Kenwood Vlge Nrsg And Rhb Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise and review a resident's behavioral health care plan that has not been effective and develop individualized interventions which affected one resident (R1) out of three residents (R1, R2, R6) reviewed for quality of care. Findings include: On 2/24/25 at 12:52 pm, R2 observed in R2's room in R2's wheelchair propelling self in room. When asked about an incident with another resident that occurred in the facility on 2/10/25, R2 stated, He (R1) came up to me (R2) and hit me. R2 stated that R2 was downstairs in the cafeteria (dining room) in the basement in R2's wheelchair, and I (R2) was just sitting. He (R1) hit me. R2 stated, It broke my nose. I felt it (pain) all the way to the back of my neck. When asked did R1 hit R2 in the face with an open hand or a closed hand (fisted hand), and R2 showed this surveyor a fisted hand. This surveyor observed faded bruise under R2's left eye as R2 is pointing to the area where R1 punched R2. When asked how many…

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 discard expired foods, failed to ensure the freezers/refrigerators was monitored and maintained at the appropriate safe temperatures, failed to ensure an accurate documentation on the dishwasher temperatures log, failed to ensure the dishwasher was working properly. These failures affected all residents in the facility receiving an oral diet from dietary services. Findings include: On 1/27/25 at 9:29 am, during the initial tour of the kitchen observed a stand-up freezer with no thermometer inside of the freezer. Observed a second freezer with a thermometer gauge inside the freezer reading 37 degrees Fahrenheit. Food items inside of the freezer not frozen were French fries, garlic bread, and fish patties. In a stand-up refrigerator there were 3 pales of cottage cheese with a use by date of 1/6/25. A walk-in refrigerator outside gauge was not working and the inside thermometer read 43 degrees Fahrenheit, which also had a pale of cottage cheese with a use by date of 12/30/24. V20 (Dietary Aide) was washing dishes…

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

Based upon observation, interview, and record review the facility failed to ensure that the 2nd and 3rd floor medication carts were locked while unattended. This failure has the potential to affect 99 residents (51 residents on the 2nd floor and 48 residents on the 3rd floor). Findings include: The (1/27/25) census includes 51 (2nd floor) residents. On 1/28/25 at 10:49am, with V7 (Licensed Practical Nurse), during observation of the nursing medication cart on the 2nd floor, V7 and surveyor walked away from the nursing medication cart to observe the medication fridge behind the nursing station. Surveyor did not observe V7 lock and secure the nursing medication cart after leaving the nursing medication cart unattended. Surveyor inquired why the medication cart was left unlocked and unattended V7 replied, I forgot to lock it. It should be locked. I'm really nervous. On 1/29/25 at 12:54pm, V2 (Assistant Director of Nursing) affirmed that the facility's expectation is that medications carts should be locked when unattended. When asked the purpose for locking the medication carts when…

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 properly label and date oxygen equipment (humidifier bottled, and nasal cannula) and failed to properly contain oxygen equipment (Continuous Positive Airway Pressure CPAP mask, and nasal cannula) per the facility's policy. These failures affected four residents (R15, R51, R70 and R99) reviewed for respiratory care in a sample of 58 residents. Findings include: R99's diagnoses include but not limited to COPD (Chronic Obstructive Pulmonary Disease), hypertensive heart disease, heart failure, diabetes, chronic kidney disease, obstructive sleep apnea and dependence on supplemental oxygen. R99's Brief Interview for Mental Status (BIMS) dated 10/23/24 shows R99 has a BIMS score of 15, which indicates R99 is cognitively intact. On 1/27/25 at 12:40 pm, surveyor observed R99's nasal cannula tubing with old dirty tape on the tubing not dated. R99 stated that the tubing had not been changed in over a month. R99's Physician Order Report as of 12/28/24 to 1/28/25 documents in part, Oxygen: Change tubing and mask weekly…

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 on the 3rd floor at each change of shift. This failure has the potential to affect all 48 residents on the 3rd floor. Findings include: The (1/27/25) census includes 48 (3rd floor) residents. On 1/28/25 at 10:35am, with V16 (Registered Nurse/RN), during observation of the medication cart on the 3rd floor, reviewed the Shift Change Accountability Record For Controlled Substances, dated January 2025, the following was observed: The 1/3/25 2nd shift had 1 licensed personnel's initials not 2 licensed personnel's initials. The 1/17/25 1st shift had 1 licensed personnel's initials not 2 licensed personnel's initials. The 1/18/25 2nd shift had 1 licensed personnel's initials not 2 licensed personnel's initials. The 1/24/25 2nd shift had 1 licensed personnel's initials not 2 licensed personnel's initials. The 1/27/25 2nd shift had 1 licensed personnel's initials not 2 licensed personnel's initials. When this surveyor inquired about…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to discard an expired opened multi dose vial. This failure has the potential to affect all 48 residents on the 3rd floor reviewed for labeling and storage of drugs and biologicals. Findings include: The ([DATE]) census includes 48 (3rd floor) residents. On [DATE] at 10:35am, with V16 (Registered Nurse/RN), observation of the medication refrigerator on the third floor, a house stock vial of Tuberculin PPD was opened with an open date of [DATE] and a discard date of [DATE]. The house stock vial of Tuberculin PPD is more than 30 days passed the open date. The tuberculin label states once opened discard after 30 days. When asked about the opened date on the house stock vial of Tuberculin PPD, V16 replied, It (tuberculin vial) should have been thrown out. It's (tuberculin vial) considered expired. On [DATE] at 12:54pm, V2 (Assistant Director of Nursing) said, I (V2) need to look at the policy for the details on multi dose medications and supplies.…

