Princeton Rehab & Hcc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all sixty one residents that reside on the 3rd floor of the facility. Findings include: Facility census, dated [DATE], documents 61 residents residing on the third floor. On [DATE] surveyor observed document titled, Emergency Cart Daily Review, month February 2025, with missing a daily crash cart check for [DATE]. On [DATE] at 11:58am, V25 (Licensed Practical Nurse/LPN) said, Yes, the emergency cart should be checked daily. We (staff) want to make sure everything is working in case of an emergency. If the crash cart is not checked, and something is missing or not working, something bad can happen to the resident that could have been prevented. On [DATE] at 12:47pm, V2 (Director of Nursing/DON), said Crash carts are checked daily and signed off that they were checked to ensure its…

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 janitor closet was locked at all times where residents with a diagnosis of dementia reside. This failure has the potential to affect all the 25 residents on the 2nd floor [NAME] Wing of the facility. Findings include: On 02/25/2025 at 3:12pm, V1 (Administrator) stated the resident's rooms on the second floor [NAME] wing are from rooms 201 to 212. The (02/22/2025) Midnight Census Report documented that there were 25 residents on the second floor's [NAME] Wing. On 02/23/2025 at 11:00 AM, the janitor closet on the second floor's [NAME] Wing was not locked. This observation was pointed out to V7 (Housekeeping Supervisor). V7 checked the closet, removed a piece of paper from the strike plate hole where the latch bolt lies when closing the door, and stated somebody put a piece of paper or something to stop the door from locking. This surveyor requested V7 to keep the door open and to tell this surveyor what's inside the Janitor'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 label opened multi dose vials. This failure has the potential to affect 2 residents (R43 and R109) reviewed for medications in the sample of 66 residents. Findings include: On 2/24/25 at 10:44am, with V13 (Registered Nurse/RN), during observation of medication storage, R43's vial of Fluticasone Propionate Nasal spray and vial of Azelastine HCl Nasal Solution 0.1 % was observed opened and not labeled with an open date. Also observed was R109's vial of Prednisolone Acetate Ophthalmic Suspension 1 % eye drops opened and not labeled with an open date. These observations were pointed out to V13 and V13 affirmed that the Fluticasone Propionate Nasal spray, Azelastine HCl Nasal Solution, and Prednisolone Acetate eye drops were opened and did not have an opened date labeled. V13 affirmed that the Fluticasone Propionate Nasal spray, Azelastine HCl Nasal Solution, and Prednisolone Acetate eye should have an opened date labeled on the medications.…

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 container of the multi blood glucose test strips was labeled with an open date. These failures have the potential to affect 10 residents (R23, R36, R41, R43, R59, R68, R72, R88, R109, and R435) on team 2 who receive blood glucose monitoring tests on the first floor, reviewed for medication storage in storage in the sample of 66 residents Findings include: On 2/24/25 at 10:44am, with V13 (Registered Nurse/RN), during observation of medication the first floor, team 2 medication cart, an opened container of the multi blood glucose test strips with no open date labeled was observed. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. This observation was pointed out to V13. V13 then open the container of multi blood glucose strips with no open date and stated, Yeah, this isn't a full container. They must have forgot to label this one because the other one in my cart is labeled with an open date (V13 showed this…

