Ryze On The Avenue

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to notify a representative for one (R7) of three residents reviewed of change in condition in a total sample of 14 residents. Findings include: R7 is a [AGE] year-old individual admitted to the facility on [DATE]. R7's current face sheet documents R7's medical conditions to include but not limited to: benign neoplasm of right breast, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, other specified abnormal uterine and vaginal bleeding, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R7's MDS (Minimum Data Set) section C (Cognitive Patterns) dated 1/27/2025, documents R7's Brief Interview for Mental Status (BIMS) as 14/15 indicating R7 has intact cognition abilities. Section GG - Functional Abilities documents R7' abilities as: Eating/ Oral Hygiene-Supervision or touching assistance, Toileting…

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 resident's call light device was functioning properly for resident use. This failure affected one resident (R10) out of three residents reviewed for call lights. Findings include: On 2/11/25 at 11:54 AM, R10 was observed wheeling himself out of his room, noted with bilateral braces to lower legs; lower legs on wheelchair leg rests. R10 alert and responsive, agreed to speak to surveyor. R10 states that he is heading to therapy. R10 states that he is doing better since he began doing therapy. R10 states that when he first came in, he could hardly do anything. This surveyor questioned R10 if his call light is functioning. R10 reports that his call light has not worked and states they told him to use his roommate's call light. R10 states that his call light has never worked. R10 states that maintenance came up twice. One maintenance staff came one time and never came back. R10 states another maintenance worker came another time. 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.

Based on observation, interview, and record review the facility failed to follow generally accepted stand of professional practice when administering IV (Intravenous) fluids rate as ordered by physician for 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed in the sample for IV therapy. This failure affected R8, R9, R10, R11, and R12 who were receiving IV fluid were observed not infusing at the right drip rate per minute to infuse 1000ml/hour as ordered. This has potential to affect all 73 residents listed as getting IV therapy. Findings include: On 1/22/25 at 10:40am, R8 noted in the room with an IV 1000ML bag infusing rapidly with flow meter left at open rate. No label to show the start time and no stop time. Highest calibration noted on the flow meter was 250ml/hour which will equal to 4 hours of infusion. V3 (Registered Nurse/RN) in charge of R8 stated that I (V3) don't do anything with the IV, there is an outside company that takes care of that. R8 stated that I (R8) would like to go in the bathroom, and I (R8) don't know what to do now should I carry it to the bathroom…

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

Based on observation, interview, and record review the facility failed to ensure that the medication cart was locked when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the 73- residents residing on the 4th floor. Findings include: On 01/27/25 at 1:30pm, on the 4th floor medication cart was noted in the hallway unlocked and not in visual view of the nurse. R14 was observed standing by the cart while V14 (Licensed Practical Nurse/LPN) was in a patient room. The surveyor asked R14 where the nurse is, R14 stated V14 went into that room and was waiting here for V14 to come out. On 1/27/25 at 1:33pm, when this observation was shown to V14 and was asked about the facility policy on medication/medication cart storage, V14 stated I should have locked the cart when I went into the patient's room for safety. On 1/27/25 at 2:18pm, when the surveyor made V16 (Assistant Director of Nurses/ADON) aware of the observation and was asked about the facility policy on medication cart storage and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that four of six residents (R2, R3, R5 and R6) were free from physical abuse. This failure affected R2, R3, R5 and R6 who had verbal altercation that resulted in physically hitting one another. Findings include: 1.) R2's medical record showed documentation that R2 was admitted on [DATE] with diagnosis list that includes but not limited to Peripheral vascular disease, chronic obstructive pulmonary disease, Acquired absence of right leg, necrotizing fasciitis, complete traumatic amputation, and type2 diabetes mellitus without complications. R2's MDS (Minimum Data Set) dated 12/23/2024 showed that R2 had a BIMS scored of 15 indicating no cognitive deficit. R2's plan of care for potential abuse last revised date 01/02/2025 showed the goal that R2 will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse and neglect). On 01/27/25 at 10:20am, R2 was observed in the bed, when the surveyor asked about the incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide individualized and person-centered care plan related to pressure ulcer and hospice care per their policies and hospice agreement for 1 out of 3 residents (R1) reviewed for plan of care. These failures affected 1 resident (R1) who acquired pressure ulcer and receiving hospice care in the facility. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 medical diagnosis includes dementia, traumatic brain injury and subdural hemorrhage. R1 has impaired cognition with brief interview of mental status result of 0. On 12/11/2024, at 10:27 AM, V3 (Wound Coordinator/Licensed Practical Nurse) stated that R1 acquired pressure ulcer on the sacrum in the facility. It first started as DTI or deep tissue injury and currently staged as 3 or stage 3 pressure injury per wound doctor. Sacral pressure injury was first identified on 11/24/2024 as DTI. V3 reviewed full care plan of R1, and was asked the reason not to include identified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide comfort measures and document that abnormal vital signs were addressed for a hospice resident. The facility failed to notify a change in the resident's physical status (abnormal vital signs) to Hospice Services per the hospice agreement and facility's hospice policy. These failures apply to 1 out of 3 residents (R1) reviewed for improper nursing care and affect 1 resident (R1) receiving hospice care in the facility. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 medical diagnosis includes dementia, traumatic brain injury and subdural hemorrhage. R1 has impaired cognition with brief interview of mental status result of 0. R1 was admitted to hospice on 07/17/2024. On 12/10/2024 at 10:16 AM, V24 (Former Certified Nursing Assistant/CNA) stated that when she worked on 10/18/2024, she took R1's vital signs and the heart rate was 147 beats per minute. R1's blood pressure was also very low. During that time R1 did not feel…

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 physician order for weekly skin assessment, monitoring, and documentation. The facility failed to follow plan of care intervention for daily skin check, failed to document daily monitoring of pressure ulcer prevention according to their policy. These failures apply to 1 out of 3 residents (R1) reviewed for skin. These failures affected 1 resident (R1) who acquired pressure ulcer on the sacral in the facility. Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1's medical diagnosis includes dementia, traumatic brain injury and subdural hemorrhage. R1 has impaired cognition with brief interview of mental status result of 0. Per admission evaluation dated 06/12/2024, R1 was admitted without pressure ulcer/injuries. Facility skin assessment dated [DATE], R1 acquired pressure ulcer/injury in the facility located on her sacrum. Per the same assessment of R1, it was staged as DTI or deep tissue injury measures (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records review, the facility failed to provide a working call light to one (R9) of four residents reviewed in a sample of six. Findings include: R9 current face sheet documents R9 is a [AGE] year-old individual admitted to the facility on [DATE]. R9's medical diagnosis includes but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, unspecified, personal history of traumatic brain injury. R9's Brief Interview for Mental Status (BIMS) dated 12/05/2024 documents BIMS of 11/15, indicating moderate cognitive impairment, and Activities of Daily Living (ADL) document R9 needs assistance for eating and oral hygiene, and requires partial/moderate assistance with toileting/shower/ bath self, upper/lower body dressing, and with personal hygiene. R9 uses a manual wheelchair. R9's nursing progress notes dated 11/29/2024 12:30 documents R9 is alert and oriented to (Person, place, time situation). Daily Skilled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their abuse prevention and residents' rights policies by failing to affirm the right of the resident to be free from abuse and to have a safe environment. This deficient practice affected one resident (R2) with severe cognitive impairment involved in an allegation of physical abuse by another resident (R1) out of three residents reviewed for resident-to-resident abuse. On [DATE], R1 placed a pillow and a blanket over R2's face. Findings Include: R1's clinical records show an admission date of [DATE] with included diagnoses not limited to Bipolar Disorder, Depression, and anxiety disorder. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively impaired and required partial/moderate assistance with activities of daily living (ADL) except for eating and oral hygiene required supervision assistance. R1's behavioral care plan date initiated on [DATE] shows R1 may voice allegations of mistreatment or exploitation by caregivers related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly assess, monitor, and document to prevent further development of pressure ulcers for a resident (R3) identified as high risk. The facility failed to document dressing changes on the treatment administration record (TAR). The facility failed to revise individualized care plan to reflect status of multiple facility acquired pressure ulcers, approaches, and goals for care. The facility also failed to properly assess and complete wound documentation timely for facility acquired pressure ulcers. These failures apply to 1 (R3) out of 3 residents reviewed for pressure ulcers. The findings include: R3's admission record showed admission date on 5/16/2023 with diagnoses not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, Unspecified lack of coordination, Weakness, Unspecified glaucoma, Benign prostatic hyperplasia, Encephalopathy, Cerebral infarction, Essential (primary)…

