Landmark of Hyde Park Rehabilitation and Nursing C

Based on interview and record review, the facility failed to ensure resident's care needs were being met by permitting one employee (V15) to sleep on duty. This failure has the potential to affect 16 residents on the unit V15 was assigned.Findings include:On 9.17.2025 2:57 PM, V2 (DON-Director of Nursing) said V15 (Former CNA-Certified Nursing Assistant) was terminated after she was caught sleeping while on duty for the second time. She was caught sleeping around 5:59 AM in the laundry room by laundry staff. That is an unauthorized area. V15 told a staff member you need to give (V15) 10-15 minutes. At 5:59 AM, (V15) should have been doing final rounds. Staff (laundry) found her in unauthorized area.On 9.18.2025 at 10:00 AM V2 (DON) said, V15 (Former CNA-Certified Nursing Assistant) should not have been sleeping while on duty, she should have been attending to her job duties, attending to the residents. It's very important we stay awake while working, something may happen to the residents. It's against the facility policy as well as union rules.On 9.18.205 at 10:33 AM V4 (Director 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to consistently administer bilevel positive airway pressure (BIPAP) therapy as ordered by a physician for one resident (R2) out of three residents reviewed for respiratory care in a total sample of seven residents. Findings include:R2's current face sheet documents R2 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: obstructive sleep apnea (adult) (pediatric), chronic obstructive pulmonary disease, unspecified, morbid (severe) obesity due to excess calories, sleep related hypoventilation in conditions classified elsewhere.R2's MDS/Minimum Data Set, dated [DATE] documents that R2 has a BIMS/Brief Interview for Mental Status score of 15/15, indicating that R2 has intact cognitive function. R2's active physician order set documents in part Bipap (bilevel positive airway pressure) at 15 cm (centimeters) H2O (water) On at Night and off while awake. No additional details were documented in the scheduled portion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to report an allegation of abuse to the administrator for one of three residents (R1) in a total sample of four. Findings include: On 6.3.2025, at 1:17 PM, V1 (Administrator) said, the incident happened on 5.10.2025. Two residents R1 and R2 got into it. It wasn't initially a reportable incident because no resident was injured and there was no mental distress of either resident. He (V3) stated CNA-Certified Nursing Assistant) came in and hit him in the face. R1 did not reference R2. On 6.3.2025, at 1:32 PM, V3 (CNA-Certified Nursing Assistant) said, I did not hit R1. V3's written statement of 5.12.2025, documents in part, V3 observed R1 and R2 involved in an altercation, intervened by separating the residents; V3 reported the incident to the nurse. On 6.4.2025, at 12:17 PM, V10 (PRSC- Psychiatric Rehabilitation Services Coordinator), said it was towards the end of my shift (5.10.2025). They called me down to the 3rd floor, because there was an incident that was going on. By the time I got down there it was over. 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 observation, interviews and record review, the facility failed to ensure that residents' rooms (R10, R11 and R12) were free from urine on the floor and urine odors. Findings include: R10 is a [AGE] year old with diagnosis including but not limited to: Encounter for attention to other artificial openings of urinary tract, personal history of malignant neoplasm of bladder, anxiety disorder, dementia and obstructive and reflux uropathy. R11 is a [AGE] year old with diagnosis including but not limited to: Essential hypertension, schizophrenia, weakness, bipolar disorder and unspecified fracture of right femur. R12 is [AGE] year old with diagnosis including but not limited to: overactive bladder, bilateral inguinal hernia, weakness, chronic obstructive pulmonary disease and bipolar. During investigation on 4/10/25 at 12:58 PM, Surveyor noted a strong odor of urine outside of residents (R10, R11 and R12) room. Surveyor observed R10 sitting in bed with urine leaking from his urostomy site and a puddle 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that urostomy supplies for one resident (R10) were available. This failure resulted in R10's lower abdomen and bedroom floor being saturated with urine. Findings include: R10 is a [AGE] year old with diagnosis including but not limited to: Encounter for attention to other artificial openings of urinary tract, personal history of malignant neoplasm of bladder, anxiety disorder, dementia and obstructive and reflux uropathy. R10 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively impaired. During investigation on 4/10/25 at 12:58 PM, Surveyor noted a strong odor of urine outside of resident's (R10, R11 and R12) room. Surveyor observed R10 sitting in bed with urine leaking from his urostomy site and a puddle of yellow fluid on the floor next to R10's bed. Surveyor requested a urostomy bag from R10's nurse (V5). On 4/10/25 at 1:00 PM, V5 (LPN/ Licensed Practical Nurse) entered R10's and said that R10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a resident the physician ordered diabetic diet. This failure affected one resident (R2) out of 9 residents reviewed for therapeutic diets. Findings include: R2's admission diagnoses include but not limited to diabetes, asthma, pancreatitis, hypertension, thrombocytosis, and benign neoplasm of bronchus and lung. R2's (3/6/25) Brief Interview of Mental status (BIMS) score is 15. R2 is cognitively intact. On 3/17/25 at 10:50 am, stated, I am not getting a diabetic diet. On 3/17/25 at 11:52 am, Lunch observed in the first-floor dining room, R2's lunch tray observed with cabbage, corn beef, roll, large sugar cookie with green frosting and sugar sprinkles on the top and a slice of lemon meringue pie and yellow color drink. R2's lunch ticket documents Diet- CCHO (Controlled Carbohydrate Diet) LCS (Low Calorie Sweetener). Texture Regular, Liquid-thin Double protein at Breakfast and Lunch. R2's order summary report for active orders as of 3/17/25 documents in part, low concentrated sweets diet, Regular texture…