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 call lights, in the third floor shower room, were functioning properly. This deficient practice has the potential to affect all sixty one residents that reside on the 3rd floor of the facility. Findings include: Facility census, dated 2/23/25, documents 61 residents residing on the third floor. On 2/23/25 at 10:22am, with V25 (Licensed Practical Nurse/LPN), during observation of the third floor shower room, 3 call lights were noted to be inoperable/non-functional. V25 attempted to turn each of the 3 call lights on but was unsuccessful. V25 sated, Let me get V24 (Registered Nurse/RN). He (V24) knows more about these (call lights). On 2/23/25 at 10:28am, with V24 (Registered Nurse/RN), during observation of the third floor shower room, 3 call lights were noted to be inoperable/non-functional. V24 attempted to turn each of the 3 call lights on but was unsuccessful. V24 said, Ididn't know these (call lights) weren't working. I'll call right now to get them fixed. When asked the purpose of assuring 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, facility failed to maintain effective pest control on the third floor. This failure has the potential to affect three (R4, R7, and R30) of three residents observed in a census of 61 residents on the third-floor unit. Findings Include: On 02/23/25 at 11:30 AM, V27, observed a brown creature crawling across the floor and Housekeeper verified that it is a live roach crawling across the floor where R4, R7, and R30 reside. On 2/23/25 at 11:33 am V27(Housekeeper) walked to R4, R7 and R30's room and verified with surveyor multiple dead roaches on glue traps and mouse traps under a wall heater. V27, (housekeeper) stated that she reports any findings of pests or rodents to maintenance and maintenance will take care of it. V27 stated that this is not the first time that she has seen roaches and that she does report any sightings of pests when she sees pests. 02/23/25 at 12:16 PM, surveyor noticed a resident jump up from his chair and step on an insect crawling on 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 observations, interviews, and record review the facility failed to ensure the call light device was within reach to use for staff assistance for two residents (R59, R84) in the sample of 66 residents reviewed for accommodations of needs. Findings include: 1. R59's admission record includes but not limited to cirrhosis of the liver with ascites, encephalopathy, osteoporosis, osteoarthritis, glaucoma, muscle wasting and atrophy of lower extremities, and diabetes. R59's Minimum Data Set (MDS), dated [DATE], documents in part, Brief Interview for Mental Status (BIMS) score is 14 which indicates that R59 is cognitively intact. R59's Functional abilities for toileting hygiene, shower/bath, sit to stand, chair/bed-to- chair transfer is coded as supervision or touching assistance-helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. On 2/23/25 at 10:15 am, observed R59 in room…

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,observation and record review the facility failed to ensure that resident was scheduled for his follow up appointment for hearing for one (R91) of one resident reviewed for hearing and vision in a sample of 60 residents. Findings include: R91's face sheet dated February 24, 2025, shows R91was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, major depressive disorder, psychosis, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and anxiety. R91's MDS (Minimum Data Set) dated February 12, 2025, shows R91 has a score of 11 which means R91 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs. R91's diagnosis includes Bipolar disorder,Major Depressive Disorder,Psychosis,Chronic Obstructive Pulmonary Disease,Anxiety,Benign Prostate hyperplasia. R91's Minimum Data Set, dated [DATE] Brief Interview for Mental Status score is 11 which means that R91's cognition is moderately intact. On 2/23/25 at 11:44 am…

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 that the oxygen tubing was labeled with dates when changed, failed to ensure the oxygen tubing was contained when not in use, failed to contain a Bipap (Bilevel positive airway pressure) mask when not in use, and failed to obtain an order for oxygen per nasal cannula. These failures affected one resident (R43) reviewed in a sample of 66. Findings include: R43 has a diagnosis of peripheral vascular disease, hypertension, diabetes, COPD (Chronic Obstructive Pulmonary Disease), dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia. R43's (1/30/25) Brief Interview for Mental Status (BIMS) score is 15. R43 is cognitively intact. On 2/23/25 at 11:37 am, surveyor observed R43's Bipap mask laying on top of the personal refrigerator uncontained and the nasal cannular laying on the oxygen machine uncontained and not dated. R43 stated that he does use both (nasal cannula and Bipap mask) and has asked staff if his mask should be covered. On 2/25/25 at 12:07 pm observed R43's nasal…

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 personal refrigerator temperature logs for one resident. This failure affected one resident (R43) out of 66 residents in the total sample. Findings include: R43 has a diagnosis which includes but not limited to peripheral vascular disease, hypertension, diabetes, COPD (Chronic Obstructive Pulmonary Disease), dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia. R43's Brief Interview for Mental Status (BIMS) dated 1/30/25 documents that R43 BIMS score is 15. R43 is cognitively intact. On 2/20/25 at 11:37 am, Surveyor observed R43's personal room refrigerator temperature log sheet for February 2025 with missing dates for checking the temperature. From February 1st to February 23rd there was only two days checked (2/5/25 and 2/6/25) on the temperature log. Food items were noted in the refrigerator with a foul odor in the refrigerator. R43 stated that the staff do not check the refrigerator. On 2/25/25 at 12:15 pm, V2 DON (Director of Nursing) stated, I have to check and see who…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to maintain an effective pest control program to ensure the facility is free of pests and rodents. This deficiency has the potential of affecting all 178 residents residing in the facility. Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnosis that include but not limited to: chronic obstructive pulmonary disease, unspecified, cervical disc disorder with myelopathy, unspecified cervical region, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral. R1's MDS (Minimum Data Set) section C-Brief Interview for Mental Status (BIMS) dated [DATE], documents R1's BIMS score as 15/15, indicating R1 has intact cognitive function. On 10/12/2024, at 10:20 AM, R1 was observed laying in bed awake watching television. R1 stated He saw mice in his room a couple of days ago and mice traps were placed around his room. R1 stated this has been going on for a while and he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the Low Air Loss Mattress (LALM) for pressure ulcer prevention is functional for a resident at risk for pressure ulcers. This failure affected one resident, R1, who is at high risk for pressure ulcers, of four residents, reviewed for pressure ulcer prevention interventions. Findings include: On 8/26/24 at 11:10am, during observation of residents on the second floor, R1 was observed on the Low Air Loss Mattress (LALM) that was not functional, without any sheet, with R1's skin directly in contact with the mattress. Again at 11:25am, R1's LALM was still in the same condition without any weight setting. At this time, V3(LPN/Licensed Practical Nurse) was called into R1's room to see the LALM. V3 stated I see there is no air in the mattress, but I don't know how to do it. The setting should be according to the resident's weight. V15(Wound Care Technician later came and stated that she would be right back with the weight of R1. V15…