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

Based on interviews and record reviews, the facility failed to protect the resident's (R3) right to be free from abuse for one of five residents reviewed for abuse. This resulted in R3 suffering psychosocial harm from verbal and emotional abuse by a staff member as evidence by verbalizing hurt feelings and feeling inferior. Findings include: R3's admission Record and Order Summary Report document in part diagnoses of osteoarthritis, muscle weakness, lack of coordination, and history of falling. R3's Order Summary Report documents in part an order for no weight bearing to both legs (active since 4/22/2024) R3's Quarterly Minimum Data Set from 10/02/2024 documents in part that R3 is cognitively intact. R3's Potential for Abuse and Neglect assessment (effective 6/05/2024 12:31 PM) documents in part a history of emotional abuse. R3's comprehensive care plan documents in part a focus of [R3] may be at risk for potential abuse [related to] physical and/or communication challenge as evidence (initiated 3/31/2022). The goal was [R3] will be free from harm through next review (initiated…

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

Based on interviews and record reviews, the facility failed to report an allegation of abuse for R3 within two hours to the state surveying agency for one out of one resident reviewed for abuse reporting. Findings include: On 11/06/2024 at 1:36 PM, R3 was alert and oriented to person, place, and date. R3 stated It started with patient care on me. [V5 Certified Nursing Assistant/CNA] wasn't doing what [V5] was supposed to do the way I asked [V5] to do it and that's what set it off. R3 stated was sitting in the motorized wheelchair that morning. R3 asked V5 for assistant to go to the bathroom because R3 felt like moving bowels. R3 stated [V5] snapped at me. R3 stated V5 used profanities towards R3. Surveyor asked if R3 can recall the statements. R3 stated I just don't want to think about it. It kind of hurt my feelings. It's something I don't want nobody to go through. R3 stated The words and paused and then said, it kind of shocked me in a way. R3 stated I felt beneath me. [V5] just down lowed me as a woman and as a person and a human being. It's just that I didn't like that feeling.…

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 affirm the right of the resident to be free from verbal abuse. This deficient practice affected 1 (R2) of 8 residents reviewed for abuse. Findings include: Facility's Reported Incident (dated 02/08/2024) states in part: based on the investigation conducted, statements received from residents involved, as well as the employees, both residents were alert and oriented. The residents engaged in a mutual disagreement. No injuries resulted and both residents are safe and comfortable. It may be concluded that there was no intention of either of the residents to inflict any harm on each other. As a result, the facility is unable to substantiate any act of abuse. Staff (V10 Previous Administrator) spoke with R3, and he said, I was going to use the bathroom when my roommate cussed me out and told me to go sit down. We exchanged words, but I didn't hit him with my walker. A staff member heard us and came to separate us. The staff member asked me to leave the 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 observation, interview and record review, the facility failed to administer scheduled pain medication on time for R1, a hospice resident with prostate and bone cancer, in a sample of 5 residents reviewed for pain management. Findings include: R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Fusion of spine, malignant neoplasm of prostate, secondary malignant neoplasm of bone, elevated prostate specific antigen, muscle weakness, (generalized), benign prostatic hyperplasia, essential (primary) hypertension, anemia. MDS (Minimum Data Set) section C (dated Sep 25, 2024) documents that R1 has a BIMS (Brief Interview for Mental Status) score of 14, indicating that R1's cognition is intact. Care plan (dated 09/25/2024) documents that R1 is on palliative care program related to life limiting illness and a desire not to have aggressive life sustaining measure (i.e. Hospitalizations, hospital visits, laboratory draws, and x-rays). Palliative care 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 on observation, interview and record review, the facility failed to ensure the 4 dryers have no accumulation of lint to provide a safe environment to the residents. These failures have the potential to affect all residents in the facility. Findings include: On 09/22/2024 at 9:50am, V17 (Laundry Personnel) pointed to this surveyor the 4 dryers inside the laundry room and stated the dryers are labeled 1, 2, 3, and 4 from left to right. V17 stated the expectation is to clean the lint trap every 2 hours to prevent fire. We have a log when the lint trap is cleaned. V17 showed this surveyor the lint trap log and noted the last entry on the log documented 7. V17 stated the other staff (V50 Laundry Personnel) cleaned the lint trap at 7am. This surveyor requested V17 to open the lint traps of the 4 dryers. All the lint traps have accumulations of lint. V17 stated V50 did not clean the lint traps and it may cause fire. V17 said V17 know that for a fact. On 09/23/2024 at 12:39pm, V2 (Director of Nursing) stated (V2) expect the lint trap to be cleaned as scheduled and as needed to prevent…

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 call lights were within reach for 3 residents (R15, R72 and R120) and failed to ensure linen was provided for one resident (R124). This failure had the potential to affect 4 residents out of a sample of 65 residents reviewed for reasonable accommodation of needs. Findings include: 1.) On 9/22/24 at 10:58am, this surveyor observed R124 lying in bed, on his left side, on a bare mattress with no linen on the mattress or a blanket. This surveyor inquired about R124 having no linen for the mattress and no blanket. R124 replied, They (staff) said they don't have any. This surveyor inquired to R124 about R124's preference for linen and a blanket. R124 replied, Of course I (R124) want sheets on my mattress. My skin sticks to this plastic mattress. It's annoying. Or at least a blanket. It can get a little cold sometimes. R124's Face sheet, documents, in part, medical diagnosis including but not limited to type 2 diabetes mellitus, schizophrenia, major depressive disorder and unspecified abnormalities 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 ensure Pre-admission Screening and Resident Reviews (PASRRs) were completed prior to resident admission. The facility also failed to ensure properly qualified staff completed Level I Pre-admission Screening and Resident Reviews (PASARR)This failure affects 4 (R38, R75, R110, R124) residents in a sample of 65. Findings include: 1.) Record review of R75's admission record documents in part that R75 was admitted on [DATE]. Record review of R75's PASRR Level I Screen indicates that V31 (Admissions Director) completed the level I PASSR screening for R75 on 9/23/24. 2.) Record review of R110's admission record documents in part that R110 was admitted on [DATE]. Record review of R110's PASRR Level I Screen indicates that V31 (Admissions Director) completed the level I PASSR screening for R110 on 9/23/24. 3.) Record review of R38's admission record documents in part that R38 was admitted on [DATE]. Record review of R38's PASRR Level I Screen indicates that V31…

