but are not limited to Bipolar Disorder, Schizophrenia, Depressive Disorders, Psychotic Disorder, Obsessive Compulsive Disorder, Manic Episodes, and Violent Behavior. BIMS score dated 12/31/24 is 15(Cognitively Intact). R5's diagnoses include but are not limited To Schizophrenia, Psychotic Disturbance, Mood Disturbance, and Anxiety. BIMS score dated…

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 own policy in reporting incident and accident. This failure affected 1 (R1) resident reviewed for reporting of incident and accident in the total sample of 3 residents. Finding include: R1 ' s (11/04/2024) Initial and Final reportable documented, in part Description of Occurrence. Res(ident) sent to Hosp(ital) ER (emergency room) for 3-4 inche(es) laceration to inner R(right) leg. Occurrence Resolution. Res(ident) received 10 stiches to inner R leg; to be removed in 10 days. On 12/27/2024, at 1:33 PM, V8 (Nurse Supervisor) stated I work 3:00 PM-11:00 PM shift. I stayed over that night. (V4-Licensed Practice Nurse) came and asked me if I could go upstairs to assess (R1) due to an open area on his right leg. When I assessed him, there was a long and deep laceration on his leg; it was like he got cut on something. In my opinion, he (R1) needed stitches. On 12/27/2024 at 1:43 PM, this surveyor read to V8, R1's (11/04/2024) Initial and Final reports' Description of the Occurrence and the Occurrence Resolution. V8…

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 an incident was investigated thoroughly. This failure affected 1 (R1) resident reviewed for incident and accident investigation in the total sample of 3 residents. Findings include: The (12/27/2024) email correspondence with V2 (Director of Nursing) and V3 (Assistant Administrator) documented, in part Kindly provide scanned copy of the investigation packet for (R1)'s incident on 11/04/2024. R1's (11/04/2024) investigation packet only include R1's witness statement taken by V10 (Wound Care Nurse). The (11/03/2024) 3:00 PM to 11:00 PM, shift daily assignment sheet documented that V9 (Certified Nursing Assistant) was assigned to R1. The (11/03/2024) 11:00 PM to 7:00 AM, shift daily assignment sheet documented that V4 (Licensed Practice Nurse) and V11 (Certified Nursing Assistant) were assigned to R1. On 12/28/2024 at 12:47 PM, V9 (Certified Nursing Assistant) stated no one interviewed me and no one told me to write a witness statement regarding his…

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 protects a resident's right to be free from physical abuse. This failure affected one (R1) resident reviewed for abuse in a total sample of 3 residents. Findings include: R1 and R2's (12/05/2024) Initial reportable documented, in part Description of occurrence. On 12/05/2024, R2 was observed to engage in an altercation with R1. R1's (12/05/2024) Witness Statement documented, in part (R2) slapped me in the face. She did not tell me why she hit me. R2's (12/05/2024) Witness Statement documented, in part When asked reason for hitting (R1), resident stated 'who is (R1)? V5 (Certified Nursing Assistant) (12/05/2024) Witness Statement documented, in part (R2) was in the hallway and just walked up and slapped (R1). V7 (Licensed Practice Nurse) (12/05/2024) Witness Statement documented, in part (R2) walked up, slapped (R1), laughed and kept walking. (R2) slapped (R1) on her right cheek. On 12/20/2024 at 11:09am, with V5 (Certified Nursing Assistant) present, R1 stated (R2) hit me on my head. On 12/20/2024 at 11:04am, V5 (Certified…