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

Based on observation, interview and record review the facility failed to label and date stored food, failed to cover and label open food, failed to prepare food in a clean area, and failed to store, date and label prepared foods properly. These failures have the potential to cause food borne illness to all residents receiving food prepared for the nursing skilled facility. Findings Include, On 1/28/25 at 9:11 AM, during initial kitchen tour with V10 [Dietary Cook], the following items were found in walk-in refrigerator: Open uncovered to environment chopped lettuce, no open nor expiration date. Pack of open turkey slices open and uncovered to environment, no open nor expiration date. V10 stated, The food is to be covered dated, with a label including an expiration date once the package is opened, and prepared food needs to be stored at the appropriate temperature to prevent cross contamination and possible food borne illness. On 1/28/25 at 9:33 AM, V11 [Dietary Manager], V10 and surveyor observed the following: Two garbage cans that was not in use was filled with garbage without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dispose of kitchen garbage properly in a contained dumpsters and failed to keep the dumpster area clean free of debris, the garbage area was not maintained in a sanitary condition to prevent harborage and feeding of pest. These failures could affect all residents that reside in the facility. Findings include, On 1/28/25 at 9:39 AM, During the initial kitchen tour, observed the outside dumpster area where kitchen garbage is disposed noted the large dumpsters uncovered with lids. All around the dumpsters were food garbage packages, papers, Styrofoam plates, food bones, cigarettes butts, and foul odors. Also observed squirrels, running around eating at the debris. On 1/28/25 at 10:15 AM, V11 [Dietary Manager] stated, I do not know why there is not any lids to cover the dumpsters. When any of the dietary or housekeeping staff takes out the garbage the lids are to be closed. Dietary and housekeeping staff are responsible to clean the area around the dumpsters. If not, this could potentially cause rodents in to hang…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective pest control program. This has the potential to affect all the residents that reside in the facility. Findings include: On 01/28/25 at 12:20 PM, R158 stated facility is infested with cockroaches and has mice running around. R158 stated asking family members to bring bug spray when they visit to spray R158's room. There was a sticky trap near R158's closet. There were two small bugs on it and multiple small, linear, black droppings on it. R158 stated the trap was recently put down. On 1/28/25 at 12:33 PM, R195 stated there was a mouse in the bedroom a couple of days ago. R195 stated the facility sprays for roaches so there isn't as much as before but R195 continues to see them occasionally. On 01/28/25 at 1:00 PM, R43 stated facility has mice and roaches. R43 saw them in previous room. On 1/28/25 at 1:09 PM, R67 stated sees bugs a lot and mice occasionally. R67 reported seeing them in the halls and on other floors too. R67 has also spotted them in the dining room. There's a sticky trap…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident (R387) with surgical wound and peripherally inserted central catheter (PICC) line was placed on an Enhanced Barrier Precaution (EBP) and failed to disinfect blood equipment between use for three residents (R225, R226 & R138) for four of nine residents reviewed for infection control. Findings Include: 1. On 1/29/25 at 08:32 AM V6 (Licensed Practical Nurse) returned to the medication cart after exiting R225's room with signage posted indicating Enhanced Barrier Precautions. V6 placed the wrist blood pressure monitor on top of the medication cart after taking R225 blood pressure without disinfecting it. On 01/29/25 at 08:44 AM V6 (Licensed Practical Nurse) entered R226's room with signage posted indicating Enhanced Barrier Precautions. V6 placed the blood pressure monitor on R226 left wrist and obtained a blood pressure reading of 115/83. V6 administered R226 medication then exited the room placing the blood pressure…