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 conduct care plan conferences to include the resident/responsible party in development of their plan of care. This failure affects 4 (R61, R75, R76, and R110) residents in a sample of 65. Findings include: 1.)R75's admission record documents in part that R75 was admitted on [DATE] and that R75 has been diagnosed with the following diagnoses including but not limited to, hemiplegia, heart failure, Alzheimer's disease, and osteoarthritis. R75's Minimum Data Set (MDS) dated [DATE], documents in part a brief interview of mental status summary score of 9, indicating resident is cognitively impaired. On 9/22/24 at 11:32 AM, R75 stated that R75 has never been invited to participate in a care conference or in the development of R75's plan of care. R75 stated that R75 has been here a long time and would have wanted to be invited to participate in the development of R75's plan of care. 2.)R110's admission record documents in part that R110 was admitted on [DATE]…

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 safe environment with laundry chute left unlocked and accessible to residents on the 3rd floor dementia unit. The facility also failed to ensure one resident (R48) has no access to an item that could potentially be used as a weapon against staff or other residents. These failures affected one resident (R48) and have the potential to affect 67 residents on the 3rd floor and 66 residents on the 4th floor. Findings include: 1.) On 09/23/24 at 09:55am observed soiled utility room with no lock and linen chute in soiled utility with no lock. Multiple residents ambulating freely throughout halls. On 09/23/24 at 10:23am V30 (Licensed Practical Nurse) stated, I'm not sure why the doors to the dirty linen room doesn't have a lock on it. Working on the dementia floor there are a lot of things that create a risk. The laundry chute could pose a risk for the residents. On 09/24/24 at 2:27pm V2 (Director of Nursing) stated, 3rd floor is the dementia floor. The dementia residents are confused. They wander throughout…

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 respiratory equipment (nasal cannulas and humidifier bottles). The facility also failed to ensure there was a physician's order for oxygen therapy. This failure affected 4 residents (R72, R100, R209, R276) who receive oxygen therapy. Findings include: 1.) R100 has a diagnosis of but not limited to Chronic Obstructive Pulmonary Disease, Shortness of Breath, and Dependence on Supplemental Oxygen. R100 has a Brief Interview of Mental Status score of 09. Surveyor reviewed R100's Order Summary Report with active orders as of 9/24/2024 that does not document an order for oxygen. R100's care plan focus respiratory dated 9/24/2024 documents, in part, administer medications/treatments as ordered, administer oxygen as ordered and monitor oxygen saturation. On 9/22/2024 at 12:03pm surveyor observed R100's oxygen tubing and humidifier bottle that was not dated. 2.) R209 has a diagnosis of but not limited to Acute Respiratory Failure, Unspecified Whether with Hypoxia Or Hypercapnia, Dysphagia,…

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, record review, the facility failed to ensure the personal refrigerator temperature log had no missing temperatures, failed to ensure a thermometer is available inside a personal refrigerator and failed to ensure the personal refrigerator has no expired food items. These failures affected 6 (R1, R11, R48, R92, R120, and R202) residents reviewed for personal food in the total sample of 65 residents. Findings include: 1.) On 09/22/2024 at 10:53 am, there was a small refrigerator inside R48's room. There were missing temperatures on the Temperature log. On 09/22/2024 at 11:06 am, this surveyor requested V11 (Licensed Practice Nurse/LPN) to check the food items inside R48's refrigerator. V11 opened the refrigerator, there were milk cartons inside the refrigerator. V11 checked the expiration dates of the 2 cartons of 2% milk, V11 stated the expiration date in on 08/23/24. V11 checked the expiration date of 1 carton of whole milk, V11 stated 08/23/24. V11 checked R48's September 2024 personal refrigerator temperature log. V11 stated there are no temps from…

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

Based on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer medications which affected one resident (R155) when reviewed for self-administration of medications in the total sample of 65 residents. Findings include: R155 has a diagnosis of but not limited to Multiple Subsegmental Thrombotic Pulmonary Emboli, Type 2 Diabetes Mellitus with other Circulatory Complications, and Asthma. R155 has a Brief Interview of Mental Status score of 15. On 9/22/2024 at 10:45am surveyor observed a red inhaler on R155's over-the-bed table. R155 said, Yes, I do have asthma, but I really don't use that inhaler. On 9/22/2024 at 11:32am via email V2 (Director of Nursing/DON) said Leaving an inhaler at the bedside of a resident who does not have a medical order or has not received proper education on its use can lead to several potential harms and risks. The resident may attempt to use the inhaler without knowing the correct technique. Inhalers require specific coordination between inhaling and pressing the canister, which, if done…

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 document the code status for one resident (R213). This failure affected one resident (R213) in the sample size of 65. Findings include: R213 has a diagnosis of but not limited to Metabolic Encephalopathy, Sepsis, Hypocalcemia and Acidosis. On [DATE] at 12:36pm surveyor reviewed R213's profile screen and there was no code status listed and in the orders section there were no order for Advance Directive (code status) in electronic medical record. R213's Orders Summary Report with Active Orders As of [DATE] documents, in part, an order for Advance Directive Code Status dated [DATE]. R213's Practitioner Order For Life-Sustaining Treatment (POLST) Form documents, in part, Attempt Resuscitation/CPR and has a date of [DATE]. On [DATE] at 10:27am V34 (Registered Nurse) stated a resident's code status should appear on the face sheet and on the profile screen in the electronic medical record. On [DATE] at 2:17pm V2 (Director of Nursing) stated 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.

Based on observation, interview, and record review the facility failed to consistently ensure that one resident (R72) was not confined to his room as evidenced by observations of one resident without documented interventions and R72 verbalizing not getting out of his room. This failure resulted in R72 stating R72 feels like R72 is in a prison and is getting worse. This failure affected one resident (R72) reviewed for involuntary seclusion in a sample of 65 residents. Findings include: On 9/22/24 at 11:04am, R72 was observed in his room, lying on his back in bed, with a nasal cannula in his nose at 2 liters of oxygen. R72 stated, I have been here awhile. It wouldn't be too bad here if they (staff) would help me get out of bed and out of this room. If I could do it myself I would, but I can't. I feel like I'm in prison. This is not a way to live. I'm not getting better here. I'm getting worse. My a hurts all day. I can't get off this oxygen cause all I do is lay in bed. The only person I talk to is my wife when she visits me. You see this curtain (R72 pointed to the privacy curtain…

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 a physician's order for infectious disease consult to treat a resident's diagnosis of hepatitis C. This failure affects 1 resident (R110) in the sample of 65. Findings include: R110's admission Record documents in part a diagnosis of hepatitis C (3/23/2020). R110's Minimum Data Set, dated [DATE], documents in part a brief interview of mental status (BIMS) summary score of 3, indicating R110 is cognitively impaired. R110's physician orders document in part an active order for Infectious disease consult for Hep (hepatitis) C at (location), dated 6/15/2020. R110's care plan dated 3/24/2020 identifies that R110 has been diagnosed with hepatitis C. R110's care plan does not indicate if R110 has received treatment or follow up by an infectious disease provider. On 9/22/24 at 11:49 AM, R110 stated that R110 didn't know that R110 was diagnosed with hepatitis. R110 could not remember if R110 ever received treatment for hepatitis C. On 9/22/24 at 1:32 PM,…

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 reviewed the facility failed to assure that a resident (R29) with a pressure ulcer received necessary treatment and services to promote healing. This failure affected 1 resident (R29) out of 65 residents reviewed for wound care. Findings include: On 09/22/24 R29 was observed alert and oriented in R29's room sitting in R29's motorized chair. R29 stated that R29 has a wound on R29's buttocks area that developed a few weeks ago. R29 stated that when R29 reported pain to R29's buttocks wound to R29's nurse a few weeks ago R29's nurse placed a bandage to R29's buttocks area. When R29 asked regarding the last time R29's buttocks wound dressing was changed, R29 stated that R29 did not know. On 09/24/24 at 9:09 am, Surveyor requested V5 (Licensed Practical Nurse/Wound Care Nurse) and V32 (LPN/Wound Care Nurse) to perform a skin check and dressing change to R29's buttocks wound. V5 stated, She (R29) does not have a wound on her (R29) buttocks. Upon V5's skin assessment of R29, the surveyor, V5 and V32 observed a piece of undated tape to R29's 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.