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

Based on interviews and record reviews the facility failed to follow their Nursing Service Policy to identify and assess a resident's needs, musculoskeletal status, need for assistive devices, and safety needs for one (R1) of three residents reviewed for accidents. Findings include: R1's clinical record indicates the following: R1 is a seventy-eight-year-old admitted with medical diagnosis of chronic gout, multiple sites, liver cancer, limitation of activities due to disability, reduced mobility, muscle wasting and atrophy, lack of coordination, abnormal gait and mobility, chronic viral hepatitis C, primary osteoarthritis right ankle and foot, spinal stenosis, hypertensive heart disease, and carcinoma of liver gallbladder and bile ducts. R1's Minimum Data Set [MDS] Brief Interview for Mental Status score is 15, which indicates R1 is cognitively intact, alert and oriented x3 and able to make his needs known. MDS section GG indicates R1 uses a wheelchair and is unable to walk alone, and is unable to wheel the wheelchair 150 feet, due to medical conditions and safety concerns. R1'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 observation, interview, and record review the facility failed to ensure that medication was locked up safely in the treatment cart when not in use and when not in proximity of the nurse, to prevent tampering and accidental hazard. This failure has the potential to affect all the residents residing on the 1st and 2nd floor of the facility. Findings include: On 10/29/24 at 12:46pm, the 2nd floor treatment cart was observed in the hallway unlocked and unattended to. When this was shown to V4 RN (Registered Nurse) and V4 was asked about the facility policy on medication storage. V4 stated that the cart should be locked. V4 stated we have a treatment nurse who should have locked the cart because I did not see that it was not locked. On 10/29/24 at 12:56pm the 1st floor treatment cart was noted in the hallway with no nurse present and unlocked. At 1:00pm, the surveyor showed that observation to V15 (RN). V15 stated that they (referring to Treatment Nurse) don't normally locked the treatment cart on this floor just in case she (V15) needs to use it. The surveyor then asked what…

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 immediately report an allegation of verbal abuse for one resident (R5) out of six residents reviewed for abuse in the sample. Findings include: R5's medical record Face Sheet documented that R5 was admitted on [DATE] with diagnoses list that includes but not limited to Meningitis due to other specified causes, other unspecified anemias, other seizures, abnormality of gait and mobility, muscle wasting, and atrophy not elsewhere classified, other lack of coordination and need assistance with personal care and cognitive communication deficit. R5's medical record Progress notes dated 10/30/24 timed 2:10pm showed that R5 was discharged AMA (Against Medical Advice) with family from the facility. On 10/29/24 at 12:38pm, V3 LPN (Licensed Practical Nurse) stated that she is familiar with R5 and that she is the assigned nurse for R5's care. V3 stated that R5 is ambulatory with assist. V3 stated that R5 was on contact isolation previously and just finished…

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 meet professional standard of medication administration and failed to follow their facility policy on medication administration for one resident (R5) in the sample. This failure affected R5 whose medication was prepared by one nurse but administered by a different nurse putting R5 at risk for medication error. Findings include: On 10/29/24 at 12:38pm, during an interview with V3 LPN (Licensed Practical Nurse), V3 stated that she has not been administering R5's medication since the 2nd day of admission that instead it is V4 (RN) who has been the nurse that has been administering R5's medication. R5's medical record Face Sheet documented that R5 was admitted on [DATE] R5's MAR (Medication Administration Record) dated 10/01/24 to 10/31/24 showed documentation that V3 has been signing out the administration of R5's medication. On 10/31/24 at 12:17pm, when this discrepancy was shown to V2 DON (Director of Nurses), V2 stated both V3 and V4 prepared 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 interview and record review, the facility failed to schedule sufficient staff to meet the behavioral needs of one resident (R1) out of out of six residents reviewed for sufficient staffing in the sample of six. Findings include: R1's medical record face sheet documented that R1 was admitted on [DATE] and latest admission was on 10/25/24. Listed diagnoses includes but not limited to type 2 diabetes mellitus with other specified complications, other schizoaffective disorders, and other symptoms and signs involving appearance and behavior. R1's MDS (Minimum Data Set) dated 08/28/24 section C scored R1's BIMS (Brief Interview for Mental Status) as 15 indicating that R1 has no cognitive deficit. R1 care plan for aggression documented that R1 has history of demonstrating aggressive behaviors that can exacerbated at times due to instability to R1's mental illness. R1 as a history of being physically aggressive at times. R2's face sheet showed documentation that R2 was admitted [DATE] with listed diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of seven residents reviewed for abuse. Findings Include: Facility's Investigation Report (dated 09/13/2024) notes, on 09/06/2024, (R1) engaged in an altercation with (R2), staff immediately intervened and separated the residents. Body assessment conducted. (R1) was noted with a laceration. MD (Medical Doctor) aware and emergency contacts made aware. (Local Police Department) contacted, administration. (R1) stated she was sitting down at a table eating her snacks and watching television while in the 3rd floor dining room when (R2) approached her and became aggressive. She indicated no precipitating factors that led to the altercation. Residents who witnessed the incident stated (R1) was sitting at the table when (R2) suddenly engaged in an altercation with (R1) for no reason. Staff interviews indicated overhearing yelling and observed (R1) and (R2) engage in an altercation.…