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

Based on interview and record review, the facility failed to provide pneumonia vaccinations in a timely manner for (R21, R24, R54, R73, R486), offer the influenza vaccine to (R24), and obtain written consent prior to administering an influenza vaccine to (R486). These failures affected five out of five residents reviewed for immunizations on the total sample of 35. Findings include: On 1/29/25 at 10:48 AM, V16 (Infection Preventionist - Nurse) provided surveyor with a stack of pneumonia vaccine consents. There were multiple consents from 12/16/24 including those from R21, R24, R54, R73, and R486. V16 stated these residents did not receive their pneumonia vaccines yet. V16 stated V27 (Director of Nursing) was helping set up a pneumonia clinic in December but it did not follow-through when V27 took an early leave. V16 stated facility was also in the process of obtaining pneumonia consents from all eligible residents at the time but did not complete the whole building. V16 stated [V16] still has not evaluated the residents on the second floor for eligibility. Reviewed R21, R24, R54,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 accommodate and follow a resident's preference to get up out of bed (R65) and a resident's preference (R194) for a shower for two residents (R65 & R194) of two residents reviewed for accommodation of needs and preferences on the total sample of 35. Findings include: F65's admission Record documents in part medical diagnoses including but not limited to end stage renal disease, weakness, and obesity. R65's Order Details document in part that R65 may use a geriatric chair daily as tolerated related to poor trunk control (ordered 7/22/2024). R65's comprehensive care plan documents in part that R65 is at risk for falls and requires ADL (Activities of Daily Living) assist for transfers and mobility related tasks (last revised 11/22/24). Interventions include for staff to respond promptly to all requests for assistance (initiated 07/12/22). Care plan also documents in part that R65 has a self-care deficit and require assistance with ADLs to maintain the highest possible level of functioning (last revised 11/22/24).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 notify the physician when a residents blood pressure was not within the ordered parameters for (R177), failed to follow their policy for positioning a resident when obtaining a blood pressure for (R138) and failed to place a dressing on R65's permacath. This failure affected 3 residents (R177, R138 and R65) reviewed for quality of care on the sample of 35. Finding Include: 1. R177 has diagnosis not limited to End Stage Renal Disease, Essential (Primary) Hypertension, Hypertensive Urgency, Chronic Obstructive Pulmonary Disease, Encephalopathy, Schizophrenia, Suicidal Ideations, and dependence on Renal Dialysis. On 01/28/25 at 12:34 PM V6 (Licensed Practical Nurse) entered R177's room and applied the wrist blood pressure monitor to her right wrist obtaining a blood pressure reading of 99/56 pulse 68. V6 exited R177 room and stated, I am going to hold the Hydralazine. V6 did not notify the physician as ordered for the systolic blood pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure a low air loss mattress was on the correct setting for one (R157) resident with a history of alterations in skin integrity in a sample of 35. Finding Include: R157 has diagnosis not limited to Type 2 Diabetes Mellitus, Anemia, Peripheral Vascular Disease, Primary Osteoarthritis, Thrombocytosis, Spinal Stenosis, Lumbar Region with Neurogenic Claudication, Hyperlipidemia, Abnormal Weight Loss, Depression and Contracture other Specified Joint. R157's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. Care plan document in part: R157 has a self-care deficit: Impaired Bed Mobility and would benefit from participation in a Bed Mobility Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: Spinal Stenosis with neurogenic claudication, Intervertebral disc degeneration lumbar region, Muscle weakness, Reduced mobility, schizoaffective disorder. Focus: R157 has an alteration in skin integrity and is 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 anti-contracture devices were applied as ordered and ensure the care plan was updated to reflect the correct area of splint application for one (R72) of four residents reviewed for limited range of motion in a sample of 35. Findings Include: R72 has diagnosis not limited to Psychosis, Epilepsy, Hemiplegia, Unspecified Affecting Right Dominant Side, Weakness, Cerebral Infarction, History of Falling, Personal History of Transient Ischemic Attack (Tia), Schizophrenia, Bipolar Disorder, Obesity, and Injury of Head. R72's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 12 indicating moderate cognitive impairment. Care Plan document in part: Focus: R72 is at risk for complications related to Cerebral Vascular Accident (Stroke) Hemiplegia affecting Right Dominant side. Focus: R72 is at risk for complications related to Monoarthritis. Intervention: Use supportive devices such as splints as recommended by therapy. Focus: I would benefit from a splint/brace due to mono arthritis to left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 expired dialysis nutritional supplements were not store and administered to two (R177, R183) of three residents reviewed for nutrition in a sample of 35. Findings Include: On [DATE] at 01:05 PM the second-floor medication room was reviewed with V5 (Registered Nurse). An opened box containing twenty 8-ounce cartons of Nova Source Renal 19% was observed on the counter with a use by date of [DATE]. V5 stated we use the Nova Source for dialysis residents, and this is the only box. There are 3 or 4 dialysis residents on the floor. On [DATE] at 01:15 PM surveyor asked V4 (Registered Nurse) are there any dialysis residents on the floor. V4 responded, R114, R177 and R183 are dialysis residents. Surveyor asked do they receive the Nova Source Renal 19%. V4 responded; they receive it every day unless they refuse. R177 and R183 received it but R114 did not want hers. Surveyor asked V4 to enter the medication room to observe the box of Nova…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 evaluate for the appropriateness of antipsychotic medication and ensure that as needed orders for anti-psychotic medications are limited to 14 days for one (R170) of six residents reviewed for unnecessary medications on the total sample of 35. Findings Include: R170's clinical records show an initial admission date of 10/16/24 with included diagnoses but not limited to Schizoaffective Disorder Bipolar type, Generalized Anxiety Disorder, and Major Depressive Disorder. R170's Minimum Data Set, dated [DATE] shows R170 has moderately impaired cognition. R170's physician orders with active orders as of 1/29/25 read in part: Haloperidol Lactate Injection Solution inject 5 mg intramuscularly every 6 hours as needed for agitation and Haloperidol 5 mg 1 tablet every 6 hours as needed (PRN) for agitation (ordered 12/27/24). R170's January Medication Administration Record (MAR) documented behavior monitoring revealed R170 did not exhibit any negative behaviors…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that a foot rest was placed on the wheelchair of one resident (R8), who had a diagnosis of left- sided weakness. This failure resulted in R8's left foot dragging on the floor, causing R2 to fall out of his wheelchair while being propelled by an employee. Findings include: R8 is [AGE] year old with diagnosis including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction, diplopia, insomnia and essential hypertension. R8 has a BIMS (Brief Interview of Mental Status) score of 13, which indicates R8 is cognitively intact. On 12/23/2024, during investigation at 11:42 AM, R8 was observed sitting in his wheelchair on the third floor. At that time, R8 was slowly being pushed by V11 (CNA/ Certified Nurse Assistant). Surveyor noted R8's left foot on the floor, right before his foot was dragged underneath the wheel chair. R8 fell forward, out of his wheelchair. 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 provide a pest and rodent free environment. This deficient practice has the potential to affect all 229 residents who reside in the facility. Findings include: 12/21/2024, at 10:55 AM, R4 said she has mice (the size of hamsters) and roaches in her room. They come at night around 9:00 PM. 12/21/2024, at 11:29 AM, R3 said he saw mice in his room a couple of nights ago on the night shift. R3 said he reported the issue to the nurse. 11/19/2024 concern documents V5 (MDS Coordinator) reported to V6 (Housekeeping Director) mouse running around in a resident's room and starting to come out during the day. Used to only come out at night. Response/Resolution: room were treated with glue traps and bait. 11/20/2024 concern documents V5 (MDS Coordinator) reported to V6 (Housekeeping Director) mice running around in a resident's room. Response/Resolution: rooms were treated with glue traps and bait. 12/21/2024, at 12:46 AM, V6 (Housekeeping Director) said I have had complaints related to mice and roaches within the past…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dependent resident with nail care for one of three residents (R2) reviewed for activities of daily living (ADL) in the sample of seven. Findings include: On 12/22/2024, at 12:40 PM, R2 was observed sitting in wheelchair at dining room table. R2 was awake and alert, singing along to music playing in the dining room. A surgical mask was covering R2's nose and eyes. At the surveyor's request, R2 showed surveyor his nails. R2's nails were long, with a thick build-up of black debris. R2 did not look at or comment about his nails. 12/22/2024, at 12:59 PM, V9 (Licensed Practical Nurse) examined R2's fingernails. V9 said R2's fingernails were long, dirty, and needed to be trimmed and cleaned. V9 said in general, residents' fingernails should be trimmed and cleaned as needed. V9 continued, he's (R2) is not a diabetic, so the CNA (Certified Nursing Assistant) can trim them. V9 said he would look into it. 12/22/2024, at 1:05 PM, V10 (CNA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain hot foods on the service steam table for meal tray assembly at 135 degrees Fahrenheit or higher and failed to serve hot foods to the residents at a temperature not less than 125 degrees F which affected R5 and has the potential to affect 60 residents residing on the floor utilizing the steam table. Findings include: On 10/7/24 at 1:35 pm, R5 stated, I (R5) eat in my room. When I get my food, it's cold. When asked if a CNA (Certified Nursing Assistant) then heats up R5's cold food from the meal tray, R5 stated, Yes, but they should not have to do that. They are not supposed to be serving food that's cold when it should be hot. R5's Order Summary Report documents, in part, R5's diet order of renal with dialysis diet indicating regular texture food, thin liquid consistency, no added salt and no concentrated sweets. R5's Minimum Data Set (MDS) dated [DATE] documents, in part, a Brief Interview of Mental Status (BIMS) score of 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform timely incontinence checks and care for one resident (R2) in the sample of three residents reviewed for activities of daily living (ADL). Findings include: R2's admission Record documents, diagnoses including dementia, pressure ulcer of sacral region stage 3, pressure ulcer of left heel stage 3, systolic (congestive) heart failure, anemia, essential hypertension, vitamin D deficiency, gastro-esophageal reflux disease, and atrial fibrillation. R2's Minimum Data Set (MDS), dated [DATE], documents, a Brief Interview for Mental Status (BIMS) score of 11 which indicates that R2 has moderate cognitive impairment. R2's Functional Abilities and Goals for Functional Limitation in Range of Motion for lower extremity is coded as impairment on both sides. R2's Toileting Hygiene for the ability to maintain personal hygiene after urinating or having a bowel movement is coded as 1: Dependent: Helper does all the effort. Resident does none of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide aseptic wound care treatments for pressure ulcer wounds; failed to ensure that a resident with pressure ulcers was repositioned timely; and failed to ensure that a resident's low air loss mattress setting for weight were at the appropriate weight which affect one resident (R2) in the sample of three residents reviewed for improper nursing care. Findings include: R2's admission Record documents, diagnoses including dementia, pressure ulcer of sacral region stage 3, pressure ulcer of left heel stage 3, systolic (congestive) heart failure, anemia, essential hypertension, vitamin D deficiency, gastro-esophageal reflux disease, and atrial fibrillation. R2's Minimum Data Set (MDS), dated [DATE], documents, in part a Brief Interview for Mental Status (BIMS) score of 11 which indicates that R2 has moderate cognitive impairment. R2's Functional Abilities and Goals for Functional Limitation in Range of Motion for lower extremity is coded as…