Based on observation, interview, and record review the facility failed to ensure a resident (R129) indwelling catheter bag was changed. This failure affected one resident (R129) in the sample of 65 residents. Findings include: R129's face sheet shows that R129's has diagnosis which include but not limited to neuromuscular dysfunction of bladder and paraplegic. R129's Brief Interview for Mental Status (BIMS) dated 06/28/24 shows that R129 has a BIMS of 15 which indicates that R129 is cognitively intact. On 09/22/24 at 10:58 am, R129 was observed sitting in R129's wheelchair in R129's room with R129's indwelling catheter attached to the side of R129's wheelchair. R129 stated that R129's indwelling catheter bag has not been changed in 2 months and that R129 informed staff that R129's indwelling catheter bag was soiled and has been asking for staff for over a month for R129's indwelling catheter bag to be changed. Surveyor observed R129's indwelling catheter bag without a date, cloudy urine and with a brownish discoloration to R129's indwelling catheter bag. R129 stated, They (referring…

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 an enteral feeding formula was changed in a timely for one resident (R209). This failure affected 1 of 8 residents who receive gastrostomy tube feedings. Findings include: R209 has a diagnosis of Acute Respiratory Failure, Unspecified Whether with Hypoxia Or Hypercapnia, Dysphagia, Pharyngoesophageal Phase, Pneumonitis Due To Inhalation Of Food And Vomit, Dyskinesia Of Esophagus, Dysphagia, Esophageal Obstruction. R209 has a Brief Interview of Mental Status score of 14. R209's Order Summary Report documents, in part, Enteral Feed Order every shift Enteral Feeding Formula: (Brand name of enteral feeding) 1.5 cal Rate 80 ml/hr (hour) total volume 1280 on at 4:00pm. R209's Dietary Evaluation with a date of 7/30/2024 documents, in part, (Brand name of enteral feeding) 1.5 to infuse 1280 mL/d @ 80 mL/hr; Flush @ 300mL q shift (TID). R209's admission Evaluation dated 7/24/2024 documents, in part, Enteral Feeding. R209's care plan focus tube feedings, document, in part, resident will receive tube feeding 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 controlled substances were stored appropriately. This failure affects 1 resident (R7) in a sample of 65. Findings include: On 9/23/24 at 09:37 AM, V21 (Licensed Practical Nurse) observed the refrigerator in the 3rd floor medication room. V21 stated that the refrigerator should be locked. An open padlock was noted on the counter above the refrigerator. V21 withdrew R7's vial of Lorazepam (controlled substance) from the refrigerator. V21 affirmed that R7's Lorazepam is a controlled substance and must be kept locked. Additionally, within the refrigerator was unopened insulin pens, bisacodyl suppositories, acetaminophen suppositories, and a vial of haloperidol lactate. No additional lock box or device was observed in the refrigerator that would prevent the lorazepam from being stored with non-controlled medications. On 9/24/24 at 2:00 PM, V2 (Director of Nursing) affirmed that all controlled substances should be kept locked behind a system of 2 locks. V2 stated the two-lock system for refrigerated…

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 (R129) with an indwelling catheter was placed on Enhanced Barrier Precautions (EBP); failed to ensure a resident (R29) with EBP had a Personal Protective Equipment (PPE) bin in place; and failed to ensure staff don PPE while providing high contact resident care for a resident (R29) with EBP. These failures affected two residents (R29 and R129). Findings include: On 09/22/24 at 9:50 am, V1 (Administrator) presented a facility census of 29 residents on the first floor. R29's face sheet shows that R29's has diagnosis which include but not limited to pressure ulcer of left buttock, stage 3. R29's Brief Interview for Mental Status (BIMS) dated 08/29/24 shows that R29 has a BIMS score of 14 which indicates that R29 is cognitively intact. R129's face sheet shows that R129's has diagnosis which include but not limited to neuromuscular dysfunction of bladder and paraplegic. R129's Brief Interview for Mental Status (BIMS) dated 06/28/24 d shows that R129 has a BIMS of 15 which indicates that R129 is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two staff members were present during ADL (Activities of Daily Living) for one of three residents (R2) reviewed for falls. This failure resulted in R2 rolling out of bed to the floor and sustaining a hematoma (bruise that forms under the skin when blood vessels are damaged and leak). Findings include: R2's medical record (Face Sheet) documents R2 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses including but not limited to Metabolic Encephalopathy, Muscle Weakness, Need for Assistance with Personal Care, Dysphagia, Unspecified Protein-Calorie Malnutrition, and Adult Failure to Thrive. R2's MDS (Minimum Data Set of 5/9/2024) documents: -BIMS (Brief Interview for Mental Status) 3 (severely cognitively impaired) -Mobility: Roll left and right: (The ability to roll from lying on back to left and right side and return to lying on back on the bed.) Dependent - Helper does ALL the effort. Resident does none of the effort to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure adequate staffing to meet the needs of four residents (R4, R12, R20 and R21). This failure has the potential to affect all 210 residents that reside at the facility. Findings include: 1.) R12 is [AGE] year-old with diagnosis including but not limited to: Cerebral infarction, idiopathic chronic gout, aphasia, muscle weakness, hemiplegia, and hemiparesis. On 7/15/2024 at 11:45 AM, R12 was observed slumped over in his bed. At that time, R12 pressed his call device for assistance and said, I need to be pulled up in bed and I need water. Surveyor went to the hallway to see if any staff were available, but no staff member was visible. On 7/15/2024 at 12:15 PM, V22 (Certified Nursing Assistant/CNA) entered R12's room and brought him (R12) water. V22 said, R12's CNA is on break, but I can help him really quick. I have another patient and family member waiting on me. I have to find someone to help me reposition R12, but I will be back 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to respond to one dependent resident's (R12) call light within a reasonable amount of time, causing R12 to stay in an uncomfortable position for an extended period. The facility failed to ensure that call lights were within reach for three dependent residents (R20, R21, and R22) who required incontinent care from staff. Findings include: 1.) R12 is [AGE] year-old with diagnosis including but not limited to: Cerebral infarction, idiopathic chronic gout, aphasia, muscle weakness, hemiplegia, and hemiparesis. R12's Minimum Data Set- Section GG dated 7/3/2024 documents, R12 requires maximal assistance with activities of daily living and toileting. On 7/15/2024 at 11:45 AM, R12 was observed slumped over in his bed. At that time, R12 pressed his call device for assistance and said, I need to be pulled up in bed and I need water. At that time, Surveyor went to the hallway to see if any staff were available, but no staff member was visible. 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 provide a functional and comfortable environment for residents. This failure affected 3 residents (R9, R10 and R17) who were observed and interviewed for inadequate cooling (and has the potential to affect their roommates R16 and R18), reviewed for comfortable and homelike environment. Findings include: R9's Brief Interview for Mental Status (BIMS) dated 4/15/24 shows that R9 has a BIMS score of 13(cognitively intact). R10's BIMS score dated 4/29 is 12(mild cognitive impairment). R17's BIMS score dated 5/15/24 is 13(cognitively intact). On 7/15/24 at 11:20am, V6 (Maintenance Director) was asked about inadequate cooling and broken air conditioners in some rooms at the facility. V6 stated that he is not aware that any air conditioners were broken, and they are all working well. On 7/15/24 at 11:45 am, R9 and R10 were observed awake in the room with windows open and stated that the room was hot (outside temperature was 95 degrees). Inquired from R9 and R10 why they left the window opened and the air conditioner…