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 cockroaches. This failure has the potential to affect all 159 residents in the facility. Findings include: On 04/15/2024 at 10:15am opened the door to the second-floor shower room and observed three small cockroaches crawling into the drain located in the middle of the floor in the shower room. On 4/16/2024 at 10:15am entered the lower-level women's bathroom and observed one brown cocroach crawling along the wall where the roll of toilet paper was hanging and eventually crawling into the toilet paper holder. On 4/16/2024 at 10:17am informed V1(Administrator) to send V7(Housekeeping Supervisor) to the lower-level women's bathroom to meet with the surveyor. On 4/16/2024 at 10:55am V7(Housekeeping Supervisor) was informed by the surveyor that one brown cockroach was observed crawling along the wall in the lower-level women's bathroom and then crawled into the toilet paper holder. V7 stated the pest control company comes to the…

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

Based upon observation, interview, and record review the facility failed to ensure that (R138's) call light was functioning properly, failed to ensure that (R55's) noisy heater was repaired, failed to ensure that (R55's) screen was repaired, and failed to provide and/or repair damaged furniture for six of 63 residents (R37, R55, R98, R126, R136, R138) in the sample. Findings include: On 4/14/24 at 10:02am, the (2nd) drawer was noted to be leaning (the hinge on one side was coming off) and the (3rd) drawer was missing from R136's dresser. R136's (2/9/24) BIMS (Brief Interview Mental Status) determined a score of 13 (cognition intact). Surveyor inquired about concerns with the dresser and R136 stated I asked if they (staff) could fix it and they said not yet because they're painting. On 4/14/24 at 10:21am, the wardrobe (left) top drawer was missing in R138's room. The large dresser (1st) and (2nd) drawers were also missing in R138's room. R138's (1/31/24) BIMS determined a score of 6 (severe impairment). Surveyor inquired about the missing drawers R138 stated In the room, everything…

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 provide ADL (Activities of Daily Living) care to five dependent residents (R7, R37, R55, R78, R138) in the sample of 63. Findings include: 1) R138's diagnoses include metabolic encephalopathy. R138's (1/31/24) BIMS (Brief Interview Mental Status) determined a score of 6 (severe impairment). R138's (1/31/24) functional assessment affirms moderate assistance is required for personal hygiene, and supervision or touching assistance are required for dressing. R138's (4/21/23) care plan states resident requires assistance from staff for personal grooming, assist resident with task as needed. Resident has an ADL self-care performance deficit due to impaired cognition, intervention: assist with personal hygiene as needed. On 4/14/24 at 10:21am, R138 was unshaven. R138's toenails were discolored, thick and long. R138's jacket collar was heavily soiled with white flakes and dried debris. R138's pants were also soiled with dried debris. On 4/14/24 at approximately 10:30am, surveyor inquired about the appearance 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 upon observation, interview, and record review the facility failed to implement (R55, R136, R138) fall prevention interventions, and failed to ensure that sufficient nursing staff were provided to meet the individualized needs for six of 52 (3rd floor) dependent residents (R7, R37, R55, R98, R136, R138). These failures have the potential to affect 52 (3rd floor) residents. Findings include: The (4/14/24) census includes 52 (3rd floor) residents. On 4/14/24 at 9:54am, surveyor inquired about the current (3rd floor) staffing. V17 (RN/Registered Nurse) stated I'm working with (V18/CNA-Certified Nursing Assistant) and (V19/CNA) today. Surveyor inquired if only one nurse was assigned to the 3rd floor. V17 responded Yes and usually two CNA's. R136 resides on the 3rd floor. R136's diagnoses include dementia, Parkinson's disease, and history of falling. R136's (2/9/24) functional assessment affirms R136 requires a wheelchair for mobility, supervision or touching assistance is required for walking. On 4/14/24 at 10:02am, R136 was in the bathroom however his wheelchair was near the bed.…