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

Based on observation, interview, and record review, the facility failed to provide the diet prescribed by the physician to residents in the form to meet the needs of the residents. This failure affects two residents (R3, R4) and has the potential to affect seven additional residents (R8, R9, R10, R11, R12, R13, R14) that have orders for a pureed diet at the facility. Findings include: On 8/19/24 at 12:05pm during meal observation at lunch time in the dining room on the third floor, the following were observed: R4 was observed with a whole banana on his plate with mashed potatoes, pureed ham/turkey, and a cup of juice. R4 drank the juice and ate less than 50 percent of the food, leaving the banana on the tray. There was no pureed banana on the trays of R4 and the other residents (R8, R11, and R14) who are supposed to be on pureed diet on the third floor. The surveyor asked V8 (Dietary Aide that was serving the food) about how many residents are on puree diet for the third floor; V8 responded 4 residents. The surveyor asked V6 (LPN/Licensed Practical Nurse) if R4 (supposed to be on…

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

Based on observation, interview and record review, the facility failed to monitor residents on the outside patio of the facility for safety. This failure has the potential to affect 4 residents (R8, R16, R17, R18) who use wheelchairs and are at risk for falls and other unsafe conditions on the patio. Findings include: On 7/22/24 between 10:51am and 11:03am, the surveyor observed residents on the patio while trying to find R8. The surveyor observed R8, R16, R17, R18 and 21 other residents on the patio while some of the residents were smoking. There was no staff watching the residents on the patio. The surveyor spoke with a few residents who helped to identify R8, as R8 did not have the ability to respond to his name. No staff around to help the surveyor to identify residents by name. After about 8 minutes, V25 (Psychiatric Technician) came and helped to identify some residents. Inquired from V25 about the staff responsible for monitoring the residents on the patio while smoking. V25 stated that he (V25) was supposed to be inside to give out the smoking materials and another staff 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, interviews and record review, the facility failed to supervise and monitor one resident (R1) of 4 residents reviewed for supervision. This failure resulted in R1 eloping from the facility by climbing over the fence surrounding the smoking patio. Finding include: According to a face sheet, R1 is a [AGE] year-old resident admitted to the facility on [DATE]. According to progress notes, R1 eloped from the facility on 04/26/2024. R1's Face Sheet documents the following diagnoses including but not limited to: bipolar disorder, schizophrenia, alcoholic polyneuropathy, local infection of the skin and subcutaneous, cocaine abuse with intoxication, alcohol abuse, tobacco use, hyperlipidemia. R1's Minimum Date Set assignment dated 04/12/2024 indicated R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates resident has intact cognitive response. R1's care plan dated 04/09/2024, indicated R1 has a history of substance abuse and has potential for complications such as recurrence…

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

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and dated; failed to ensure food items were 6 inches off the floor; failed to ensure food items which passed their shelf life, use-by-date and/or expiration date were discarded, and failed to ensure staff donned beard covers in an effort to prevent food borne illness. These failures have the potential to affect all 199 residents who receive food from the kitchen at the facility. Findings include: The (03/17/2024) facility census was 224. The (03/2024) G-tubes attached document upon the request of this surveyor for list of residents not taking oral nutrition at the facility documented that there were 5 residents in the list. On 03/17/2024 at 9:23am in the facility's kitchen, V6 (Dietary Manager) has a beard and was not wearing a beard restraint. V6 stated it's in my pocket. V6 took a hair restraint in his (V6) pocket and used the hair restraint to cover his beard. On 03/17/2024 at 9:25am, a box of thickened water was on the floor, keeping the door of the 'dry storage' room 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.