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 four residents (R20, R21, R22 and R23) received timely incontinent care. This failure has affected four of nine residents reviewed for incontinent care. Findings include: 1.) R20 is [AGE] year-old with diagnosis including but not limited to: Adult failure to thrive, contracture of muscle, unspecified osteoarthritis, hemiplegia, and hemiparesis. R20's Minimum Data Set- Section GG dated 4/26/2024 documents, R20 requires maximal assistance with activities of daily living. R20 is dependent on staff with toileting. On 7/17/2024 at 5:00 AM, R20 was observed lying in bed restless. Surveyor noted a strong urine odor in R20's room. R20 said, I am wet, I need to be changed. On 7/17/2024 at 5:15 AM, V35 (Certified Nursing Assistant/CNA) entered R20's room to change her brief. V35 removed R20's blanket. R20's brief, bed pad and sheet saturated with urine. R20's bed pad was noted with a brown stain in the shape of a ring. Surveyor asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one dependent resident with a 1:1 feeding order was fed. This failure has affected one (R4) of four residents reviewed for nutrition. Findings include: R4 is a [AGE] year-old with diagnosis including but not limited to: Need for assistance with personal care, weakness, fasciculation, type 2 diabetes mellitus and unspecified convulsions. R4's Physician Order sheet documents, 6/3/2024, 1:1 assistance while eating or drinking. On 7/15/2024 at 1:40 PM, R4 was sitting in bed and inquired about (R4's) lunch. R4 said, Someone started feeding me, but she left. I didn't finish my food. I am still hungry. Surveyor went into the hallway to find V23 (Certified Nursing Assistant/CNA) who was assigned to R4. On 7/15/2024 at 1:42 PM, V23 (CNA) said, Someone must have taken his (R4's) lunch tray. I wasn't done feeding R4. I left his room to go and assist with another patient, but I was planning to come back. I left his tray on his table so…

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 nutritional supplement as ordered by the physician. This failure affected 1 resident (R7) reviewed for therapeutic supplements. Findings include: R7's admission record documents in part the following diagnosis: plasma cell leukemia in relapse, type 2 diabetes with hyperglycemia, tumor lysis syndrome, chronic kidney disease stage 3, chronic ulcer of skin. R7's minimum data set (dated 3/15/24) documents in part a brief interview of mental status score of 15 indicating that R7 is cognitively intact. R7's physician orders dated 5/7/24 documents in part the following order: house supplement two times a day (nutritional supplement) with B + L (breakfast and lunch). R7's care plan (dated 6/21/24) identifies that R7 has or has a potential nutritional problem related to R7's medical diagnoses and requires therapeutic diet restrictions and supplements to maintain adequate nutritional status. On 6/24/24 at 10:42 AM, R7 affirmed R7 has received (nutritional supplement) from the dietary department in 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.

Based on observation, interview and record review, the facility failed to provide supervision and individualized fall prevention interventions as indicated in residents' care plans for cognitively impaired residents. The facility also failed to ensure that residents assessed to be at risk for falls don't have repeated falls. These failures affected three residents (R1, R6, and R7), reviewed for falls and fall prevention interventions. Findings include: 1. On 6/3/24 between 11:18am and 11:20am, the surveyor was in the third-floor dining room where about 20 residents (including R6 and R7) were sitting at the tables with no activity going on, and there was no staff in the dining room watching the residents. The surveyor went to the nursing station and asked V3 (MDS/Minimum Data Status Nurse) if someone was supposed to be in the dining room watching the residents. V3 followed the surveyor back to the dining room and responded that there was supposed to be staff in the dining room to watch the residents. V3 stated I will get someone to watch the residents. V6 (CNA/Certified Nurse…

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

Based on observation and interview, the facility failed to ensure proper maintenance and housekeeping services were provided to maintain a clean and sanitary environment related to air vents, water stains, and ceiling tiles throughout all nursing floors. These failures have the potential to affect all 189 residents residing in the facility. On 5/14/24 at 1:06 PM, R4 stated, I told V1 about all the mold, dirt, and dust coming through the vents in the ceiling. V1 was aware and did not have the vents cleaned or fixed. The ceiling tile have all these stains from the third floor leaking down here to the second floor. V5 (Maintenance) spray painted the mold and the dirt on the ceilings, instead of replacing the ceiling tile. The leaking water, mold and dirt makes my nose run and sneeze, just makes me sick. On 5/14/24 at 1:38 PM, surveyor, V4 (Maintenance Director), and V5 (Maintenance) toured the nursing floors on the second, third, and fourth floors. All the nursing stations were observed to have a large vent with a thick black substance on the outside and inside vent rim edges. 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 food was served at a palatable temperature. This deficient practice has the potential to affect 190 residents receiving food prepared in the facility's kitchen. Findings Include: On 4/23/24 at 11:48 AM, R2 stated the breakfast is cold at times, R2 would like to eat hot food when the food is supposed to be hot. On 4/23/24 at 12:41 PM, R4 stated the breakfast is cold. On 4/23/24 at 1:15 PM, R3 stated the breakfast is cold and the food does not taste good cold. On 4/24/24 at 1:21 PM, test tray was conducted V10 (Food Service Area Manager), and another surveyor. After last tray on the unit was delivered, observed V10 use a digital thermometer to check temperature of food served. The temperature of the breaded pork chop was 112.4 degrees Fahrenheit. V10 stated the pork-chop is cold, below the normal 135 degrees Fahrenheit for hot food. The other surveyor tasted the breaded pork chop and stated the pork chop tasted cold which made it unappealing and unappetizing, and that the surveyor would not eat it. 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 follow standards of professional practice and facility policy in providing activities of daily living specific to bathing or showering at least once a week in eleven out of eighteen total opportunities in a sample of nine randomly selected residents. Findings include: On 4/23/2024 at 1:56 PM during interview V18 (Certified Nursing Assistant/CNA) described that there is a list of when residents are offered showers and it is based on the day of the week. V18 stated that residents typically shower three times a week. On 4/23/2024 at 2:03 PM during interview V16 (Registered Nurse/RN) reviewed the shower schedule. V16 stated that residents shower twice a week. During the shower, the nurse performs a front-to-back skin assessment of the resident. If a resident refuses a shower, the nurse will involve the family or try to change the resident ' s shower day and encourage the resident to shower. Social Services may also get involved and encourage the resident. However, the resident does have the right to refuse. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure by not completing the fall risk evaluation assessments and updating the care plan with new interventions for 1 (R1) resident with history of multiple falls. These failures affected 1 (R1) of 3 residents reviewed for improper nursing care. Findings include: R1's health record documented admission date on 12/11/23 with diagnoses not limited to Cerebral infarction, Hemiplegia unspecified affecting left nondominant side, Transient cerebral ischemic attack, other abnormalities of gait and mobility, Dysphagia, Alcohol use, Nicotine dependence, Solitary pulmonary nodule, Nontoxic single thyroid nodule, Benign neoplasm of parotid gland, Dysarthria and anarthria, Cognitive communication deficit, Essential (primary) hypertension. R1 was discharged to hospital on 4/22/24. On 4/23/24 at 2:55pm V24 (Restorative Director) said fall risk evaluation should be completed upon admission, readmission, quarterly and after every fall to…