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 container of the multi blood glucose test strips were labeled with the open date. These failures have the potential to affect 4 residents (R4, R34, R60 and R80) who receive blood glucose monitoring tests on the third floor. Findings include: Facility presented document titled, Diabetic List, undated, that documents 4 residents (R4, R34, R60 and R80) that receive blood glucose monitoring using multi blood glucose test strips. On [DATE] at 10:35am, with V16 (Registered Nurse/RN), during observation of the medication cart on the 3rd floor, an opened container of the multi blood glucose test strips with no open date labeled was observed in the medication cart. When asked if there should be an open date on the container of the multi blood glucose test strips, V16 stated, I (V16) think the open date is in a binder at the nurse's station. V16 and surveyor went to the nurse's station and V16 was unable to locate a binder with the open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review facility failed to 1. ensure proper hand hygiene in between resident care when passing meal trays; 2. [NAME] Personal Protective Equipment when providing care to residents on Contact Precautions; 3. Failed to ensure Personal Protective Equipment and garbage cans are available and accessible and failed to prevent the urinary catheter drainage bag from touching the floor. These failures affected 8 residents (R6, R27, R36, R58, R77, R88, R95, R106) in a sample of 58 residents reviewed. Findings Include: R27 has a medical diagnosis of but not limited to Enterocolitis due to Clostridium difficile, Essential (primary) hypertension, Anemi, Iron, Hypothyroidism, Weakness, Peripheral Vascular Disease, Unspecified Dementia, The Minimum Data Set (MDS) dated [DATE] shows R27's cognition is impaired, with a seven out of fifteen points required on the Brief Interview for Mental Status (BIMS). R27 Physician Order Sheet documents Strict Contact Isolation related to Clostridium-Difficile:…

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 handrail was firmly secured to the wall. This failure has the potential to affect all 51 residents on the second floor. Findings include: The (1/27/25) census includes 51 (2nd floor) residents. On 1/27/25 at 10:42am, surveyor observed the handrail on the second floor was cracked and not securely fixed to the wall. Surveyor inquired about the handrail to V17 (Licensed Practical Nurse/LPN/Restorative Nurse) and V17 replied Oh yeah, there's a crack in it. On 1/29/25 at 11:06am, surveyor pointed out the cracked, unsecured handrail on the second floor to V4 (Maintenance Director). V4 grabbed the one corner of the handrail where the crack was the hand corner of the handrail cracked off. V4 said, I (V4) will get this fixed right away. I (V4) was not aware of this. On 1/29/25 at 12:40pm, V4 (Maintenance Director) said, The handrail and hand corner have been replaced. On 1/29/25 at 12:54pm, V2 (Assistant Director of Nursing) said, The handrails are used for residents when they walk. The handrails should be…

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 call device was within reach for one resident (R74). This failure had the potential to affect the 58 residents in the sample. Findings include: R74 has a diagnosis of but not limited to Fracture of Shaft of Left Ulna, Dementia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy. R74's has a Brief Interview of Mental Status score of 10, which indicates that R74 is cognitively impaired. R74's care plan focus for falls dated 11/20/2024 documents, in part, keep call light in reach at all times. On 1/27/2025 at 11:26am surveyor observed R74's call light on the floor behind the bed. R74 said, There it is on the floor, and I cannot reach it (call light). On 1/27/2025 at 11:28am V8 (Central Supply) stated it's (R74's call light) right here, as he picked it up off the floor, and stated it should be attached to her bed and close to the resident. On 1/27/2054 at 11:58am V6 (Registered Nurse) stated call lights should be within reach of the resident and clipped to the bed. On 1/29/2025 at 1:15pm V2…

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 doctor's order for an advance directive which affected one resident (R58) reviewed for advanced directive in the sample of 58 residents. Findings include: R58's admission record documents in part, Atherosclerotic heart disease, chronic kidney disease, end stage renal disease, dependence on renal dialysis, and bilateral below the knee amputations. R58's Minimum Data Set (MDS), dated [DATE] documents in part, Brief Interview for Mental Status (BIMS) score of 14 which indicates that R58 is cognitively intact. R58's Physician Order Report as of [DATE] to [DATE], documents that no physician order for advance directives (Full code or Do Not Resuscitate) status for R58. R58's admission Record Form for Advance Directive section documents in part, There are no Advance Directives selected for this resident. On [DATE] at 10:56 am, V2 ADON (Assistant Director of Nursing) stated, There should be a doctor's order for an advance directive. 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 electronic health records were kept in a private manner. This failure has the potential to affect 2 residents (R63 and R44) in a sample of 58 residents reviewed for confidentiality of records. Findings include: On 1/28/25 at 10:35am, with V16 (Registered Nurse), during observation of the nursing cart on the 3rd floor, surveyor observed V16 walk away from the nursing cart to the nursing station near the end of the hall. Surveyor noted R63's medication administration record (part of the electronic medical record) open on the attached laptop. Surveyor did not observe any other staff present near the nursing cart. Upon V16's return to the nursing cart, surveyor asked V16 why R63's electronic medical record was left open and unattended, and V16 replied, Ugh. I (V16) should have closed down the record. When asked the purpose of not leaving the electronic medical record open and unattended, V16 replied, HIPAA (Health Insurance Portability and Accountability Act of 1996). On 1/28/25 at 10:49am, with V7…

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 closet drawers were not missing in effort to provide a homelike environment. This failure affected 4(R75, R80, R7, and R1) residents reviewed for homelike environment in the total sample of 58 residents. Findings include: On 1/27/2025 at 10:25am observed R7's closet with a missing bottom drawer. In the same room observed R1's closet with a missing bottom drawer. On 1/27/2025 at 10:26am observed R7's clothing in a plastic bin, with more clothing stacked on top of the plastic bin in front of R7's missing bottom drawer. On 1/27/2025 at 10:27am, R7 stated I would like to put my clothes in the closet drawers instead of having the clothes in bins sitting on the floor. On 1/28/2025 at 9:19am observed both R75 and R80's closets with missing bottom drawers. On 1/28/2025 at 9:20am, R75 stated the missing drawers on the closet have been missing since I have been a resident at this facility, and I have been here for about five years. R7 has a Brief Interview for Mental Status (BIMS) dated 12/03/2024 which…