Based on observation, interview, and record review, the facility failed to ensure the dumpsters were kept closed and failed to ensure the ground surrounding the dumpster was free of trash in an effort to prevent pest and rodents migration to the facility. These failures have the potential to affect all 224 residents residing at the facility. Findings include: On 03/17/2024 at 9:45am, the 2 outside dumpsters were open. Trash was inside the dumpster. There was also a big bin with a dead rat inside. These were pointed out to V6 (Dietary Manager). V6 stated I (V6) don't know why the dumpsters are not closed. That is housekeeping. The dumpsters should be closed so we don't attract that thing (pointing to the dead rat in the big bin) going to the dumpster. On 03/17/2024 at 9:49am, V6 stated our garbage goes to the dumpsters as well; all facility garbages go there. The expectation is to keep the dumpsters closed when not in use because pest and rodents could smell the food and go to the dumpsters. The (03/19/2024) facility documented presented by V1 (Administrator) documented, in part…

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

Based upon interview and record review, the facility failed to ensure that the facility's designated Infection Preventionist staff member has completed the specialized training in infection prevention and control for the facility's infection prevention and control program (IPCP). This failure has the potential to affect all 224 residents who reside in the facility. Findings include: On (03/17/24) Long Term Care census was 224. On 3/17/24 at 10:36am, V19 (Infection Preventionist) stated that she (V19) has been the Infection Preventionist at the facility since October of 2023 but does not have her (V19) Infection Preventionist Certificate. V19 said that (V19) is the only Infection Preventionist at this facility. On 3/19/24, V3 (Director of Nursing) provided document written, in part (V19) is currently the Infection Prevention Nurse here at (facility) and currently in the process of obtaining her (V19) Infection control certification. Facility job description undated and titled Job Description Infection Preventionist, documents, in part, Qualifications: Completion of training on…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that the facility is free of rodents. This failure has the potential to affect all 224 residents at the facility. Findings include: The (03/17/2024) facility census was 224. On 03/17/2024 at 9:45am, the 2 outside dumpsters were open. There was trash inside the dumpsters. Besides the dumpsters was a big bin with a dead rat inside. These were pointed out to V6 (Dietary Manager). V6 stated I (V6) don't know why the dumpsters are not closed. That is housekeeping. The dumpsters should be closed so we don't attract that thing (pointing to the dead rat in the big bin) going to the dumpster. On 03/17/2024 at 9:49am, V6 stated the kitchen garbage goes to the dumpster as well as all facility garbages go there. The expectation is to keep the dumpsters closed when not in use because pest and rodents could smell the food and go to the dumpsters. On 03/19/2024 at 10:45am, there were black matters at the workstation inside the Kitchen's Dietary Manager's office. V6 checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a homelike environment for four residents (R45, R61, R77, R107) reviewed for homelike environment on the sample list of 63. Findings include: On 03/17/24 at 10:20 am, R45's room had a brown dried substance smeared on the wall across from R45's bed. R45 stated that the brown substance has been smeared on the wall across from R45's bed for months. R45 did not know what the brown substance was. R45's Brief Interview for Mental Status (BIMS) dated 01/04/24 documents that R45 has a BIMS score of 8 which indicates that R45 has some cognitive impairments. On 03/17/24 at 10:30 am, R61, R77 and R107's bathroom had a brown dried substance smeared on the bathroom wall and toilet area. On 03/18/24 at 9:21 am, the wall across from R45's bed still had the brown dried substance smeared on the wall across from R45's bed. On 03/18/24 at 9:22 am, R61, R77 and R107 bathroom continued to have the brown dried substance smeared on the bathroom wall and toilet area. On 03/28/24 at 9:27 am, V21 (Housekeeping Director) stated,…

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

Based on observation, interview and record review the facility failed to ensure three of the three medication carts were kept clean and free from clutter. This deficient practice has the potential to affect 51 residents on one floor and 25 residents on an additional floor who receive medications from the medication carts. Findings include: On 3/19 2024 at 10:16am inspected a 5th Floor medication cart with V15(LPN/Licensed Practical Nurse). The following was observed: V15 pulled 1 loose white tablet from the second drawer of this medication cart. On 3/19/2024 at 10:23am inspected an additional 5th Floor medication cart with V15(LPN/Licensed Practical Nurse). The following was observed: V15 pulled 1 loose blue tablet from the second drawer of this medication cart. On 3/19/2024 at 10:55am inspected the 3rd Floor medication cart with V31(LPN/Licensed Practical Nurse). The following was observed: V31 pulled 1 loose blue tablet, 1 loose pink tablet, 1 loose yellow tablet, 6 loose white tablets, 3 loose orange tablets, 1 loose tan tablet, 1 loose green/blue capsule, and 1 loose green…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct hand hygiene prior to passing meal trays and failed to ensure that Personal Protective Equipment was accessible for rooms requiring this equipment. These failures affected 5 residents (R97, R145, R160, R219 and R467) reviewed for infection control on the sample list of 63 residents. Findings include: On 3/17/24 at 10:00 am, observed a enhance barrier precaution sign posted on R467's door without accessible Personal Protective Equipment (PPE.) No PPE bin noted outside of R467's room. V23 (License Practical Nurse-LPN) outside R467's room passing medication. Surveyor inquired to V23 that R467 has an enhance barrier sign on the door where is the PPE. V23 stated that R467 has the enhance barrier sign posted because R476 has an indwelling catheter and wounds. Surveyor observed 2 PPE bins down the hallway from R476's room with no gowns in the bins. The bins were not stationed in front of a resident's rooms. On 3/18/24 at 3:36 pm, V19…