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

Based on observations, interviews, and record reviews, the facility failed to provide a comfortable and homelike environment for residents that reside on the second (46 residents) and third floor (57 residents) for two out of four floors in the building. Findings include: On 04/02/2024 at 11:09 AM, R4 stated there is possibly mold in the ceiling and heating unit in R4's room. Brown/tan stains noted to at least five ceiling covers near R4's bed. Brown/tan stains also noted on the heater. R4 stated facility paints over the stains and don't check it for mold. R4 also stated facility has not replaced the trim behind R4's bed. Missing trim noted only to area behind R4's bed. R4 took surveyor on a tour of the second floor. There were brown, tan, and black stains to ceiling covers outside of the R4's room near the wall. Shower room closest to R4's room had two shower stalls. One stall was broken. The other shower stall had a missing shower head. It also had black stains along crevice between the wall and floor on one side. The vent in the shower room did not have a vent cover. The vent 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 interviews and record review the facility staff failed to report an injury of unknown origin to the surveying state agency within the required time frame for 1 (R3) of 4 residents reviewed for resident injury. The facility also failed to follow the facility policies for reporting an accident, incident, or unusual occurrence. Findings include: R3's diagnosis includes and is not limited to Crohn's Disease, Dementia, Calculus of Gallbladder with other Cholecystitis without Obstruction, Vitamin D Deficiency, Colostomy, Chronic Pain, Constipation and Hyperlipidemia. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating severe cognitive impairment. Progress note dated 03/07/24 08:11 document in part: Nursing Note: Writer received resident alert and verbally responsive with a bruise to her forehead. MD (Medical Doctor) made aware, new order to start neuro checks and to continue to monitor the resident. Progress note dated 03/08/24 04:39 in part: Nursing Note: Resident observed resting in bed, resident has a bruise to R (right) side of the head.…

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 an injury of unknown origin was thoroughly investigated related to bruising for 1 (R3) of 4 residents reviewed for Resident Injury. Findings Include: During staff interviews V2 (Director of Nursing) failed to interview all staff that had direct contact with R3 prior to the bruising. V2 failed to identify an injury of unknown source, did not do a thorough investigation of R3 bruising and failed to follow the facility policy for injury of unknown source as the basis of the conclusion. R3's diagnosis includes and is not limited to Crohn's Disease, Dementia, Calculus of Gallbladder with other Cholecystitis without Obstruction, Vitamin D Deficiency, Colostomy, Chronic Pain, Constipation and Hyperlipidemia. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating severe cognitive impairment. Progress note dated 03/07/24 08:11 document in part: Nursing Note: Writer received resident alert and verbally responsive with a bruise to her forehead. MD (Medical Doctor) made aware, new order to…

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

Based on observations, interviews, and record reviews, the facility failed to provide a homelike environment to 15 (R1, R5, R6, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R25) residents reviewed for home-like environment and has the potential to affect all residents on the second and third floors. Findings include: On 02/20/2024 at 11:14am, on the hallway of 3rd floor, there was water staining noted on the ceiling tiles. On 02/20/2024 at 11:20am, V9 (Maintenance - Corporate) stated there are water stains on ceiling tiles. The water stain could be a condensation from the pipe's sweat. When we (facility) turn the heat, the cold water in the pipe causes water condensation and this condensation cause water stain on the ceiling tiles. On 02/20/2024 at 11:24am, V9 checked the vent in second floor by the nurse's station and stated it is dust for sure. V9 wiped the vent with V9's finger and collected accumulation of dust on V9's finger. On 02/20/2024 at 11:32am, R1's room has water staining on ceiling tiles. V9 stated it is a home like environment issue. The water staining…

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 personal trust fund allowance to 1 (R2) resident. This failure affected 1 (R2) out of 3 residents reviewed for access to resident funds. The findings include: R2's health record documented admission date of 12/14/2021 and discharged date of 10/14/2022 with diagnoses not limited to Heart failure, Covid-19, Other stimulant use, Bilateral inguinal hernia, Shortness of breath, Chronic kidney disease stage 3, Major depressive disorder, Bilateral primary osteoarthritis of hip, Other specified disorders of bone density and structure, Personal history of covid-19, Unspecified atrial flutter, Essential (primary) hypertension, Type 2 diabetes mellitus without complications. On 12/19/23 at 9:54am R2 was interviewed via phone, stated that he stayed in the facility for 10 months and was discharged on 10/14/22. He stated that he was supposed to get a monthly trust fund/allowance of $30 but he only got it once. R2 stated that he signed the receipt when he got it. He stated that the facility owed him $270 of his trust fund money…

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 comfortable environment for residents by not ensuring residents have routine access to warm/hot water. This failure has the potential to affect 2 (R1 and R3) of 3 residents reviewed for access to warm/hot water. The findings include: R1's health record documented admission date of 12/8/23 with diagnoses not limited to Guillain-Barre syndrome, Quadriplegia, Aphasia, Acquired absence of spleen, Anxiety disorders, Asthma, Type 2 diabetes mellitus without complications, Major depressive disorder, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Gastro-esophageal reflux disease without esophagitis, Chronic kidney disease, Insomnia due to other mental disorder, Obstructive sleep apnea (adult), Other pulmonary embolism without acute cor pulmonale. R3's health record documented admission date of 9/26/2022 with diagnoses not limited to Osteoarthritis of knee, Anxiety disorder, Major depressive…

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

Based on observations, interviews and records review, the facility failed to follow their call light system policy by failing to maintain a properly functioning call light system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This deficient practice has the potential to affect all 173 residents residing in the facility. Findings include: On 10/14/2023 at 9:10am, during observation on the fourth-floor unit near the nursing station, surveyor observed call light system by the nursing station ringing constantly from several rooms, and the call light above the nursing station on the ceiling was observed to be on, with a color purple blinking. The phone call light system by the nursing station, and above the nursing station were observed to be ringing/blinking constantly. On 10/14/2023 at 10:12 am, R3 was observed in his room laying on the bed. R3 said it is annoying to be called every minute to be asked if he is ok because his call light is broken. He said his call…

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 Daily Nurse Staffing was posted in a prominent place readily accessible to residents and visitors and failed to ensure the Daily Nurse Staffing information was complete. This failure affected all 167 residents residing in the facility. Findings: On 8/13/2023 the facility's census was 167. On 8/13/2023 at 8:57am, did not observe the Daily Nurse Staffing posted in the reception area. On 8/14/2023 at 9:08am, did not observe the Daily Nurse Staffing posted in the reception area. On 8/14/2023 at 9:14am, did not observe the Daily Nurse Staffing posted in the reception area. On 8/15/2023 at 10:59am V11 (Staffing Coordinator) stated, the Daily Nurse Staffing is normally at the front desk, right here, pointing to the glass at the reception window. Surveyor did not observe a Daily Nurse Staffing for 8/15/2023 on the window. V11 stated, she is responsible for posting the Daily Nursing Staffing during the week and the receptionist is responsible for posting on the weekends. On 8/15/2023 at 11:06am V11 provided…

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 refrigerated items were stored at an appropriate temperature, failed to ensure red meat was stored on a shelf below crème pies, failed to ensure drainage pipes were clear to prevent sewage backup in the kitchen, and failed to maintain foods at an appropriate temperature before plating. These failures have the potential to affect 162 residents receiving meals from the kitchen. Findings Include: On 8/13/23 at 9:30 am, small refrigerator in main kitchen outside thermometer and inside thermometer read 60 degrees. Surveyor touched the racks inside the refrigerator for temperature and the racks were not cold. Opened condiments and liquid substances were observed. On 8/13/23 at 9:35 am, surveyor observed water on floor in the main kitchen by the three compartment sinks. Coming from a drain in the floor. On 8/13/23 at 9:40 am, surveyor observed water on the floor in the dry storage room with a pollution smell. V26 (Cook) stated, the room must be cleaned four times a day, two times on day shift and two times 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 observations, interviews, and record reviews, the facility failed to date humidifier bottles, failed to ensure humidifier bottle was changed weekly, and failed to ensure nasal canula was connected to the oxygen concentrator to deliver prescribed oxygen to a resident. These failures affected 4 (R15, R65, R99 and R362) residents reviewed for respiratory care in the total sample of 57 residents. Findings include: 1.) R99's (Active Order as of: 08/14/2023) Order Summary Report documented, in part Diagnoses: (include but not limited to) chronic obstructive pulmonary disease and hypertension. Order Summary. Change O2 tubing weekly on Sunday night. Oxygen (02) @ 2 Liters/Minute per Saturation @ 92% or greater as needed related to chronic obstructive pulmonary disease. Change O2 Tubing Weekly on Sunday Night every night shift every Sun related to chronic obstructive pulmonary disease. R99's (05/25/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R99's mental status as cognitively…