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 two licensed personnel conducted a physical inventory of controlled substances at each change of shift. These failures have the potential to affect nine residents (R45, R86, R130, R201, R202, R203, R204, R205, R206) receiving controlled substances residing on the second floor. The facility also failed to follow physician's order for one resident (R14) during an observation of medicatoin administration. Findings include: 1) On 4/14/24 at 11:27am, surveyor reviewed the (2nd floor) April (year incorrect) Controlled Substance Shift Count Documentation form for R201 and R202, with V27 (Licensed Practical Nurse/LPN). The 4/13/24 second shift has one not two signatures. This observation was pointed out to V27 and V27 stated, (V27) did count with the off going nurse. (V27) don't know why she (off going nurse) didn't sign it. When asked when the sheet should be signed, V27 replied, It should be signed right after the count is done. On 4/14/24…

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 label an opened multi dose vial. This failure has the potential to affect 1 resident (R132) reviewed for medications in the sample of 63 residents.The facility also failed to ensure that the (3rd floor) medication cart was locked while unattended, this failure has the potential to affect 52 (3rd floor) floor residents Findings include: 1) On 4/14/24 at 11:27am, with V27 (Licensed Practical Nurse/LPN), during observation of medication storage, R132's vial of Fluticasone Propionate Nasal spray was observed opened and not labeled with an open date, in the medication cart for rooms 226 to 236. This observation was pointed out to V27 and V27 stated, (V27) do not see a date on here that shows when it was opened. This medication does not need to be labeled with an open date because it does not expire. It does not come with a sticker to label it with an open date like the other medications. When asked if Fluticasone Propionate nasal spray is a…

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

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 6 residents (R45, R103, R204, R207, R208 and R209) who receive blood glucose monitoring tests. Findings include: On [DATE] at 1:00pm, with V28 (Licensed Practical Nurse/LPN), during observation of medication storage, an opened container of the multi blood glucose test strips with no open date labeled was observed in the medication cart for used for R45, R103, R204, R207, R208 and R209. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. This observation was pointed out to V28 and V28 stated, The container should be labeled when opened because the strips expire after 28 days. If you use expired strips, it may give the wrong readings. We cannot use these strips since they are opened without an open date on it, so (V28) am…

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 provide a mobility device for one of 63 residents (R55) in the sample reviewed for range of motion/mobility. Findings include: R55's diagnoses include paraplegia. R55's (3/28/24) functional assessment includes lower extremity impairment on both sides. No impairment of upper extremities. R55's (5/26/21) care plan states resident is wheelchair bound due to history of multiple gunshot wounds resulting in paraplegia. Intervention: (4/25/23) Resident uses trapeze for reposition. R55's (3/28/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 4/14/24 at 11:11am, R55 was observed lying in bed. Surveyor inquired if staff provide active and/or passive range of motion. R55 stated They used to but stopped, it's been probably about a year ago. Surveyor inquired if R55 could move his legs. R55 responded No, not really. I was shot in the head, face and spine. Surveyor inquired if R55 can reposition himself in bed. R55 replied I need a trapeze. I had one a long time ago, but now I…

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 policy procedures and failed to take prevantative safety measures to ensure a resident's bed reduced the risk of a fall or injury for two of 63 residents (R55, R138) in the sample. Findings include: 1) R138's diagnoses include metabolic encephalopathy and ataxic gait. R138's (1/31/24) BIMS determined a score of 6 (severe impairment). R138's (1/31/24) functional assessment states resident walks independent. R138's (8/15/23) care plan states resident is at risk for falls due to antipsychotic use, impaired cognition, and unsteady gait. On 4/14/24 at 10:21am, R138's bed was noted to be angled and away from the wall. R138 subsequently sat on the bed, and it moved. On 4/14/24 at 10:28am, surveyor inquired if R138's bed was locked V18 (Certified Nursing Assistant) pushed R138's bed (which moved) stated Nope then locked the bed. 2) R55's diagnoses include paraplegia. R55's (3/28/24) BIMS determined a score of 15 (cognition intact). R55's (3/28/24) functional assessment affirms resident is dependent on staff…