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 complete a new pre-admission screening and resident review (PASSR) when a new mental health diagnosis is identified. This failure affects 1 resident (R69) out of a sample of 58. Findings include: R69's has an admission date of 7/24/2019 and has a diagnosis of Schizophrenia with a diagnosis date 4/18/2022. R69 has a Brief Interview of Mental Status score of 15. R69's Minimum Data Sheet section D (Mood) dated 12/20/2024 documents a severity score of 10. On 1/29/2025 at about 10:30am surveyor reviewed R69's Obra-I Initial Screen dated 7/24/2019 that documents No reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness). R69's Physician Order Report dated does not document any medications for Schizophrenia. On 1/29/2025 at 12:08pm V30 (Administrative Assistant/Office Manager) stated I request the PASRR when the resident is coming from the hospital, and I don't know who processes another PASRR request when there is a change of condition. On 1/30/2025 at 11:38am via email V1 (Administrator)…

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, facility failed to provide the necessary treatment to promote healing and failed to assess accurate site to a resident with a skin impairment. These failures affected 1 (R105) of 1 resident reviewed for wound care. Findings Include: R105 has a medical diagnosis of but not limited to hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, Congestive Heart Failure, Aphasia and Osteoarthritis. The Minimum Data Set (MDS) dated [DATE] shows R105's cognition is impaired, with a four out of fifteen points required on the Brief Interview for Mental Status (BIMS). R105 Physician Order Sheet dated 1/22/2025 documents right posterior thigh: Cleanse with Normal Saline Solution, skin prep to peri wound, apply hydrocolloid dressing. On 01/28/25 at 10:28 am, with V13, Registered Nurse (RN), observed R105's wound to the left upper proximal posterior thigh without a dressing which appears red, moist, and non-blanchable. V13 confirmed there was…

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

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress was not layered with multiple linens for 1 resident (R78). This failure affected 1 resident reviewed for pressure ulcer/injury prevention and treatment in a sample size of 58. R78 has a diagnosis of but not limited to Sequelae of Infarction, Schizophrenia, Dementia, Palliative Care, and Cellulitis. R78 has a Brief Interview of Mental Status Score of 7, which indicates that R78 is cognitively impaired. R78's order from hospice company dated 12/24/2024 documents, in part, new air mattress and air mattress for hospital bed. R78's care plan focus Pressure Ulcer/Injury dated 7/24/2023 documents, in part, use low air loss mattress in bed. R78's Minimum Data Sheet section GG dated 11/26/2024 documents, in part, Functional Limitation in Range of Motion: for upper and lower extremities: impairment, and dependent (Helper does all the effort) for all self-care and mobility performance. R78's Braden scale dated 11/27/2024 documents a score of 12 that indicates high risk and documents…

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 an adaptive device (splint/palm grip) was in place of a contracted hand which affected one resident (R61) in the total sample of 58 residents when reviewed for limited mobility. Findings include: On 1/27/25 at 10:25am, R61 was observed lying in bed on her (R61) left side, with both right and left hands clenched tightly in a fist shape. Surveyor did not observe a hand assistive device (splint/palm grip) on R61's left or right hand. On 1/27/25 at 10:25am, surveyor inquired about R61's right and left hands and R61 replied, Sometimes my hands hurt but the nurses are good at cutting my nails which helps. I (R61) don't think I'm (R61) supposed to have something for my hands to help. On 1/28/25 at 11:46am, R61 was observed lying in bed on her (R61) back, with both right and left hands clenched tightly in a fist shape. Surveyor did not observe a hand assistive device (splint/palm grip) on R61's left or right hand. R61's Face Sheet documents, in part, diagnoses of hemiplegia and hemiparesis 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 properly log refrigerator temperatures for 2 residents' (R7 and R16) with personal refrigerators in their rooms. This failure has the potential to affect all 58 residents in the sample. Findings include: On 01/27/2025 10:20am observed a black and gray colored personal refrigerator sitting on the floor in R7's room. Observed the January 2025 personal refrigerator temperature log, which was located on a dresser, laying underneath the television. Observed missing documentation of a temperature for the following days: 1/14/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/20/25, 1/21/25. 1/22/25, 1/23/25, 1/24/25, 1/25/25, and 1/26/25. Observed the inside of R7's personal refrigerator, the thermometer reading was 40 degrees Fahrenheit, the refrigerator contained food items. On 1/29/2025 at 12:52pm V2(ADON/Assistant Director of Nursing) stated anybody who goes into the resident's room can check the temperature in a resident's personal refrigerator. V2…

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 received the education addressing the benefits and risk or had the opportunity to receive the Influenza and Pneumonia vaccines. This failure affected three residents (R50,58, R119) out of five residents reviewed for immunizations. Findings include: On 1/29/2025 at 1:45pm, R50 stated the facility did not offer the Pneumococcal vaccine to R50, nor did the facility provide R50 with education on the benefits or risk of the vaccine. The Minimum Data Set (MDS) dated [DATE] shows R50's cognition was intact with a twelve out of fifteen points required on the Brief Interview for Mental Status (BIMS). On 1/29/2025 at 1:00 pm, V3 (Infection Preventionist) was interviewed and stated that R50 was offered the Pneumococcal vaccine and declined to have the vaccine administered. A copy of the Informed Consent was requested and V3 stated that there was no copy of informed consent available. The Informed Consent for Vaccination explains the risks…

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 one resident (R2) was free from resident-to-resident physical abuse. This failure affected one resident (R2) in a total sample size of three residents (R1, R2, and R3) reviewed for physical abuse. Findings include: On 01/22/2025 reviewed the reportables (initial and final Facility Incident Report Forms) for incident of resident-to-resident physical abuse which occurred on 1/6/2025 between R1 and R2. R1's diagnosis includes, but are not limited to, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Paroxysmal atrial fibrillation, Polyneuropathy, unspecified, Unspecified protein-calorie malnutrition, Depression, unspecified, Essential (primary) hypertension, Benign prostatic hyperplasia without lower urinary tract symptoms, Vitamin D deficiency, unspecified. R1 has a Brief Interview for Mental Status (BIMS) dated 12/26/2024 which documents that R1 has a BIMS score of 09, indicating R1's cognition is moderately impaired. R2's diagnosis…