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 sufficient number of skilled licensed nurses to provide nursing related services to meet resident needs. This failure affected 2 residents, (R29 and R141) and has the potential to affect all 46 residents on the second-floor unit. Findings include: On 08/13/23 at 10:39 am, surveyor observed the second floor with a census of 46 residents with V15 (Registered Nurse/RN). Surveyor observed V15, V16 (Certified Nursing Assistants/CNA), V17 (CNA), V18 (CNA), and V19 (CNA) working on the second-floor unit. On 08/13/23 at 10:40 am, V15 stated, V15 is assigned to Team 3 and half of Team 2 (room [ROOM NUMBER] through room [ROOM NUMBER]). V15 explained, the nurse for Team 1 did not arrive on the unit. V15 stated, I (V15) did my best to start that side (Referring to the Team 1 assignment). On 08/13/23 at 11:35 am, observed V14 (Licensed Practical Nurse/LPN, Unit Manager) arrive to the second-floor unit. Surveyor asked V14 if V14 was the nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the code status order entered in the resident's electronic medical record (EMR) correlates to the resident's physician orders for life-sustaining treatment (POLST) form which affected one resident (R150) in the sample of 57 residents. Findings include: R150's admission Record documents, in part, diagnoses of post-traumatic stress disorder, dementia, major depressive disorder and agoraphobia with an initial admission to the facility of [DATE]. R150's POLST form, signed by V41 (Physician) on [DATE], for R150's choice of cardiopulmonary resuscitation (CPR) is checked as Do Not Attempt Resuscitation/DNR with Comfort Measures Only (Allow Natural Death). R150's Order Summary Report, dated [DATE], documents, in part, two code status orders for R150 which include Code Status: DNR with active phone order dated [DATE] and Code Status: Full Code with active phone order dated of [DATE]. R150's profile screen in the EMR shows two code status orders,…

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

Based on interview and record review the facility failed to report a serious bodily injury to State Agency within the mandated time frame and failed to develop policies and procedures which ensures reporting of serious bodily injury within the mandated time frame. These failures affected 1 (R15) resident reviewed for reporting of incident and accident in the total sample of 57 residents. Findings include: R15's (admission Date: 8/8/2023) Hospital Record documented, in part History of present illness. Pt (patient) states she rolled out of bed onto the floor . CTH (Computer Tomography Head) showed mixed density L (left) SDH (subdural hematoma) with acute component. MRI Brain 8/11 1. Bilateral acute cerebral convexity subdural hematomas as before. CT head Comparison: Multiple prior CT head exam, most recent 8/8/23 at 13:33 (1:33pm). Findings Redemonstrated is a subdural collection along cerebral convexity, which appears more homogenous compared to the immediate prior CT head exam, however, is decrease in maximum thickness measuring 1.0cm previously, 1.4 cm possibly due in part to…

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

Based on observation, interview and record the facility failed to provide pressure ulcer prevention measures correctly to 3 residents (R15, R48, R83). This failure has the potential to affect all 3 residents (R15, R48, R83) out of the sample of 57 residents. Finding include: 1.) R48's diagnosis includes but not limited to Dysphagia, Gastro Esophageal Reflux Disease, Hypertension, Anemia and Hemiplegia. R48 has a Brief Interview of Mental Status score of 11 that indicates moderately impaired. On 8/13/2023 at about 12:15pm surveyor observed R48's low air loss mattress set to a weight of 120lbs. R48's Weights and Vitals Summary dated 8/09/2023 at 9:07am documents a current weight of 150.2 lbs. R48's Care plan focus for skin breakdown documents pressure redistribution mattress in place for pressure relief. 2.) R83 's diagnosis includes but not to Quadriplegia, Pressure Ulcer Sacral Region, Type 2 Diabetes Mellitus, Hypertension and Neuromuscular Dysfunction. R83 has a Brief Interview of Mental Status score of 15 that indicates cognitively intact. On 8/13/2023 at 12:22pm surveyor…

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

Based on observation, interview and record review, the facility failed to maintain an accurate count of a controlled substance which affected one resident (R27) in the sample of 57 residents reviewed for narcotics accountability. Findings include: On 8/14/23 at 11:42 am, with V15 (Registered Nurse) performed a controlled substance count together for the second floor Team 3 medication cart. Observed R27's dispensing card for Lacosamide 200 milligram (mg) tablet with a count of nine tablets. R27's Controlled Drug Receipt/Record/Disposition Form for Lacosamide 200 milligram (mg) tablet documents, in part, an amount left of ten tablets. When seeing the discrepancy with R27's medication count against the controlled drug record, V15 stated, When I (V15) counted this morning, it was right. I (V15) know what happen. They didn't sign for last night. V15 was asked regarding the importance of the narcotics accountability sheet being accurate V15 stated, So that the residents are not missing medications. On 08/15/23 at 1:29 pm, V2 (Director of Nursing) stated, the narcotics accountability…

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

Based on observation, interview and record review, the facility failed to have a less than five percent (5%) medication error rate. There were 3 medication errors out of 27 medication opportunities, resulting in a 11.11% medication error rate and affected 2 residents (R130 and R141) observed for medication pass. Findings include: On 08/13/22 at 12:38 pm, V14 (Registered Nurse/RN) was observed on the second floor at the Team 1 medication cart. Observed V14 prepare and count 4 pills total that were administered to R130. V14 stated, I (V14) do not have calcium vitamin D on this cart. Upon surveyor reconciling R130's medication for medications that were order for administration and medications that were observed as administered and documented by V14, the following medication error was identified: 1.) Omission error: Calcium 500 +D tablet 500-200 mg (milligram) per unit give one tablet by mouth in the morning for supplement. R130's Medication Administration Audit Report (MAAR) documents that Calcium 500 +D tablet 500-200 mg per unit give one tablet by mouth in the morning for supplement…

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

Based on observation, interview and record review, the facility failed to discard expired insulin medication and failed to refrigerate unopened eye drop medication per pharmacy instructions which affected two residents (R66, R67) in the sample of 57 residents. Findings include: 1.) On 8/15/23 at 11:19 am, V34 (Licensed Practical Nurse/LPN) performed a medication storage review of the 3rd floor medication cart, identified by V34 as the 1st team medication cart. V34 opened this locked medication cart for to view. In the top drawer, observed R67's Latanoprost Solution 0.005% eye drops bottle in a plastic pharmacy bag with R67's pharmacy label and a separate pharmacy label (blue in color) reading Refrigerate until open. Removed R67's Latanoprost Solution 0.005% eye drops bottle from the pharmacy bag and observed that the seal is intact on the lid of the eye drop bottle. It was also noted to have an attached yellow label from pharmacy, which is blank, that is to be filled out by the nurse when Latanoprost Solution 0.005% eye drops bottle is opened. A small, soft gel pack (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 observation, interview, and record review, the facility failed to follow their policy and procedure to ensure that residents are free from misappropriation of property by a deliberate transfer of money from R2's bank account without R2's consent. This failure has affected 1 (R2) of 3 residents reviewed for abuse. The findings include: R2's health record documented admission date of 12/28/2019 with diagnoses not limited to Chronic obstructive pulmonary disease, Major depressive disorder, long term use of oral hypoglycemic drugs, Vitamin D deficiency, Insomnia, Seizures, Alcohol abuse, Fracture of unspecified part of right clavicle, Hereditary and idiopathic neuropathy, Type 2 diabetes mellitus, Hyperlipidemia, Personal History of COVID, Essential hypertension, and Asthma. On 8/2/23 at 9:30 am R2 observed up and about, ambulatory with steady gait, with sling on left arm. R2 observed alert, cognitively intact and verbally responsive. R2 stated that he has been residing in the facility for 3 years. R2…