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 have privacy curtains which extend around the bed. This failure affected seven residents (R21, R22, R23, R24, R25, R26, and R27) reviewed for residents' privacy. Findings include: On 09/10/24 between 11:10 am and 11:30am on the second and third floors, the Surveyor observed R21, R22, R23, R24, R25, R26, and R27 with missing privacy curtains. On 09/11/24 at 11:00 am on the second floor, all of the residents' privacy curtains were still missing and the surveyor called V18(RN/Registered Nurse) and showed V18 the missing privacy curtains for R21, R22, R23, R24 and R25. V18 stated that she would ask housekeeping because they sometimes take the curtains for washing. On 9/11/24 at 11:25am on the third floor, the privacy curtains of R26 and R27 were also still missing, and the surveyor called the attention of V19(CNA/Certified Nurse Assistant). V19 stated that she(V19) would ask the Housekeeper. On 9/11/24 at 11:03am, the Surveyor interviewed V21 (Housekeeping Supervisor). V21 stated We have 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.

Based on observation, interview, and record review, the facility failed to have a functioning call light in the community shower rooms on the second floor and third floor of the facility. This failure has the potential to affect all 38 residents on the second and all 48 residents on the third floor. Findings include: On 9/10/24 at 10:30am after the entrance conference, V2(Assistant Administrator) presented the residents census as follows: Second Floor - 38 residents and Third Floor - 48 residents. On 09/10/24 between 11:10 am and 11:50am on the second and third floors, the Surveyor observed that the call lights by the toilet in both community shower rooms were not functional. On 09/11/24 at 11:25 am on the second floor with V16((CNA/Certified Nurse Assistant), the call light in the second-floor community shower room was still not working when it is pulled. V16 pulled it again and V16 stated It's not lighting up or making any sound, I will let them know. On 9/11/24 at 11:45am on the third floor with V19(CNA), the surveyor observed that the call light by the toilet in the community…

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 fails to maintain an effective pest control program so that the facility is free of insect pests in 1 of 4 facility levels in one residents room. Findings include: On 9/10/24 at 11 AM R17's room was observed with an active infestation of fruit flies. A 5x5 inch hole was observed at the floor wall junction next to the toilet room entrance. 100 plus fruit flies were observed originating from the hole. Fruit flies were observed on all wall surfaces and ceiling. R17 was sitting on his bed. Fruit flies were observed on R17's face and arms. On 9/10/24 at 11:05AM R17 stated yes the fruit flies are bad in this room. They are coming from the hole in the wall. There was a water leak from that hole. It has been like this for a couple weeks. On 9/11/24 at 10AM V11 (Maintenance Supervisor) stated R17 has a behavior of clogging up the toilet and hand sink in the bathroom. The water overflows and floods the room and rooms below all the way to the basement. The hole in wall is from water damage and the fruit fly infestation is coming…

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 protect the resident's right to be free from verbal abuse by staff for one resident (R1) and failed to protect a resident's right to be free from physical abuse by another resident for two residents (R2 and R3) reviewed for abuse in the sample of 5 residents. Findings include: 1. R1 is [AGE] years old, initially admitted in the facility on 1/15/2024, with diagnosis of schizoaffective disorder, major depressive disorder, psychosis. The facility reported incident dated 6/16/2024, docuemnts V3 (Housekeeper) went into the soiled utility room that R1 followed and went inside the same soiled utility room that V3 went into. V4 (Licensed Practical Nurse/LPN) observing that R1 followed V3, attempted to redirect R1 but the door was closed. When the door finally opened, V4 saw R1 on the floor and overheard V3 being verbally inappropriate to R1. R1's progress notes dated 6/16/2024 at 7:55 AM by V4 (LPN), docuemnts R1 sustained scratches on her left hand. Per…