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

Based upon observation, interview, and record review the facility failed to follow physician orders, implement care plan interventions, ensure staff are aware of policy procedures, follow policy procedures, and failed to provide catheter care for one of 63 residents (R98) in the sample reviewed for indwelling urinary catheters. Findings include: R98's diagnoses include neuromuscular bladder dysfunction and paraplegia. R98's (10/31/23) Physician Orders include indwelling urinary catheter care daily and as needed. R98's (2/20/24) care plan states resident requires the use of an indwelling catheter due to neurogenic bladder. Interventions: provide catheter care, monitor output every shift. R98's (3/14/24) functional assessment affirms substantial/maximal assistance is required for toileting. R98's (3/14/24) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 4/14/24 at 10:46am, R98's indwelling urinary catheter bag contained 1900cc (cubic centimeters) in the bag. Surveyor inquired who empties the catheter bag. R98 stated The CNA (Certified Nursing…

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

Based on observations, interviews, and record review the facility failed to ensure nebulizer masks were labeled and contained, failed to ensure the nebulizer tubing was off the floor, failed to ensure nasal cannula was dated, and failed to ensure a resident's nebulizer machine and CPAP (Continuous positive airway pressure) Mask were not on roommate's dresser. These failures affected two (R78 and R136) residents reviewed for respiratory care in the total sample of 63 residents. Findings include: 1) On 04/14/2024 at 11:18am, R78's nasal cannula was connected to a large tank of oxygen via a humidifier bottle. This surveyor requested V25 (Resident Care Coordinator/Registered Nurse (RN)) to check R78's nasal cannula and humidifier bottle for labels. V25 checked the nasal cannula tubing and humidifier and stated there are no labels. These are not dated. On 04/14/2024 at 11:20am, R78's nebulizer mask and tubing were not contained. This surveyor requested V25 to check the nebulizer mask and tubing for labels. V25 checked the nebulizer mask and tubing and stated there are no labels. These…

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 follow policy procedures and failed to maintain a medication error rate below 5%. There were two medication errors out of 26 opportunities, resulting in a 7.69% medication error rate. Two of 13 residents (R14, R100) in the medication administration sample were affected. Findings include: R100's (10/21/22) POS (Physician Order Sheets) include EC (Enteric Coated) Aspirin (Delayed Release) 81 MG (milligrams) tablet daily. On 4/15/24 at 9:27am, V31 (LPN/Licensed Practical Nurse) dispensed R100's (9am) medications into a medication cup and affirmed that she was prepared to administer them. However, the Aspirin 81mg dispensed was not enteric coated. Surveyor inquired about the dispensed Aspirin. V31 reviewed the Aspirin container and affirmed it was not enteric coated. V31 subsequently removed the EC Aspirin 81mg from the medication cart and stated, You made me nervous; this is the enteric coated Aspirin. R14's (2/24/23) POS includes Sodium Chloride Oral Tablet 1 gm (gram) give 2 tablet by mouth three times a day.…

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 3 of 3 garbage dumpster's had lids to properly contain disposable waste. Findings Include: On 12/21/23 at 09:00 AM, V27 (Maintenance Director/Building Manager) and the surveyor conducted an exterior tour of the facility. There was a gap observed to the lower bracket of the southeast delivery door number 6. The extension door was observed to have rust to the lower right corner with a visible gap. V27 stated, This is the delivery door where the garbage is stored in the trash roller bins. Three- large, uncovered garbage bins with no lids, full of multiple filled with bags of garbage, were observed in the area near door number 6 next to the wall. On 12/21/23 at 09:54 AM, the surveyor entered the garbage room with V32 (Housekeeping Supervisor). There were three uncovered garbage dumpster's located in the room R32 referred to as the garbage room and V32 acknowledged there were three uncovered garbage dumpster's. V32 stated, The dumpster…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the pest control recommendations to help prevent pest from gaining access to the facilities interior. This failure has the potential to affect 159 residents residing in the facility. Findings Include: On 12/19/23 at 12:25 PM, V29 (Resident Assistant) stated, Residents have complained about seeing mice, but I have not seen any. On 12/19/23 at 12:29 PM, V7 (Licensed Practical Nurse) stated, People say they see mice, but I have not seen any. On 12/19/23 at 12:54 PM, V31 (Housekeeping) stated, I have seen mice in rooms. If the mouse is dead on a trap, we clean up and get the trap out of the room. I have only seen one dead mouse; it was on the sticky trap. On 12/19/21 at 1:02 PM, V18 (Certified Nurse Assistant) stated, Residents will tell me what happened on the 11 pm - 7 am shift as far as seeing mice. We will notify Maintenance and put it in the logbook. On 12/19/23 at 1:17 PM, R8 stated, There are mice here. I saw a rat and a mouse…