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

Based on observations, interviews, and record reviews, the facility failed to follow a resident's (R1) meal preference as written in the physician's order for 1 of 4 residents reviewed during meals. Findings include: R1's physicians' order sheets contain an active diet order dated 07/26/2023. It documents in part that R1 should receive double portions with all meals along with two glasses of milk with all meals. On 08/01/2023 at 11:30 AM, R1 was alert and oriented to person, city, and month. R1 was sitting up in wheelchair in the bedroom. R1 stated [R1] was hungry and waiting for lunch. R1 stated the facility does not provide enough during meals. On 08/01/2023 at 11:40 AM, V4 (Nurse - Unit Manager) stated R1 is supposed to get double portions. V4 stated it is printed on R1's meal tickets. On 08/01/2023 at 12:20 PM, R1 received one bag of cheese puffs, one six-inch roast beef sandwich, and one 16-ounce bottle of water. Sandwich had one slice of roast beef and cheese along with lettuce. At 12:29 PM, R1 finished the sandwich. At 12:32 PM, R1 showed the surveyor the meal ticket that…

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

Based on interviews and record reviews, the facility failed to maintain complete and accurate Medication Administration Records for 1 (R1) of 4 residents reviewed for medications. Findings include: On 08/01/2023 at 11:03 AM, surveyor reviewed R1's July 2023 MAR (Medication Administration Record). R1's order for Lantus has no charting (blank) for the 7/16 and 7/23 doses. R1's order for Latanoprost Ophthalmic Solution has no charting for 7/1, 7/3, and 7/17. R1's MAR also documents in part an order for Hydralazine HCL (Hydrochloride) 25 MG (Milligram) by mouth every eight hours. Parameters to hold Hydralazine HCL if the systolic blood pressure is less than 110 mmHG (millimeters of mercury) or if R1's heart rate is less than 60 beats per minute. R1's MAR documents in part multiple blanks for the vitals and for the administration times for Hydralazine HCL. There is missing documentation on 7/01-7/03, 7/05, 7/07, 7/10, 7/15-7/17, 7/22, 7/23, and 7/30. Reviewed R1's electronic medical records. Reviewed R1's blood pressure and heart rate under the Vital Signs section of the medical record.…

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 date opened boxes of food in the refrigerator and freezer, properly thaw meat, and store clean dishes and utensils under sanitary conditions. This had the potential to affect all resident who receive food from the kitchen. Findings include: On 06/14/2022 at 11:08 AM the following food items were found in the refrigerator opened with no date. 2 5lb (pound) cheese blocks in an opened undated box. 1 10lbs box hot dogs in an opened undated box. 1 5lb box of diced chicken in an opened undated box. On 06/14/2022 at 11:15 AM the following food items were found in the freezer: 1 cup of ice cream was unsealed-undated, found in an open box with 5 cups of ice cream in it. On 06/15/2022 at 10:59 AM one 50 pack of hot dogs observed thawing in the sink. Hot water observed on and running over the hot dogs. Steam observed coming from the water and the hot dog package. On 06/15/2022 at 11:05 AM V7 (Cook) stated, the hot dogs should not be thawing under hot water. I made a mistake and turned the hot water on. I will turn on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for two (R497, R500) of seven residents reviewed for baseline care plans in the sample of 33. Findings include: R497's medical record (Face Sheet) document R497 as admitted to the facility on [DATE]. R497's care plans were initiated on 06/13/2022 (Restorative program, ROM-range of motion) and 06/15/2022 (Potential for falls, Diet order, Pain). R500's medical record (Face Sheet) document R500 as admitted to the facility on [DATE]. R500's care plans were initiated on 06/14/2022 (Impaired bed mobility, ROM) and 06/15/2022 (Potential for falls, Current diet order, At risk for alteration in comfort, Potential for skin integrity impairment, Antibiotic therapy, Potential/actual impairment to skin integrity, Pressure ulcers, rash). 06/15/2022 at 3:49 PM, V2 (Director of Nursing) said, all care plans are found in (electronic health record) and baseline care plans should be completed within 24 hours of 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.

Based on observations, interviews, and record review, the facility failed to follow their Infusion Therapy policy by not dating and labeling a resident's (R151) peripheral intravenous catheter (PIV). This deficiency had the potential to affect 1 (R151) out of 1 resident reviewed for peripheral intravenous catheters in a sample of 35 residents. Findings Include: On 6/14/2022 at 11:45 AM, R151 was observed with a right hand peripheral intravenous catheter (PIV), 20 gauge, saline locked. PIV site noted with a transparent dressing in place. Transparent dressing observed with no labeling of date or initials of who inserted the PIV. On 6/14/2022 at 11:45 AM R151 stated, they gave me some of that water in a bag through this thing, but it's finish now though. They gonna take it out. On 6/15/2022 at 12:35 PM, R151 was observed with a different right forearm PIV, 20 gauge, saline locked. PIV site noted with a transparent dressing in place. Transparent dressing observed with no labeling of date or initials of who inserted the PIV. On 6/15/22 at 11:45 AM, V4 (Unit Manager/Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to discard expired house stock medications for 1 of 5 medication carts reviewed in a total of 9 medication carts; the facility also failed to ensure that medications and 1 medication cart was secure while unattended. These failures have the potential to affect 26 residents that resides on the XXX floor and all 59 residents that resides on the YYY floor for a total of 85 residents. Findings Include: On [DATE] at approximately 9:52am, V6 (Licensed Practical Nurse/LPN) observed on the YYY floor of the facility performing a medication administration pass. V6 located with medication cart identified as Team 2 middle cart in front of R60s' room. Prior to preparing medication for R60, V6 stated I have to wash my hands. V6 observed walking away from medication cart and into R60s' washroom with the door closed, leaving the medication cart unattended and unlocked. On [DATE] at approximately 9:51am, V6 observed exiting the washroom of R60 and returning…

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

Based on observation, interviews, and record reviews, the facility failed to follow their Transmission Based Precautions policy by allowing a visitor in a resident's (R503) room without wearing the appropriate personal protective equipment (PPE). This affected one (R503) out one resident reviewed for transmission-based precautions in a sample of 35 residents. Findings include: On 06/16/2022 at 12:45 PM, a contact and droplet isolation sign was observed on the door of R503. Visitor observed in R503's room standing over R503's bed with no isolation gown on. R503 observed lying in bed. V12 (Unit Manager) entered R503's room and delivered a lunch tray to R503. V12 observed leaving the room. On 06/16/2022 at 10:49 AM, V12 confirmed that there is a visitor in R503's room without an isolation gown on. V12 stated, the visitor must have taken her gown off. I will go and tell the visitor to put an isolation gown on. V12 stated visitors must wear an isolation gown when a resident is on contact isolation to prevent the spread of infection. 06/16/22 2:18 PM V9 (Infection Preventionist) 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.