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 the interview and record review, the facility failed to report abuse in a timely manner for two residents (R2 and R3) reviewed for abuse out of the sample of 5 residents. R3 is [AGE] years old, initially admitted in the facility on 9/19/2018 with the following diagnosis schizophrenia, hallucinations, conduct disorder, bipolar disorder, and depressive disorder. R2 is [AGE] years old, initially admitted in the facility on 9/20/2018 with the following diagnosis chronic obstructive pulmonary disease (COPD), anxiety disorder. Facility reported incident dated 6/19/2024 involving R2 and R3 are as follows: Incident description by V4 (Licensed Practical Nurse) documents that on 6/19/2023 at 11:42 AM, it was reported to staff by a resident that R2 and R3 engaged in a physical altercation that occurred on 6/18/2024. Per description of occurrence documentation, on 6/19/2024 11:42 AM, it was reported to staff by a resident alleging that R3 and R2 engaged in a physical altercation that occurred on 6/18/2024. R3 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to (a) ensure incontinence care is provided in a timely manner for one (R1) resident who needed assistance with toileting; and (b) provide a shower as scheduled for one (R1) resident who needed assistance with shower / bathe. These failures affected one (R1) of three residents reviewed for improper nursing care. The findings include: R1's health record documented diagnoses not limited to Spinal stenosis, cervical region, Hypertensive heart disease without heart failure, Other specified anemia, Nontoxic multinodular goiter, Carpal tunnel syndrome left upper limb, Type 2 diabetes mellitus with other specified complication, Celiac artery compression syndrome, Other specific joint derangements of right hip, Primary generalized (osteo)arthritis, Other neuromuscular dysfunction of bladder, Overactive bladder, Unspecified lump in the right breast, Personal history of other venous thrombosis and embolism, Pain in leg. On 6/16/24 at 10:45am Observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one (R1) resident out of five residents reviewed for abuse in a sample of five. Findings Include: The facility's incident final report shows incident date of 4/15/24 with description of occurrence that reads in part: On 4/15/2024 at approximately 6:25PM, staff observed (R1) hit (R2) unprovoked in facial area with chair. Staff immediately intervened and separated both residents. (R2) was assessed by NOD [Nurse on Duty], with injury noted. R1's progress notes written by V5 (Licensed Practical Nurse/LPN) dated 4/15/24 at 5:14 PM documents in part that during dinner time V5 was informed that R1 had thrown a chair at another resident, hitting the resident in the lower eye causing laceration with light bleeding. R2's progress notes written by V12 (Registered Nurse/RN) dated 4/15/24 at 5:23 PM documents that R2 was hit in the face with a chair unprovoked by another resident…

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 medications were locked and secured while unattended, remove and discard expired medication, and label liquid medications that had been opened in five of five medication carts reviewed for medication labeling and storage. These failures have the potential to affect all 113 residents residing in the facility. Findings Include: On 03/12/2024 at 9:39AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart (identified as the First Floor medication cart) unlocked and unattended. Surveyor observes five pills inside of an unlabeled clear medication cup on top of the unattended medication cart with the following pills inside: one small, pink, oblong pill one small, orange, square pill one yellow capsule one small white, circle pill one small, yellow circle pill Surveyor also observes the following medication bingo cards on top of the unattended medication cart: One medication bingo card labeled: Metoprolol 25mg with R56's name and 15 pills inside of medication bingo card. One…

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 review of records, facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This failure has the potential to affect all 113 residents in the facility. Findings include: On 03/12/2024 at 09:30 AM, surveyor observed the foods in the dry food storage room. Surveyor observed opened bread package without any date. V3 (Dietary Manager) stated that the bread should have a date. Surveyor also observed foods inside the freezer with V3. Surveyor noted the ham and the chicken patties package inside the freezer were not dated. V3 stated that the ham and chicken patties should have been dated. V3 stated that her aide did date the package but apparently not. V3 stated that it is important to date foods when opened to know how long the foods are good for before going bad. On 03/12/2024 at 09:47 AM, surveyor asked V3 for the temperature logs for the refrigerator and freezer. V3 provided surveyor with the temperature logs 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.