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 of four residents (R1) remains free from abuse/neglect, and failed to appropriately follow the abuse/ neglect policy and the elopement policy and procedure. As a result, R1 eloped from the facility on 08/07/23 during the night shift (11pm to 7am shift) and facility was unaware that she had eloped for approximately 11 hours. These failures had the potential to affect other residents residing on the 1st floor. Findings include: R1's medical record admission record documentated R1 was admitted to the facility on [DATE], with diagnosis including but not limited to non-ST elevation (NSTEMI) Myocardial Infarction, History of falling, Unspecified Dementia moderate with other behavioral disturbances, Restlessness and agitation, other Schizophrenia, Cough Variant Asthma and Essential (Primary) Hypertension. R1 is an [AGE] year-old female, who went missing from the facility on 8/07/23,, and the facility was unaware. According to the Emergency Medical…

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 follow professional standards by documenting medication as given when the resident was not in the facility. This affected one resident (R1) reviewed for professional standards. Findings include: R1's admission record showed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: non-ST elevation (NSTEMI) Myocardial Infarction, History of falling, Unspecified Dementia moderate with other behavioral disturbances, Restlessness and agitation, other Schizophrenia, Cough Variant Asthma, and Essential (Primary) Hypertension. R1 is an [AGE] year-old female that went missing from the facility on 08/07/23 night, and the facility was unaware she was missing until 08/08/23 morning. According to the EMS (Emergency Medical Services) report, R1 was taken to a local hospital on [DATE] at 9:55pm (21:55). R1's care plan for mental illness, initiated 02/28/23 and revised 05/08/2023, under focus documented R1 has a diagnosis and history 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 observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 157 residents residing in the facility. Findings include: On 3/05/23 V1 (Administrator) present facility's census of 157 residents. On 3/05/2023 at 8:55 am, upon entrance to the facility, the facility's daily staff posting was observed posted at the receptionist window, dated 3/03/23. On 3/05/23 at 3:05 pm, V18 (Receptionist) stated, I do not post that (referring to the daily staff posting). When V18 was asked who is responsible for posting the facility's daily staffing at the receptionist area, V18 stated, (V16, Assistant Administrator 1). On 3/05/23 at 3:09 pm, V16 (Assistant Administrator 1) stated, No I do not post the facility's daily staffing. Surveyor, V18, and V16 acknowledged the facility's daily staff posting, dated for 3/03/23. V18 then stated, No not him (referring to V16); the other administrator (V17, Assistant Administrator 2) is responsible. On 3/05/23 at 3:11 pm, V17 (Assistant Administrator 2) stated, No, I am not…

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

Based on observation, interview, and record review, the facility failed to ensure the outside dumpsters were not overflowing with trash, and the dumpsters' lids were closed; failed to ensure the dumpster area was clean; and failed to ensure the interior and exterior receiving doors had no gaps in an effort to maintain a sanitary environment and to prevent pest and rodent migration in the facility. These failures have the potential to affect all 157 residents in the facility. Findings include: The (03/05/2023) facility census was 157. On 03/06/23 at 8:51am, surveyor parked in back parking lot near the overflowing garbage receptacles with lids open. Surveyor observed a small dark brown/black raccoon with white and black striped tail moving on ground away from garbage receptacles. On 3/06/2023 at 9:27am, 2 big dumpsters were overflowing with trash, and the dumpster lids were open. 3 small carts were overflowing with trash and were not covered. There were bags of trash on the ground surrounding the dumpsters. These observations were pointed out to V10 (Food Service Manager). V10 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 stored food items were labeled with the date the food items were made or opened, and failed to ensure food items were stored 6 inches off the floor to prevent foodborne illness. These failures have the potential to affect all 147 residents receiving oral nourishment in the facility. Findings include: The (03/05/2023) facility census was 157. The (printed: 03/07/2023) Diet Type Report documented there were 10 residents on NPO (nothing by Mouth). On 3/05/2023 at 9:19am, there was an opened bag of 5 pound grit, not labeled with open date. V5 (Dietary Aide) checked the container for label and stated, There is no open date. This surveyor inquired about the policy with labeling of opened food items. V5 stated, We are supposed to label with the date it was opened so we know when it was opened; to know if the food is stale or how fresh it is. On 03/05/2023 at 9:29am, inside the walk in freezer, there was box of Tater Gems and 2 boxes of Salisbury Steak on the floor. V5 stated, They probably fell. On 03/05/2023…