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 post the daily nursing staffing. This failure has the potential to affect all 109 residents residing in the facility. Findings include: On 11/12/24 V1 (Administrator) present facility's census of 109 residents. On 11/12/24 at 9:30 am, upon entrance to the facility, the facility's daily staff posting was not observed posted in the lobby of the facility. On 11/12/24 at 11:40 am, received the daily staff posting sheet from V11 (Staffing Coordinator). The sheet did not include the resident's census and the nursing staff hours. On 11/12/24 at 9:50 am V1 (Administrator) stated that the daily staffing sheet should be posted in the front, but it is not there. I don't believe it has been there, but we are working on it. On 11/13/24 at 12:40 pm, V1 (Administrator) stated that. The scheduler brought me some posting and it was not right with the information that is required to be on it. What she gave you yesterday was wrong it did not have the census and hours. The reason for having the staffing posting in the lobby is…

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

Based on observation, interview, and record review the facility failed to ensure that the resident environment remain free of accident hazard and failed to ensure that treatment cart was locked when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard for one resident (R7) in the sample and the. This failure has a potential to affect R7 whose oxygen tank was stored on the bare floor in the room and inhaler was left on the bedside table visible to hallway. This as the potential to affect all the residents on the 1st and 3rd floor of the facility. Findings include: On 09/10/24 at 10:28am, on the 1st floor a treatment cart left in the hallway across from the elevator was observed unlocked and not in visual vicinity of the nurse. At 10:30am, this was shown to V3 ADON (Assistant Director of Nurse's) and was asked about the facility policy and protocol on medication cart/ treatment cart regarding being locked. V3 stated it should be locked when not in use and not within nurse's view. At 11:05am, on the 3rd floor noted from the hallway on R7's over…

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 one resident (R2) was free of abuse (theft). This failure affected R2 whose money and debit card were stolen with activities of withdrawal from their funds and has the potential to affect all the 100-resident residing at the facility. Findings include: On 09/10/24 at 10:46am, R2 stated that I (R2) kept my money and my card in my pillow, I (R2) count it now and then to make sure it's there. And then it was gone, I (R2) told the person in social services (referring to V13 PRSD Psychiatrist Rehabilitation Service Director) just to find out that my card was used. They (referring to the facility) gave me back my money and they called the police but I still want to know who stole my money so I (R2) can knock them out. The police did not tell me yet who did. When asked how it makes R2 feel. R2 stated awful sad and leery, It's just sad. R2 did not know who or how the money and the debit card got stolen. R2's medical record showed that R2's current admission was 02/05/2024 and latest admission was on 08/28/24. R2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the breakfast menu was followed. This failure affected 100 residents in the facility who were receiving an oral diet. Findings Include: On 2/4/24 at approximately 7:55 AM, first floor breakfast food cart was inspected. Surveyor noted no seasonal fruit on the residents' trays. Noted R3's tray consisted of a toast, scrambled egg, chopped up meat, coffee, and juice. R3's meal ticket shows double portion, NCS (No Concentrated Sweet)/NAS (No Added Salt) mechanical soft diet. R4's tray consisted of cereal, two sausages, one boiled egg, coffee, and juice. R4's meal ticket shows low fat diet regular. At 8:12 AM, R5 was just finished eating breakfast in the 2nd floor dining room. R5 stated R5 got two sausages, orange juice, coffee, toast, a boiled egg, jelly, and sugar. R5 stated that sometimes R5 does not get what's on the menu like today, R5 did not get the cereal R5 wanted. At 8:21 AM, R3 was in bed eating breakfast. R3 stated that R3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's personal belongings were recorded on admission and failed to provide proper storage and access to personal items. This failure affected one resident(R2) out of four residents reviewed personal property. Findings include: R2 is [AGE] year-old admitted to facility on 10/15/2023 and discharged from facility on 11/14/2024 according to electronic medical records. R2 had diagnosis including but not limited to: Chronic Obstructive Pulmonary Disorder, Hypertension, Anxiety disorder, Depression and Unspecified Lack of coordination. R2 's BIMS (Brief Interview for Mental Status) score is 15, which indicates cognitively intact. On 01/02/2024 during investigation, Surveyor inquired about R2 ' s belongings. On 01/02/2024 at 9:30 AM V1 (Administrator) said, R2 no longer resides here at the facility. She was discharged to another facility. I saved R2's belongings and had been corresponding with V16 (Ombudsman) via email about R2's items. I told V16…

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

Based on observation, interview and record review the facility failed to a) store and label food items in accordance with professional standards for food service safety and b) follow proper sanitation for cleaning dishes. This failure has the potential to affect 99 residents that eat food from the kitchen. Findings include: On 12/5/23 at 9:45 AM, surveyors conducted kitchen observation with V20 (Dietary Director). Observations in the walk-in refrigerator: -six hotdogs, a few dozen chicken nuggets and four cooked hamburgers, each in separate silver metal trays, not labeled and not dated -an open container of mandarin oranges dated 11/29/23. V20 stated We keep canned fruit for seven days after opening. -an open gallon container of sweet relish not labeled and not dated -a container of mild giardiniera with the lid not securely closed -a plastic bag of cooked ground ham labeled 11/6/23 and not securely closed -an open bag of a dozen dinner rolls not labeled and not dated and not securely sealed -an open bag of cooked diced turkey ham labeled 11/6/23 We keep these 14 days after opening.…

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

Based on observation, interview and record review the facility failed to properly contain waste in dumpsters and failed to ensure dumpster lids were securely closed. Findings include: On 12/6/23 at 10:10 AM, Surveyors observed two garbage dumpsters labeled with facility name and address, and one recycling dumpster labeled with facility name and address. Surveyors observed one of the facility's garbage dumpsters overfilled with trash bags and the dumpster lid was not closed. On 12/7/23 at 9:05 AM, V10 (Operations Director) stated I oversee the dumpsters. All facility staff have access to put trash in the dumpsters, mainly EVS (Environmental Services) and Dietary put trash in the dumpsters. The dumpster lids should be closed at all times. The dumpsters should not be overflowing at any time. There is a chance for rodent issues. There is no chance for the rodents to enter the facility because the facility is sealed. Facility policy Garbage Disposal, not dated, documents in part: keep dumpster closed at all times.