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

Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter drainage bag was covered. This failure affects one resident (R467) reviewed for dignity on the sample list of 63 residents. Findings Include: R467's admission record includes diagnoses of atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, coronary angioplasty, and anemia. R467's (3/8/24) Minimal Data Set documents, a Brief Interview for Mental Status (BIMS) score of 13 which indicates that R467 is cognitively intact. On 3/17/24 at 9:50 am surveyor observed R467's indwelling catheter drainage bag hanging on the lower right side of the bed visible from the hallway. The drainage bag was not covered with a privacy bag. On 3/19/24 at 10:58 am, V1 DON (Director of Nursing) stated that all catheter drainage bags should be covered to provide dignity to the resident. Facility policy (undated) titled, Dignity documents in part, Dignity Concerns: 9. Urinary drainage bags will be covered unless residents are in their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review and interview the facility failed to ensure that the call light was within reach for 2 residents (R134 and R76) out of 63 residents reviewed for call lights. Findings include: 1. R134's diagnoses include hyperlipidemia, unspecified, schizophrenia, unspecified, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, long term (current) use of anticoagulants, acquired absence of right leg below knee, acquired absence of left leg below knee, unspecified lack of coordination, muscle wasting and atrophy, not elsewhere classified, right thigh, muscle wasting and atrophy, not elsewhere classified, left thigh and weakness. R134's Brief Interview for Mental Status (BIMS) dated 12/27/2023 documents R134's BIMS score of 14, indicating R134's cognition is intact. On 3/17/2024 at 10:24am observed R134 sitting on the right-side edge of the bed. When R134 was asked where the call light was located, R134 was unable to locate the call light. At this time, R134's call light was on the left side of the resident's bed wrapped around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 (R98 and R113) residents reviewed for pre-admission screening on the sample list of 63 residents. Findings include: 1. R98's admission Record documents R98's diagnoses include Schizoaffective Disorder (onset date: 03/02/2023) and Schizophrenia (onset date: 07/29/2017). R98's (Active Order as of: 03/20/2024) Order Summary report documented, in part Diagnoses: Schizophrenia, schizoaffective disorder bipolar. Order summary: QUEtiapine Fumarate Oral Tablet 200 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for Chronic schizophrenia. Order Date: 09/18/2023. Start Date: 09/19/2023. R98's (02/16/2017) Interagency Certification of Screening Results documented, in part Screening indicated nursing facility services are appropriate. Screening Certified by: Department On Aging. Based upon all information and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to 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 two residents (R38, R78) reviewed for screening on the sample list of 63. Findings include: 1. R38's admission Record documents, in part, that R38 was admitted to the facility on [DATE] and current diagnoses include but are not limited to: bipolar disorder, major depressive disorder, schizoaffective disorder, anxiety disorder. R38's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R38's cognition is moderately impaired. R38's Care Plan, date initiated 12/3/2022, documents, in part, Psychiatric Illness/psychological services . (R38) has been screened and determined to have diagnoses that include schizoaffective disorder, major depressive disorder, anxiety disorder, psychosis, 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 ensure a privacy curtain to provide privacy as needed. This failure affects two residents (R68 and R155) reviewed for privacy on the sample list of 63 residents. Findings include: R68's Brief Interview for Mental Status (BIMS) dated 02/15/24 documents that R68 has a BIMS score of 10 which indicates that R68 has some cognitive impairments. On 03/17/24 at 10:25 am, R68's room was observed without a privacy curtain. R68 stated that R68 has never had a privacy curtain since R68 has been a resident at the facility. R155's Brief Interview for Mental Status (BIMS) dated 12/19/23 documents that R155 has a BIMS score of 15 which indicates that R155 is cognitively intact. On 03/17/24 at 10:57 am, R155's room was observed without a privacy curtain track in the ceiling or a privacy curtain for R155. R155 stated that R155 has not had a privacy curtain since R155 has been at the facility. On 03/18/24 at 9:20 am, R68 and R155's room still did not have privacy curtains in place. On 03/18/24 at 9:27 am, Surveyor brought R68'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 provide pressure reducing devices for wheelchairs as stated in the assessments for residents at risk for pressure ulcers. This failure affected five residents (R3, R4, R5, R6 and R7) of 6 residents, reviewed for pressure ulcer prevention interventions. Findings include: On 3/11/24 at 11:20am, during observation of residents on the third floor, with V5(CNA/Certified Nurse Assistant), R3, R4, R5, R6 and R7 were observed in the dining room sitting in the wheelchair without the cushion to reduce pressure on the buttocks. V5 stated I will call restorative to let them know. At this time, V7(Wound Care Nurse) came to the day room and stated If the residents who don't move around don't have cushion in the wheelchair, they could have pressure ulcers. Again, on 3/12/24 at 12:15pm, with V5 watching the residents in the dining room, all 5 residents were observed in the wheelchairs without any pressure reducing devices. V5 stated I informed…