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 performs appropriate hand hygiene during dining in an effort to prevent the spread of infectious microorganisms including Covid-19. This failure has the potential to affect 51 residents residing on the 3rd floor. Findings include: The (printed 03/08/2023) Resident listing report provided by V1 (Administrator) as an email attachment when this surveyor requested for list of residents who eat in 3rd floor dining room, documented there were 51 residents who eat in the 3rd floor dining room. On 3/05/2023 at 12:17pm, V9 (Behavior Counselor) was observed assigned in placing meal ticket, table napkin, utensil, beverage, bread and dessert to residents' meal tray. On 3/05/2023 at 12:20pm, V9 touched his (V9) mask and proceeded with preparing meal tray for residents without performing hand hygiene. On 3/05/2023 at 12:31pm, V9 touched his (V9) mask and proceeded with preparing meal trays for residents without performing hand hygiene. On 3/05/2023 at 12:45pm, this surveyor pointed out these observations with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain fall prevention interventions care planned for one resident (R74) in the sample of 50 reviewed for fall prevention. Findings include: R74's admission Record documents, in part, diagnoses of epilepsy, narcolepsy, metabolic encephalopathy, type 2 diabetes mellitus, essential hypertension and schizoaffective disorder. R74's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 4, indicating R74 has severe cognitive impairment. R74's Care Plan, with an initiated date of 11/22/14 and revision date of 7/20/21, documents, in part, a focus of (R74) is at risk for falls secondary to: Use of psychotropic medication, cognitive deficits, poor balance, poor safety awareness, non-compliance with safety measures. Dx (Diagnoses) of narcolepsy, DM (Diabetes Mellitus), use of antihypertensives, HTN (hypertension), non-ambulatory, incontinence and seizure disorder with interventions of Floor…

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

Based on observation, interview, and record review, the facility failed to provide incontinent care to one dependent resident (R95) in a sample size of 50 residents. Findings include: R95's admission Record documents, in part, R95's diagnoses include asthma, acute respiratory failure, need for assistance with personal care, anoxic brain damage, metabolic encephalopathy, and traumatic brain injury. R95's (2/2/23) Brief Interview of Mental Status (BIMS) score is 14. R95 is cognitively intact. R95's functional status for toilet use is coded total dependence with two-person physical assist. R95's Care plan, dated 11/21/22, documents, in part, (R95) experiences bladder incontinence and bowel due to anoxic brain damage. Goal: (R95) will be socially continent: clean, dry, and odor free. Interventions: Change clothing PRN (as needed) after incontinent episodes. On 3/5/23 at 11:10 am, R95 was in bed with a strong odor of urine smell in the room. V40 (Family Member) was at bedside and stated staff was asked to come change R95. V40 stated, Staff still has not come to change (R95), and I have…

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

Based on observation, interview, and record review, the facility failed to maintain an accurate count of a controlled substance, which affected one resident (R134) in the sample of 50, reviewed for medication labeling and storage. Findings include: On 3/6/23 at 11:42 am, V20 (Licensed Practical Nurse, LPN) was observed with the medication cart keys on V20's person, and opened the Team 1 medication cart on the 1st floor. V20 then unlocked the controlled substance box within the medication cart, and this surveyor and V20 performed a controlled substance count together. This surveyor and V20 observed R134's dispensing card for Pregabalin 100 milligram (mg) capsules with a count of 32 capsules. However, R134's Controlled Drug Receipt/Record/Disposition Form (pink in color) for Pregabalin 100 mg capsules documents, in part, an amount left of 33. When seeing the discrepancy with R134's medication count against the controlled drug record, V20 stated, That's me. V20 stated R134 gets the Pregabalin 100 mg capsule, which is scheduled at 9:00 am, 1:00 pm, and 5:00 pm, and V20 administered 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.