Based on observations, interviews, and review of records the facility failed to follow storage of medications policy for 1 out of 3 medication carts for a total of 3 medication carts reviewed. These failures includes opened vial of insulin that are expired, and house stock medications that are not kept with cover. Failures have the potential to affect 16 residents that are on the same floor that may receive insulin and medications that are not in the right container exposed to environment. Findings include: On 12/05/2023 at 10:53 AM, with V5 (Licensed Practical Nurse / Agency) medication cart was seen with a vial of Novolog Aspart with sticker with written marker that reads: Date vial open 11/4/2023, Date vial expires 12/2/2023. V5 then took the vial and discarded in the sharp container attached to the medication cart. V5 stated that since the insulin was expired on December 2 it should not be in the medication cart. On the topmost drawer white round tablets around 20 to 30 tablets with treatment tape on top not fully covered with marker written that reads Melatonin. Medication cup…

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 records review, the facility failed to follow their policy on dignity by failing to provide privacy bag for indwelling urinary catheter for one (R6) of two residents reviewed in a sample of 21. Findings include: R6's current physician order sheet documents R6's medical diagnosis includes but not limited to: Pressure ulcers Left/light buttocks, Quadriplegia, neuromuscular dysfunction of bladder. R6's MDS (Minimum Data Set) section C-Cognitive Patterns dated 10/04/2023 documents R6 has a BIMS (Brief Interview for Metal Status) scare of 15/15, indicating R6 has intact cognation. On 12/05/2023 at 12:24pm, R6 was observed lying in bed with his indwelling catheter hanging on the side of the bed on the bed frame, below the bladder. R6's catheter was observed draining yellow/amber urine. The catheter bag did not have a dignity cover and was facing R6's exit door, visible to anyone passing near R6's room and it was visible to residents sharing the room with R6. R6 said his urinary bag used to have a cover, but he does not know why it was taken out, 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 grooming care for three (R23, R31, R47) dependent residents reviewed for Activities of Daily Living/ADL care. Findings include: 1.) On 12/05/2023 at 11:15AM, R31 was observed inside of her room lying in bed in a supine position. R31 observed with gray facial hair growing on her neck and chin. R31 states it's been about three weeks since she has gotten her facial hair shaven. 2.) On 12/05/2023 at 12:35PM, R47 observed inside of her room lying in bed in a supine position with head of bed at 90 degrees. R47 was observed with gray facial hair growing on her neck and chin. R47 states she does not remember when her facial hair was last shaven. 3.) On 12/05/2023 at 12:50PM, R23 observed inside of her room lying in bed in a supine position reading a book. R23 was observed with her hair on her head disheveled and uncombed. R23 also observed with gray facial hair growing on her neck and chin. R23 states it has been a couple of months since someone has combed her hair or shaved her facial hair. On 12/06/2023 at…

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

Based on observation, interview and record review the facility failed to ensure low air loss mattress devices were in the correct settings for two (R32 and R53) residents using a low air loss mattress. Finding include: 1.) On 12/5/23 at 12:32 PM, observed R32 lying on a low air loss mattress. R32's low air loss mattress unit was set to 315 pounds. On 12/5/23 at 4:08 PM, V5 (Licensed Practical Nurse) stated R32's low air loss mattress is set to 315 pounds. R32 does not look to weigh 315 pounds at all. The low air loss mattress should be set to within the resident's weight range. R32's mattress was not set anywhere near R32's weight range. The purpose of the low air loss mattress is to prevent pressure ulcers and to reduce the pressure on wounds or boney prominences. If the low air loss mattress is not correctly set, then it is ineffective. On 12/5/23 at 4:15 PM, V3 (Director of Nursing) stated wound care staff sets the low air loss mattresses. The low air loss mattress should be set according to the resident's weight. If the floor nurse notices that the mattress is not set correctly…

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

Based on observation, interviews, and review of records the facility failed to follow enteral tube medication administration policy related to proper tube placement prior to administering medication via gastronomy tube. These failures apply to 1 resident (R47) out of 7 residents observed during medication administration review. Findings include: On 12/6/2023 at 8:20 AM, V7 (Licensed Practical Nurse) was preparing medication for R47 via gastronomy tube. V7 prepared six medication tablets that were crushed and individually in a medicine cup. Medication tablets are as follows: Acidophilus Extra Strength one tablet; Amlodipine 10 MG one tablet; Glipizide 5 MG one tablet; Multivitamins with Minerals one tablet; Vitamin D3 5000 IU one tablet; Carvedilol 12.5 MG one tablet. Prior to administering medication via gastronomy tube, V7 did not check placement of gastronomy tube. During medication administration, R47 was observed coughing. After administering all six medications, V7 stated that she forgot to check for patency or placement prior to medication administration. And that it is…

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

Based on observation, interview and review of records, the facility failed to administer the right dose of medication as ordered. There were 26 opportunities with 3 errors resulting to 11.54% (percent) error rate. These failures applies to 2 residents (R104 and R57) out of 7 residents observed for medication administration. Finding includes: On 12/05/2023 at 10:07 AM, with V5 (Licensed Practical Nurse / Agency) the following medications were administered to R104 by mouth: Eliquis 5 MG, one tablet; Multivitamins one tablet; Geri-kot 8.6 MG one tablet; Tylenol 325 MG one tablet; Metoprolol Succinate 25 MG one tablet; and Amlodipine 5 MG one tablet. During review of medication physician orders of R104. The following medications have discrepancies with physician orders: Geri-kot 8.6 MG 1 tablet was given. Physician order reads: Sennosides - Docusate 8.6 - 50 MG give 2 tablets. And Tylenol 325 MG one tablet was given. Physician order reads: Acetaminophen (Tylenol) 325 MG two tablets. On 12/06/2023 at 07:48 AM, with V6 ((Licensed Practical Nurse / Agency) the following medications were…