Based on interview, and record review, the facility failed to ensure controlled substances were counted and documented at the beginning and end of each shift for 26 out of 34 shifts and failed to keep an accurate count of all narcotic medications for one (R24) resident. These failures have the potential to affect 72 residents residing in the facility. Findings include: On 03/12/2024 at approximately 9:55AM, V9 (Registered Nurse/RN) states she did perform a narcotic drug count with another nurse but did not sign the Controlled Substances Check Form. V9 was responsible for the 1st floor medication cart. On 03/12/2024 at approximately 9:55AM, review of the Controlled Substances Check Form for the month of March 2024 for a medication cart identified as the First Floor medication cart located on the 1st floor of the facility indicates the nurses had not counted and docuemnted the controlled substances for 17 shifts in the month of March 2024. The following dates were missing signatures: On 03/01/24, 1st shift (7am-3pm) and 3rd shift (11pm-7am) On 03/02/24, 1st shift (7am-3pm) On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to follow their policy on Resident rights for one (R36) of six residents reviewed for clean comfortable and homelike environment in a sample of 24. Findings include: R36 is a [AGE] year-old individual first admitted to the facility on [DATE] and readmitted on [DATE]. R36 Medical diagnosis listed in his current face sheet include but not limited to: Type 2 diabetes mellitus with hyperglycemia, other schizophrenia, Legal blindness, as defined in USA, Other cerebral infarction, and his MDS (Minimum Data Set) SECTION C (Cognitive pattern) documents R36's Brief Interview for Mental Status dated 1/15/2/24 as 15/15 indicating R36 has intact cognation. R36's MDS section GG (Functional abilities and Goals) dated 01/17/2024 documents R36 needs supervision or touching assistance with activities of daily living. On 03/12/24 11:32 am, R36 was observed laying on his bed in his room. R36 stated he has not changed for two days now because he does not have…

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

Based on observations, interview and review of records, facility failed to follow their policy to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints for one (R51) of three residents reviewed for restraints in a sample of 24. Findings include: On 03/12/2024 at 10:30 AM, surveyor observed R51 laying in her bed. R51 has her bed rail up on the left side of the bed that prevents her from get out of bed freely and the wall on her right side of her bed. On 03/13/2024 at 11:39 AM, surveyor observed R51 continues has that left bed rail up that prevents her from getting out of bed. On 03/13/2024 at 01:02 PM, V2 (Director of Nursing) stated that bed rails are only up if the resident or the POA (Power of Attorney) consents to using the bedrails to help them with mobility. If the whole bed rails are up there should be a doctor's order and it should be care planned otherwise it is considered a restraint. On 03/13/24 at 01:28 PM, V10 (Licensed Practical Nurse) stated that R51's side rails are up because she is a high fall risk. So, 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 interview and record review, the facility failed to ensure a resident had an individualized comprehensive care plan to meet the residents' medication need for one (R3) of four residents reviewed for care plans in a sample of 24. Findings include: R3 facesheet provided by facility 3/14/24, reads in part: diagnoses include but are not limited to chronic pulmonary embolism, chronic kidney disease, stage 1. R3 physician order summary, 2/14/24-3/14/24, reads in part: warfarin tablet, 2 mg (milligram) oral at bedtime; start date 12/6/2023. On 3/14/24 approximately 12:00 PM, surveyor requested the care plan for R3's anticoagulant usage. Surveyor was given a care plan reading in part: Problem start date 3/8/2024, Nursing care plan: R3 has increased risk for bleeding and bruising r/t (related to) anticoagulant therapy, created 3/14/2024. On 3/14/24 at 12:16 PM, V16 (Care Plan Coordinator) stated I did not have a care plan for R3's Warfarin. I was only told to do a care plan for Lovenox injection. Warfarin is an anticoagulant. The purpose of the care plan is so the residents, staff…

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 a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion by not applying/maintaining a left hand splint. This failure affects one (R21) of four residents reviewed for limited range of motion in a total sample of 24 residents. The findings include: R21's Facesheet documents R21 was admitted to the facility on [DATE]. R21 has diagnosis not limited to: Hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, Dementia, hypertensive heart disease with heart failure, and Type 2 diabetes mellitus. On 03/13/2024 at 8:51AM, R21 observed on the third floor of the facility self-ambulating in a manual wheelchair down the halls. R21's left hand observed contracted and immobile. No device or splint observed on R21's left arm or hand. On 03/13/2024 at 9:40AM, surveyor located at the third floor nurses' station with V5 (Registered…