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

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so the the facility is free of rodents on 3 of 4 (2nd , 3rd and 4th) resident floors and in the Dietary area (1st floor). This affects all residents in the facility. Findings include: On 1/16/24 at 11 AM to 1PM, mouse droppings were observed on the floor, in corners, and under room bedside cabinets and heat registers in R8's room, R9's room, R11's room, R12's room, R13's room, R14's room, R5's room, R15's room, R16's room, and R7's room . The food service 1st floor dry food storage room was observed with mouse droppings in corners and under shelving on floor. On 1/16/24 at 10:16AM, R4 stated, Yes, I see mice all the time in my room. On 1/16/24 at 10:18AM, R5 stated, I see one small mouse regularly at night. He comes into my room and runs across the floor to under the heater on the wall. On 1/16/24 at 10:25AM, R6 stated, There are mice in my room all the time. On 1/16/14 at 11AM, R7 stated, Yes I see mice. On 1/16/24 at 11:05AM, R8 stated, I see mice. There were 4 in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff to resident mental and verbal abuse did not occur for one of four residents (R4) reviewed for abuse. Findings include: Facility's incident report (11.27.2023) documents: It was alleged that (R4) was spoken to inappropriately by (V7, Former Licensed Practical Nurse). During the investigation, it was determined that (R4) and (R12) engaged in a verbal exchange of words. When the verbal exchange occurred with (R4) and (R12), (V7) intervened and according to (R4) made an inappropriate statement towards (R4). On 12/2/2023 at 1:13 PM, V6 (APRSD-Assistant Psychiatric Rehabilitation Services Director) said, (R4) was arguing with (V7, Former- LPN-Licensed Practical Nurse). I spoke with (R4); I did not get a chance to speak with the nurse. (R4) told me she got into an argument with the nurse, because she was recording staff. (R4) did not tell me why she was recording staff. (R4's) mother came in and showed me the recording. I saw (R4) yelling at staff, he (V7) did not call her any names, there were inappropriate words…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a shared shower room on the third floor was free of feces on the floor. This failure has the potential to affect all 61 residents that utilize the third floor shower room. Findings include: On 11/21/23 during floor rounds on 3rd floor, there was a strong odor of feces. On 11/21/23 at 10:50 AM, V9 (CNA/ Certified Nurse Assistant) opened the 3rd floor shower room. There were 4 lumps of brown substance on the floor in the shower room. On 11/21/23 at 10:51 AM, V2 said, That is BM (bowel movement). I will have housekeeping clean it up now. At that time, V2 (Nurse Manger) said, Feces in the shower room is not sanitary. It should never be left there. On 11/21/23 at 10:55 AM, V2 (Nursing Manager) said, There are two shower rooms on the 3rd floor, but maintenance is working on one of the shower rooms right now. Everyone on the 3rd floor uses the shower rooms. The bedbound residents are showered on the shower bed and the wheelchair residents use the shower chair. On 11/21/23 at 12:15 PM, V4 (Housekeeping…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two resident (R2 and R5's) room was free of odor, and without feces on the floor and waste basket. Findings include: R2 is [AGE] year old with diagnosis including but not limited to: Weakness, Unspecified osteoarthritis, Unspecified fracture of right femur sequela, Schizophrenia, and Hypertension. R2 has a BIMS (Brief Interview for Mental Status) score of 14, which indicates cognitively intact. R5 is [AGE] year old with diagnosis including but not limited to: Dementia, Anxiety disorder, Type 2 Diabetes Mellitus, Chronic Ischemic heart disease and Age-related nuclear cataract. R5 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates moderately impaired. R2 and R5 share a room in the facility. On 11/21/23 at 10:35 AM, R2 was observed in hallway sitting in a wheelchair outside of his bedroom. Surveyor noted the smell of feces near R2's bedroom. On 11/21/23 at 10:42 AM, V9 (Certified Nursing Assistant/CNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dietary orders were followed for four residents (R1, R6, R7, and R8). This failure has the potential to affect all 226 residents that receive meals/ nutrition from the facility. Findings include: R1 is [AGE] year old with diagnosis including, but not limited to: Displaced comminuted fracture of shaft of right femur, end stage renal disease, dependence on renal dialysis and hypertension. R1 has a past medical history including, but not limited to: osteoarthritis and polycystic kidney disease. R6 is [AGE] year old with diagnosis including, but not limited to: Anemia, Hyperlipidemia, Dysphagia, Gastro-Esophageal reflux disease, and Hypertension. R7 is [AGE] year old with diagnosis including, but not limited to: Anemia, End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. R8 is [AGE] year old with diagnosis including, but not limited to: Anemia, Muscle wasting and atrophy, Muscle weakness, Other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility: failed to obtain a physician order for oxygen administration upon admission for a resident with a diagnosis of Respiratory Failure; failed to ensure that a physician order is obtained before administering oxygen; failed to replace the humidifier bottle when empty; and failed to check pulse oximetry reading per policy. These failures affected one resident (R4) of two residents reviewed for oxygen administration. Findings include: R4's care plan, dated 9/20/23, states: Diagnosis Chronic Respiratory Failure. Problems manifested by: Drop in blood oxygenation (hypoxia). Displays complications with gas exchange and receives oxygen. Goal states: Will have adequate gas exchange without increased airway resistance though next review. Intervention states: Administer Oxygen as ordered per MD (Medical Doctor). On 10/23/23 at 10:50 AM, during observation of residents on the third floor, R4 was observed in the day room with oxygen concentrator and an empty/dry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that one resident's (R1) scheduled pain medication was entered into the resident's orders to manage pain. This failure has affected one of eight residents reviewed for pain management. Findings include: R1 is [AGE] year old with diagnosis including, but not limited to: Displaced comminuted fracture of shaft of right femur, end stage renal disease, dependence on renal dialysis and hypertension. R1 has a past medical history including, but not limited to: osteoarthritis and polycystic kidney disease. R1 has a BIMS (Brief Interview for Mental Status) score of 14, which indicates cognitively intact. R1's admitting Hospital records, dated 9/26/23, documents, start taking these medications: acetaminophen (Tylenol) 235 mg tablet, take 2 tablets by mouth four times daily. R1's Ambulatory Progress note, dated 10/17/23, documents, this patient is here today to follow up after presenting to the emergency room for evaluation of right knee…

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

Based on observation, interview, and record review, the facility failed to ensure that residents' call light system is maintained, functional and adequately equipped to allow residents to call for staff assistance. This failure affected one resident (R5) of three residents, reviewed for functional resident call system. Findings include: On 10/23/23 at 10:55 AM, R5 asked the surveyor for help while at the edge of the bed and almost about to fall. The surveyor asked R5 to use the call light, but R5 stated the call light has not functioned for a while. The surveyor pulled the call light, and it was observed to be non-functional; R5 could not reach the call light to call staff for assistance. Surveyor went to the nursing station and called V13(CNA/Certified Nursing Assistant). V13 helped R5 to get in the wheelchair. V22(CNA) later stated she(V22) would call maintenance, and V22 recorded the non-functioning call light in the maintenance log. On 10/23/23 at 2:29 PM, V12 (Maintenance Director) was interviewed regarding R5's call light. V12 stated he was notified about the call light issue,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one resident (R2) of 3 residents reviewed for wound care receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Findings include: According to R2's face sheet, R2 was admitted to the facility on [DATE]. R2 diagnoses include but are not limited to end stage renal disease, dependence on renal dialysis, gangrene, acquired absence of right leg below knee, atherosclerotic heart disease of native coronary artery, and peripheral vascular disease. Review of hospital record, sent 7/11/2023, indicates R2 had gangrene to the left foot before admittance to the facility. According to discharge hospital record from a local hospital, R2's wound care treatment plan reads in part: Site 1 - left foot/great toe to third toe Cleanse affected area with wound cleanser pay dry with gauze paint with betadine solution QHS and PRN; Site 2 - left leg Cleanse affected area with wound cleanser pay…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 kitchen staff perform appropriate and timely hand hygiene; failed to ensure that kitchen staff wear gloves when handling food; failed to label opened food items with an open date; failed to discard expired foods; failed to wash produce properly; failed to ensure that kitchen staff store their personal items and drinks out of the facility kitchen; failed to ensure that hair restraints covered all head hair of the kitchen staff; failed to properly sanitize kitchen dishware, utensils and equipment in the 3 compartment sink and allow to air dry before next use; failed to maintain cooked food items on the steam table at 135 degrees Fahrenheit (F) or higher; failed to sanitize the thermometer between food items when obtaining food temperatures; and failed to ensure that kitchen staff use utensils to plate food from the steam table. These failures had the potential to affect all 204 residents in the facility. Findings include: 1. On 5/21/23 at 9:38 am, V8 (Dietary Aide) was at the preparation (prep) table…