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 recommended menu for three residents (R67, R68 and R112) that receive a puree diet. Findings include: On 12/6/23 at 11:20 AM, Surveyors observed V20 (Dietary Director) prepare the puree meal, ground pork, rice, broccoli. After plating the ground pork, rice, and broccoli, V20 wrapped each plate with plastic wrap and placed them in the oven. V20 then began the tray line for the regular diet plates. V20 did not puree bread as puree bread was listed on the menu/spreadsheet. On 12/7/23 at 11:50 AM, V25 (Cook) stated I prepare the puree meals. The puree meals get the same as the regular diet. They get puree bread if it is on the regular diet. I don't know if the menu is cleared by the dietitian. Not sure if the puree residents would get the nutrients if they don't get the same as the regular diet. On 12/7/23 at 2:50 PM, V26 (Registered Dietitian) stated the purpose of the spreadsheet shows the kitchen what food items they should be giving the resident, regular and therapeutic diets. It is important 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 review of records the facility failed to follow the policy of infection control aseptic techniques by stacking five medication cups containing medication that were exposed to high touch areas and then administered the medication via a gastronomy tube. The facility also failed to follow Enhanced Barrier Precautions by not wearing required personal protective equipment during medication administration via gastronomy tube. These failures apply to 1 resident (R47) out of 7 residents observed during medication administration review. Findings include: On 12/6/2023 at 8:20 AM, with V7 (Licensed Practical Nurse) preparing medication for R47 via gastronomy tube. V7 prepared six medication tablets that were crushed and individually in a medicine cup. Medication tablets are as follows: Acidophilus Extra Strength one tablet; Amlodipine 10 MG one tablet; Glipizide 5 MG one tablet; Multivitamins with Minerals one tablet; Vitamin D3 5000 IU one tablet; Carvedilol 12.5 MG one tablet. All six medication cups are placed on top of medication carts which has high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to offer pneumonia vaccines to eligible residents residing in the facility. This failure affects four of five residents (R25, R31, R40, R47) reviewed for pneumonia vaccines in the sample of 21. Findings include: 1.) R25's Face sheet documents that R25 was admitted to the facility on [DATE] and is currently [AGE] years of age. R25's immunization record provided by the facility does not document that a pneumonia vaccine was administered to R25. Facility is unable to provide documentation to show the pneumonia vaccine was offered to R25 prior to 12/05/2023. Facility is also unable to provide documentation that shows the resident/resident's representative was provided education on the risks and benefits of the pneumonia vaccines. 2.) R31's Face sheet documents that R31 was admitted to the facility on [DATE] and is currently [AGE] years of age. R31's immunization record provided by the facility does not document that a pneumonia vaccine was administered to R31.…

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 observations, interviews, and review of records the facility failed to provide privacy curtain for a resident that has daily treatment order on perennial area for 1 out of 1 resident (R77) for a total sample 21 residents. This failure affects 1 resident (R77) privacy during scheduled treatment. Findings include: On 12/05/2023 at 09:50 AM, R77 informed survey team members that for a long time he does not have privacy curtain. In R77's room there are four beds all with privacy curtain, except R77's bed. On 12/06/2023 at 9:31 AM, V10 (Maintenance Director) stated that R77's privacy curtain was just taken out yesterday (12/05/2023). And that it will place back later today. At 12:01 PM, R77 stated that he has no privacy curtain for a long time. R77 said that he was admitted in the facility two years ago, and after a few days a CNA (Certified Nursing Assistant) accidentally pulled the curtain that caved in. Since then, he (R77) does not have privacy curtain. Above R77's bed on the ceiling the rails that hold the curtain was missing. On 12/07/2023 at 10:11 AM, there was still 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 observations, interviews, and record reviews, the facility failed follow their policy on hand washing by staff not washing hands after handling dirty dishes and before handling clean dishes. These failures have the potential to affect all 103 residents receiving food prepared in the facility's kitchen. Findings include: On 11/21/23, at 12:06 PM, observed V16 (Dietary Aide) working in the dish room breaking down dirty resident lunch trays scraping food debris from the trays into the garbage, soaking dishes and silverware and then using a water hose to rinse off the items after they were placed in a rack before pushing the rack into the dish machine to be washed. At 12:08 PM, observed V16 move to the clean side of the dish machine and pull out the rack containing cleaned dome lids and plates. V16 did not perform any type of hand hygiene in between handling dirty and cleaned plateware. On 11/21/23 at 12:09 PM, observed V15 (Dietary Aide) breaking down dirty resident lunch trays by scraping food into the garbage can. At 12:11 PM, observed V15 go to the clean side of the dish…

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 maintain an effective pest control program so that the facility is free of pests and rodents. This failure has the potential to affect all 105 residents residing in the facility. Findings include: On 11/21/2023 at 1:47pm, during tour of R1's room with V12(Housekeeping) and V5(Operations Director), observed large amounts of mice droppings in R1's bottom draw of her side table and all around the perimeter of R1's room including behind R1's bed. V5 stated if the pest control plan was working, he would not expect to see this large amount of mice droppings in the room. V5 said mice also like to eat the wooden drawers in resident room, and that's why the facility will replace the drawers. V12 pulled papers behind a drawer in R1's room. The paper was observed with edges chewed off. V12 said the mice ate(chewed) the papers and the mice will use the paper to make their nest. On 11/21/2023 at 2:13pm, during tour of R4 and R5's room, surveyor and V12 observed large amounts of mice droppings all around the perimeter of…

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

Based on observations, interviews, and record reviews, the facility failed to ensure the 3-lid outside dumpster was closed at all times and failed to ensure the 3-lid outside dumpster was not overflowing with trash in an effort to prevent pest and rodent migration. These failures have the potential to affect all residents residing at the facility. Findings include: On 09/05/2023 at 12:44pm, surveyor observed 2 lids of the 3-lid dumpster open; one end of the dumpster had an overflowing pile of trash. These observations were pointed out to V9 (Environmental Service Director). V9 attempted to close the lid with the overflowing pile of trash to no avail. V9 opened the middle lid and stated this is not even full. I (V9) don't know why staff keep on throwing trash on this side of the dumpster (referring to the part of the dumpster with overflowing pile of trash). The lids should not be left open so rodents like squirrel and mice will not go into the dumpster. On 09/05/2023 at 12:51pm, there was a translucent garbage bag tied to the fence of the facility. The garbage bag was open with…