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

Based upon record review and interview the facility failed to ensure that required medical records were provided to EMS (Emergency Medical Service) for one of three residents (R1) reviewed for transfer. Findings include: R1's (12/11/23) progress notes state resident called 911 and was transported to hospital for evaluation. [Medical records provided to EMS was not documented]. R1's diagnoses include asthma. R1's (1/23/23) BIMS (Brief Interview Mental Status) determined a score of 14 (cognitively intact). On 1/9/24 at 2:24pm, surveyor inquired about concerns with R1's (12/11/23) hospital transfer. R1 stated I couldn't breathe, I have asthma. I called 911 myself. The ambulance driver said he didn't get a face sheet, list of meds I take, or nothing. On 1/16/24 at 9:27am, surveyor inquired about the requirement for transferring residents to the hospital. V2 (Director of Nursing) stated We just send the face sheet and POS (Physician Order Sheets) and give it to the ambulance attendant. Surveyor inquired if an SBAR (Situation, Background, Assessment Recommendation) form - which includes…

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

Based upon record review and interview the facility failed to follow policies/procedures, failed to timely follow-up on x-ray results, failed to timely notify the physician of serious injury, and failed to provide timely care for one of three residents (R3) reviewed for injury of unknown origin. R3 had an acute fracture to the distal right fibula. R3 went 5 days without treatment or care for the fracture. Findings include: R3's diagnoses include but not limited to heart failure, difficulty in walking, and non-displaced oblique fracture of right fibula. R3's (12/21/23) right ankle x-ray affirms soft tissue swelling and acute fracture distal right fibula. Electronically signed by physician 12/21/23 at 7:43pm. R3's progress notes include (12/21/23) Right ankle swelling noted, circulation good at site. Denies pain. Doctor notified, order for right ankle x-ray received. Resident received (portable) x-ray of right ankle. (12/26/23) Results from (x-ray department) received with finding fracture of right tibula (sic). Doctor informed, received orders to transfer resident to hospital 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to protect resident's right (R3) to be free from physical abuse by another resident (R2). These failures affect 2 residents (R2 and R3) out of 4 residents reviewed for abuse. Findings include: R3 is [AGE] years old, initially admitted on [DATE]. R2 has diagnosis that includes, but not limited to, Cerebral Palsy, schizoaffective disorder; profound intellectual disabilities; cognitive communication deficit; epileptic spasms, not intractable, without status epilepticus. R3 minimum data set assessment dated [DATE] shows Brief Interview of Mental status (BIMS) scored as 15 out of 15. R2 is a [AGE] year-old admitted to the facility on [DATE]. R2 has a primary diagnosis of Diabetes mellitus Type II and an admission diagnosis of other bipolar disorder; Later was diagnosed with other symptoms and signs involving appearance and behavior and schizophrenia. R2 minimum data set (MDS) assessment dated [DATE] shows Brief Interview of Mental status (BIMS) scored as 12.…

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 record review, the facility failed to provide a sanitary environment by failing to ensure that resident rooms were free of pests, failing to implement cleaning of resident drawers, and failing to notify the appropriate department of the presence of pests detected. The facility also failed to ensure a functional environment by failing to notify maintenance about equipment that needed repair. As a result, roaches were found in a resident's room and a broken faucet that needed repair was not fixed in a timely manner. This failure affected two residents (R1 and R5) of the 4 residents reviewed. Findings include: On 11/30/23 during the tour of the facility, noticed that the sink in R1 ' s room had a constant flow of water. When checking the faucets, it was noted that they didn't work. The bathtub in the short hallway has a constant flow of water as well. On 11/30/23 at 09:40 am R1 says the constant flow of water in the sink has been like that for weeks. R1 says he saw roaches in the closet drawer in room XXX (R5's current room) when he was there. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based interviews, and review of records the facility failed to provide a person-centered care plan for refusal of care for 1 out of 3 residents (R1) for a total of 3 residents reviewed for plan of care. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 has a BIMS score dated 8/23/2023 of 15 indicating his cognition is intact. On 10/17/2023 at 11:31 AM R1 was seen in his bed alert and verbally able to express his thoughts during conversation. On 10/17/2023 at 12:51 PM, V12 (Psychiatric Residential Service Coordinator) stated that R1 likes to use words with profanity aimed at staff and at times, is verbally aggressive. V12 also stated R1 refuses care multiple times. On 10/17/2023 at 1:29 PM V6 (Licensed Practical Nurse) stated that R1 refuses care and does not let staff change him (R1). Progress notes of R1 documents verbal aggression to staff and refusal of care. Notes dated 9/22/2023 by V6 (Licensed Practical Nurse) and V12 (Psychiatric Residential Service Coordinator) document that R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an involuntary discharge was not solely based on the residents' condition at the time of transfer to acute care and failed to provide Physician's documentation of the reasons a resident was involuntarily discharged from the facility and any needs the facility is unable to meet in the resident's medical record. These deficient practices affected two of three residents (R1 and R3) reviewed for involuntary discharge. Findings include: On 8/11/2023 at 11:0 0 AM, V1 stated there were only 2 involuntary discharges for since June of 2023. 1. R1 is a [AGE] year-old female admitted to the facility on [DATE] and discharged to the hospital on 6/20/23 with the following medical history: Polyosteoarthritis, Paranoid Schizophrenia, Hyperlipidemia, Major Depressive Disorder, Seizures, Legal Blindness, Rhabdomyolosis. R1's progress notes document the following: 6/19/23 by V3 (Licensed Practical Nurse/LPN): Nurse on duty observed resident aggressive…