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

Based on observation, interview, and record review, the facility failed to ensure staff performed appropriate hand hygiene during dining on 5th floor, failed to ensure the 4th floor's ice cooler's lid was not touching the floor and ice scoop was contained, and failed to ensure dirty linens were bagged prior to tossing in a laundry chute in an effort to prevent the spread of infectious microorganisms, including COVID-19. These failures have the potential to affect all 204 residents in the facility. Findings include: The (05/21/2023) facility census was 204. 1. R99'S (03/08/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R99's mental status as moderately impaired On 05/21/2023 at 11:29am, R99 opened the ice cooler on a cart located by the 4th floor's nurse's station, and placed the lid leaning on the side of the cart with one side of the lid touching the floor,. R99 took the ice scoop at the bottom shelf of the cart, and scooped ice from the cooler. R99 did not sanitize his hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean the lint compartment which housed the lint screen in an effort to provide a safe environment to the residents. This failure has the potential to affect all 204 residents in the facility. Findings include: The (05/21/2023) facility census was 204. On 05/22/2023 at 2:53pm, V31 (Housekeeping/Laundry Director) opened the lint compartment of the Dryer labeled #1. V31 pulled the lint screen completely out of the lint compartment. The lint screen was clean, however, there was an accumulation of lint which covered the bottom of the lint compartment that housed the lint screen. V31 stated, The lint compartment has not been cleaned. V32 (Laundry Aide) stated, I have been working here for 4 years. I did not know this thing could come out (pointing to the lint screen). On 05/22/2023 at 2:55pm, this surveyor inquired about the importance of cleaning the lint compartment. V31 stated the dryer could catch fire. The (05/23/2023) email correspondence with V1 (Administrator) documented V32's start date was 8/8/2019. 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 residents were not using disposable cutlery during lunch in an effort to promote dignity during dining. This failure affected R85 and has the potential to affect 94 residents residing on the 4th and 5th floors of the facility. Findings include: 1. F85's (02/17/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 6., indicating R85's mental status as severely impaired. On 05/21/2023 at 10:10am, V10 (Certified Nursing Assistant) stated there were 37 residents on the 4th floor, and all residents were encouraged to eat in the dining area. On 05/21/2023 at 12:05pm, V10 (Certified Nursing Assistant) was placing diet slips and cakes on the food trays, and started placing plastic spoons on the food trays. V12 (Dietary Aide) placed plates with rice, green beans, bread and pork on the trays, then V10 got beverages from V13 (Human Resources/HR Manager), and passed the trays to V14 (Restorative Aide) and V11 (Registered Nurse). V14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 environment remained free of accident hazards for two residents (R159 and R458); failed to ensure fall interventions were in place for one resident (R204); and failed to ensure smoking supervision and interventions were in place for one resident (R137). These failures affect 4 residents (R19, R458, R204, and R137) reviewed for safety and hazards. Findings include: 1. R159 has diagnoses including, but not limited to: metabolic encephalopathy, cerebral infraction, hemiplegia, and hemiparesis following cerebral infarction, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and major depressive disorder. R159's Brief Interview for Mental Status (BIMS), dated 04/12/23 Section C, documents R159 has a BIMS score of 11, which indicates R159 has some cognitive impairments. R458 has diagnoses including, but not limited to: hypertensive urgency, encephalopathy, acute kidney failure, rhabdomyolysis, weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 contain oxygen equipment in accordance to the facility policy. This failure affected one resident (R52) reviewed for oxygen equipment. Findings include: R52 has diagnoses of, but not limited to: Moderate Persistent Asthma with (Acute) Exacerbation, Acute and Chronic Respiratory Failure with Hypoxia and Pneumonia. R52 has a Brief Interview of Mental Status of 15. On 5/21/2023 at 10:57am, R52's nebulizer mask was laying in the top drawer, unlabeled, uncontained, and undated. On 5/21/2023 at 10:59am, V4 (Assitant Director of Nursing/ADON) said, Let me see. Surveyor observed V29 (Licensed Practical Nurse/LPN) putting R52's nebulizer mask in a plastic bag. V29 stated, The nebulizer mask should have been kept in the plastic bag to avoid infections. On 5/23/2023 at 2:58pm, V2 (Director of Nursing/DON) stated, Nebulizer masks should be stored in a plastic bag when not in use. Oxygen Therapy Policy, dated 3/19/2015, states, in part, discard disposable mask after use in accordance with equipment change…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 log refrigerator temperatures for one resident (R194). Findings include: R194 has diagnoses including, but not limited to: type two diabetes mellitus without complications, essential hypertension, depression, adjustment disorder with depressed mood, and schizoaffective disorder unspecified. R194's Brief Interview for Mental Status (BIMS), dated 02/21/23 Section C, documents R194 has a BIMS score of 15 which indicates that R194 is cognitively intact. On 05/21/23 at 10:36 am, Surveyor observed room R194's room refrigerator without a refrigerator temperature thermometer, and without a temperature log sheet. R194 stated, I never see them (referring to staff) check my refrigerator. I never had a thermometer for my refrigerator. On 05/22/23 at 11:00 am, R194's room refrigerator was without a refrigerator thermometer, and without a temperature log sheet. On 05/23/23 at 11:18 am, V31 (Housekeeping Director) stated, The housekeeping department is responsible for monitoring the temperature log sheets 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.