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

Based on observations, interviews, and record reviews, the facility failed to provide a home like environment for 6 (R5, R6, R7, R8, R9, and R10) residents reviewed for safe, clean, comfortable, and home like environment in a total sample of 11 residents. Findings include: On 09/05/2023 at 11:15am, R5 and R6 were both lying on beds with no sheets and no pillows. R5's mattress was torn. On 09/05/2023 at 11:20am, V8 (Certified Nursing Assistant/CNA) stated I stripped all the dirty linens and sheets, and I wiped the bed down and disinfected it. I am waiting for the linens to come up so I can make the beds. I stripped the bed right after breakfast at 8:30am. When the linen cart came up, there was not enough linens and sheets to change all the soiled linens. I talked to V9 (Environmental Services Director), and he said he is going to give me some. The linens and sheets were soiled that's why I stripped them this morning. On 09/05/2023 at 11:27am, R5 stated, I have no idea who stripped my bed. What difference does it make? I don't remember when the last time I had pillows. On 9/05/2023 at…

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

Based on interview and record review the facility failed to report an allegation of physical abuse to the local state agency. This failure affected one resident (R4) out of four residents reviewed for physical abuse. Findings include: R4 has a diagnosis which includes but not limited to bipolar, anxiety, depression, and borderline personality disorder. R4's Brief Interview for Mental Status (BIMS) Dated 07/03/23 shows that R4 has a BIMS of 15 which indicates that R4 is cognitively intact. On 09/05/23 at 11:18 am, V25 (Regional Director of Admissions) stated, V25 received a call at the facility from the V35 (R4's hospital social worker) stating R4 was alleging abuse at the facility on 08/15/23. V25 stated, V25 informed V35 that V25 did not feel comfortable receiving the call and that V25 would let V1 (Administrator) take the call. V25 stated, V25 gave V25's work phone to V1 to speak to V35 regarding R4's allegation of abuse at the facility and that V25 stepped out of V1's office while V1 spoke with V35 regarding R4's allegation of abuse. On 09/05/23 at 12:10 pm, R4 stated around two…

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 adequately supervise a resident and failed to implement individualized fall prevention interventions for a resident operating a motorized wheelchair to avoid a fall for one resident (R4) who was identified at risk for falls. This failure affected one resident (R4) out of 4 residents reviewed for fall injury prevention interventions. Findings include: R3's has a diagnosis which includes but is not limited to abnormalities of gait and mobility, other lack of coordination, bipolar and major depressive disorder. R3's Brief Interview for Mental Status (BIMS) Dated [DATE] shows that R3 has a BIMS of 15 which indicates that R3 is cognitively intact. On [DATE] at 11:28 am, R3 was observed in awake and alert in R3's room sitting in a manual wheelchair. R3 stated, R3 has resided at the facility for a few months. R3 stated, R3 does not recall having a fall from R3's wheelchair while at the facility. R3 stated, R3 recalls having a fall while at R3's last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews ,and record review the facility failed to maintain a clean environment in multiple areas. The dry storage room was seen with dirt and dropping like particles. The dishwashing room and food preparation area large fans have dirt and accumulation of particles. Multiple kind of breads were not dated when received. The facility also failed to take food temperature before placing on the plate for consumption. These failures have the potential to affect 112 residents in the facility who are receiving oral diet. Findings include: On 11/01/2022 at 10:17 AM with V8 (Dietary Manager) during initial kitchen review the following was observed: Inside walk-in refrigerator on the shelves with multiple breads (10 raisin bread, 5 rolls, 10 wheats, salty rolls) not dated. V8 stated that facility follows first in first out (FIFO) policy and there should have to be a date on those bread to determine which to use first. Inside dry storage room at the back of the shelves was small particles that looks…

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 maintain accurate records of usage and accountability, for 5 residents (R15, R26, R50, R93, and R214) receiving controlled substances on 2 of 5 medication carts reviewed for medication storage and labeling. Findings include, On 11/1/22 at 9:45 AM, during the narcotic reconciliation count with V25 (Licensed Practical Nurse) observed on the third-floor cart #1, Controlled Substance Check Form with missing signatures every day on two controlled substances check form sheets. R26, R50, R93, and R214 receives controlled substances from cart #1. V7 stated, There are two Controlled Substance Check Forms one for 8hr shifts and the other for 12-hour shifts. I'm not sure why they are both missing a lot of signatures. On 11/1/22 at 10:00 AM, during the narcotic reconciliation count with V26 (Licensed Practical Nurse) observed on the third-floor cart #2, Controlled Substance Check Form with missing signatures every day on two controlled substances check form sheets. R15 receives controlled substances from cart #2. V26…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to label individual resident's insulin [NAME] with an open date, failed follow their policy to discard expired insulin and house stock medications, and failed follow pharmaceutical storage instructions to refrigerate unopened insulin in 2 of 5 medication carts reviewed for medication storage and labeling for 4 residents (R15, R57, R82, R213) in a sample of 43 residents. Findings include: On 11/1/22 at 10:45 AM, V25 (Licensed Practical Nurse) and surveyor inventoried the third-floor medication cart #1. Medications not labeled with an open date: R15's Humalog Insulin 100 units/ml R15's Lantus Insulin 100 units/ml R57's Lispro-Insulin 100 units/ml R82's Novolog Mix 70/30 Insulin 100units/ml R213's Lantus 100 units/ml-unopened in the cart with a Refrigerate label on vail. On 11/1/22 at 10:55 AM, V25 stated, Once the insulin is opened, we put an open and expiration date on the insulin vial. The insulin should be stored in the refrigerator until…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to date and store respiratory supplies per facility's policy for 6 (R7, R63, R71, R94, R100, and R163) of 6 residents reviewed and failed to ensure a urinary catheter storage bag was stored properly for 1 (R14) out of 1 resident reviewed for infection control and prevention. These failures have the potential to affect 7 residents (R7, R14, R63, R71, R94, R100, and R163) in minimizing risk of infections for a total of 25 residents in the final sample. Finding include: 1. On 11/01/22 at 11:19 AM, surveyor observed R63 sitting in chair at bedside with nasal cannula in R63's nose and oxygen being administered via oxygen concentrator. R63's oxygen tubing attached to nasal cannula was observed laying on the floor. Oxygen tubing was not dated. Humidification container filled with water was not dated. Surveyor did not observe a storage bag near oxygen concentrator or near R63. On 11/01/22 at 11:52 AM, surveyor asked V7 (Licensed Practical Nurse) if…