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 procedure for sanitizing cook/service ware in three-compartment sink according to manufacturing guidelines, failed to follow the procedure for cleaning dishware, and failed to perform hand hygiene. These deficient practices have the potential to affect all 101 residents receiving food prepared in the facility's kitchen. Findings include: On 02/01/23 at 09:30 AM, observed V9 (Kitchen Cook) finish using industrial blender to pureed lima beans. At 09:35 AM, observed V9 bring industrial blender to the three-compartment sink and begin to wash plastic blender lid, metal blade, and plastic base of blender. At 09:36 AM, V9 rinsed each item and then quickly dipped each item in the sink containing sanitizer for less than 10 seconds. At 09:36 AM, V7 (Food Service Manager) came out of V7's office with a different blender base which was stainless steel instead of plastic and gave the stainless-steel base to V9 who then placed the stainless-steel blender base in the sink containing sanitizer. V9 removed 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 garbage and refuse were disposed of properly by not closing the lids of the dumpsters outside the facility. This deficient sanitation practice has the potential to affect all 102 residents who reside in the facility. Findings include: On 02/01/23 at 9:59 AM, an observation of the outside garbage dumpster was conducted with V7 (Food Service Manager). Surveyor observed one large garbage dumpster outside with two of the lids fully opened. On 02/01/23 at 10:00 AM, V7 stated that the lids of the dumpster should be kept closed to prevent pests from getting inside. On 02/01/23 at 12:59 PM, V13 (Housekeeping Supervisor) stated that all of the lids to the dumpster need to be closed when not in use to prevent pests from entering the dumpsters and from attracting more pests by providing a food supply for them. Kitchen Facility policy titled, Garbage Disposal undated documents in part that purpose is to prevent odors, minimize breeding places for insects and rodents and procedure including to keep dumpster closed…

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 residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 11 residents (R11, R12, R24, R25, R39, R82, R84, R86, R99, R255, and R306) reviewed during dining in a total sample of 21 residents. Findings include: On 01/31/23 at 11:44 AM, observed the following residents (R24, R25, R39 and R99) sitting at the same table in the unit dining room. At 11:45 AM, observed R99 eating R99's lunch tray. At 11:48 AM, R24 received R24's lunch tray and began to eat. At 11:53 PM, 2nd cart arrived on the unit. At 11:55 AM, R25 received R25's lunch tray and began to eat. Surveyor observed R39 sitting at the table watching R24, R25 and R99 eating and drinking. At 12:02 PM, R39 received R39's lunch tray and R39 started eating immediately. On 01/31/23 at 11:44 AM, observed the following residents (R12, R255, R306) sitting at the same table in the unit dining room. At 11:50 PM, observed R12 and R255 eating lunch. Surveyor observed…