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

Based on observation, interviews, and record review the facility failed to follow their policy to care plan a resident to self-administer an inhaler. Resident verbalized taking the medication more than what was ordered by physician. Failures include 1 out of 1 resident (R71) reviewed for self-administration of medication for a total of 25 residents in the final sample. Findings include: R71's medical diagnosis of Chronic Obstructive Pulmonary Disease (COPD) exacerbation on 8/2/2022. R71 brief Interview for mental status (BIMS) score dated 9/8/2022 was 15 that means R71 cognition is intact. On 11/03/2022 at 11:56 AM R71 was seen sitting at the edge of the bed with nasal cannula attached in his nares. R71 was alert and able to express his thoughts well. On the bedside table was an inhaler Albuterol Sulfate bluish gray colored. R71 was asked if he is using the inhaler. R71 said, I do it myself. I have been using that inhaler every day. Like 8 to 9 times a day even more. Anytime I need it, I used it. On 11/03/2022 at 12:15 PM V3 (Assistant Director of Nursing) stated that R71 is using…

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

Based on observations, interviews and record reviews, the facility failed to follow a resident's (R86) preferences for getting out of bed for 1 out of a total sample of 25 residents. Findings include: On 11/01/2022 at 10:58 AM, R86 was lying in bed. R86 stated [R86] wanted to get up out of bed and into a chair. R86 stated [R86] wants to start getting up out of bed daily. R86 pressed the call button. On 11/01/2022 at 11:02 AM, V4 (Certified Nurse Assistant/CNA) answered R86's call light. R86 told V4 that [R86] wanted to get up out of bed every day. Surveyor conducted observations on 11/01/2022 at 11:16 AM, 11:34 AM, 11:51 AM, and 12:31 PM. R86 was in bed during listed observations. On 11/01/2022 at 12:37 PM, R86 remained in bed. R86 stated staff did not return to get [R86] out of bed. R86 stated staff did not inform [R86] as to why they were not getting [R86] up. R86 informed surveyor [R86] wanted to get up out of bed and sit in a chair. On 11/01/2022 at 12:48 PM, R86's call light was on. At 12:49 PM, V4 answered R86's call light. R86 told V4 that [R86] wanted to start getting up out…

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 provide transfer assistance and repositioning to a dependent resident (R86) for 1 out of a total sample of 25 residents. Findings include: R86 is a resident of the facility with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinson's disease, bilateral primary osteoarthritis of knee and weakness. R86's Quarterly MDS (Minimum Data Set) dated 09/05/2022 documents in part that R86 requires extensive assistance with two plus persons physical assist for bed mobility and transfers. On 11/01/2022 at 10:58 AM, R86 was lying in bed on backside. R86 stated [R86] wanted to get up out of bed and into a chair. R86 stated [R86] needs staff assistance and mechanical lift for transfer. R86 stated the last time [R86] was out of bed has been a while. R86 stated staff did not get [R86] out of bed last week. R86 stated [R86] wants to start getting up out of bed daily. R86 pressed the call button. On 11/01/2022 at 11:02 AM, V4 (Certified Nurse…

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 apply a resident's (R41) ordered splints/orthotics for 1 of 3 residents reviewed for splints/orthotics in a total sample of 25 residents. Findings include: R41 is a resident of the facility with diagnoses including but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. R41's Annual MDS (Minimum Data Set) assessment dated [DATE] documents in part that R41 is cognitively intact and has impairment on one side for functional limitation in range of motion. On 11/01/2022 at 11:21 AM, surveyor entered R41's room for an interview. Observed R41's right hand contracted. R41 stated [R41] has a splint for the right hand but staff have not placed it on yet. R41 pointed to a blue, soft splint on the bottom shelf of [R41's] television stand. No other splint or orthotic to right upper or lower extremities. On 11/01/2022 at 02:14 PM, R41's right hand splint was not on. On 11/01/2022 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 observation, interview, and record review the facility failed to provide a functioning walker, failed to assess for fall risk and failed to care plan a resident for fall. These failures affected 1 out of 3 residents (R31) reviewed for accidents and hazards in a total of 25 residents in the final sample. Findings include: R31's medical diagnosis of Polyneuropathy. Minimum Data Set assessment dated [DATE], under Brief Interview for Mental Status documents that R31 has a score of 15. Indicating that R31 cognition is intact. Under functional status on the same assessment. R31 needs assistance during ambulation, bed mobility and transfers. On 11/01/2022 at 12:02 PM R31 was seen in her room with her walker in front of her. [NAME] has 4 wheels, 2 wheels in front and 2 wheels at the back. [NAME] also has a platform at the center where R31 can sit. R31 said, I have been requesting for a new walker since I first came here but nothing was given. Look at this. It does not have a brake. Unlike the right handle there…

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

Based on observation, interview, and record review the facility failed to provide food in the appropriate form as prescribed by the physician's diet order for 1 resident (R110) out of 7 residents reviewed for nutrition for a total of 25 residents in the final sample. Finding include: On 11/01/22 at 11:00 AM, surveyor observed R110 sitting at the side of R110's bed looking at his (R110)'s lunch tray located on the side table next to the bed. R110's diet order on meal ticket read mechanical soft, NAS (No Added Salt). R110 was provided on this lunch tray the following items: ground fish, rice, black beans, strawberry dessert with whipped topping, and juice. R110 stated that he (R110) won't eat this food, look at it! and what is this? as R110 made a pointing gesture toward the ground fish on his (R110)'s lunch tray. Staff reported that they were already aware of R110 refusing his (R110)'s lunch tray and stated that a menu alternative from the kitchen had already been ordered for R110. At 11:20 AM, surveyor returned to R110's room and observed R110 eating a regular cheeseburger. Surveyor…

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.