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 menus for pureed diet consistency for 4 residents (R9, R15, R26, and R53) reviewed for special diets. Findings Include: On 01/31/23 after initial kitchen tour, V7 (Food Service Manager) provided document titled, Client List Report printed 01/31/23 at 10:13 AM. Five residents receive pureed diets prepared in the facility however one of the residents listed on the diet census was transferred to the hospital (01/29/23) and therefore was not included in this review. On 02/01/23 at 09:30 AM, observed V9 (Kitchen Cook) use an industrial blender to pureed lima beans. V9 did not measure the amount of lima beans added into the blender. V9 then added 1 large scoop of food thickener to the blender and then a large amount of chicken broth (unmeasured) from a pitcher. Surveyor asked V9 for the amount of lima beans V9 added to the blender and V9 stated, enough for 5 purees. Surveyor asked how much chicken broth V9 was added and V9 responded 2 Tablespoons at a time. There were no other food ingredients added to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review and interviews the facility failed to document code status preference in the resident profiles for 2 residents (R14, R255) in a sample of 21 residents reviewed. Findings include: On [DATE] at 11:26am R255 was observed in the dining room watching TV. R255 was alert and oriented to person, place, and time. R255 said that R255 has a POA (Power of Attorney) for health, who makes R255's health decisions. R255 was admitted to the facility on [DATE]. R255's diagnosis includes but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Other cerebrovascular disease, Chronic obstructive pulmonary disease with (acute) exacerbation, Aphasia: Broca's Aphasia. R255's Brief Interview for Mental Status (BIMS) [DATE] document R255's BIMS as 13. R255's Activities of Daily Living (ADL) Assistance dated [DATE] document R255's ADL needs as R255 needing extensive assistance with ADLs. On [DATE] at 12:44pm during tour and record review of R255'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 observation, interview and record review the facility failed to provide the appropriate equipment for residents with contractures to prevent further decrease in range of motion for one of three residents (R9) reviewed for range of motion in the sample of 21. Findings include: R9's medical record (Face Sheet, MDS-Minimum Data Set 1/23/2023) notes R9 is severely cognitively impaired and was admitted to the facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Dementia, Adult Failure to Thrive, and Gastrostomy Tube. R9 has functional limitation in range of motion to the upper extremity (left hand). On 2/1/2023 at 11:28 AM, R9 was observed sitting in wheelchair at dining room table without splint to left hand. On 2/1/2023 at 12:32 PM, V19 (Certified Nursing Assistant/CNA) said V19 should have a splint on left hand. V19 said, I didn't put it on. I'll go and look in V9's room for it (hand splint). V19 returned to the dining room with a splint and was observed attempting to apply the splint to R9's right hand without success. V19 said, I don't…

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, date, and store oxygen tubing for 1 (R8) resident out of 5 reviewed for oxygen therapy out of a total sample of 21. Findings Include: R8 has diagnosis not limited to Chronic Obstructive Pulmonary Disease, Dementia, Hypertensive Heart Disease with Heart Failure, Shortness of Breath. R8's MDS (Minimum Data Set) from 11/10/22 BIMS (Brief Interview for Mental Status) score is 08 indicating moderately impaired cognition. R8's Physician Order Report dated 01/01/2023-02/01/2023 documents, in part oxygen with nasal cannula rate at 2L oxygen per minute as needed with start date from 12/02/2022. On 01/31/23 at 12:48 PM, surveyor observed R8 in R8's room with oxygen concentrator at bedside with nasal cannula tubing wrapped in a ball around the outside of the oxygen concentrator. The nasal cannula tubing was not in a bag. The oxygen tubing was dated 01/15/23. On 01/31/23 at 12:49 PM, R8 stated that R8 uses the oxygen when R8 needs it. R8 stated, there is no bag for me to put the tubing into. R8 was not aware if 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 observation, interview, and record review, the facility staff failed to ensure a resident received and consumed liquids in the appropriate consistency according to physician orders for one(R9) of three residents who was on nectar thickened liquids. Findings include: R9's medical record (Face Sheet, MDS-Minimum Data Set 1/23/2023) notes R9 is severely cognitively impaired and was admitted to the facility with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Dementia, Adult Failure to Thrive, and Gastrostomy Tube. On 2/1/2023 at 12:05 PM, R9 was observed seated in a wheelchair at the dining room table during the lunch meal, drinking from a brown cup. Upon closer look, there was a red liquid in the cup and the liquid did not appear to be nectar thick. R9's meal ticket documented R9 was to receive with nectar thick liquids. On 2/1/2023 at 12:10 PM, V18 (Licensed Practical Nurse) said R9 should have nectar thick liquids but she has thin; a resident could aspirate if given the wrong consistency of fluids. On 2/3/2023 at 7:37 AM via telephone, V24…

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