Sheridan Village Nrsg & Rhb

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one [R1] of three [R3, R4] residents reviewed for abuse. Findings Include: R1 clinical record indicate the following: R1 is a thirty-nine-year-old admitted with medical diagnosis including but not limited to cerebral palsy, schizoaffective disorder, chronic obstructive pulmonary disease, morbid obesity, hypertensive heart disease, sleep apnea, psychosis, bipolar disorder, and mood affective disorder. R1's minimum data set brief interview indicates R1 is cognitive intact. R1's care plan: 12/23/24, R1 has persistent mental illness. R1 experienced psychosis in the form of both auditory hallucinations [hearing voices, information in her head often of a negative nature] and delusional [falsely believing things that never happened, not true nor valid]. R1 made an allegation against staff member that may be the result of a disordered thinking R1 told a staff member…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 records review, the facility failed to assess and conduct investigations for allegations of physical abuse for one (R1) resident in a sample of three reviewed. Findings include: R1's medical diagnosis includes but not limited to: Cerebral Palsy, unspecified, Schizoaffective disorder, unspecified, Morbid (severe) obesity, Unspecified Psychosis not due to a substance or known physiological condition, Bipolar disorder, unspecified. R1's MDS (Minimum Data Set) section C dated 01/06/2023 documents R1's Brief Interview for Mental Status (BIMS) as 13/15, indicating R1 has intact cognitive functional abilities. MDS section GG-Functional Abilities documents R1 needs Substantial/maximal assistance, dependent on staff for Activities of Daily Living (ADL) care, uses a mechanical lift for transfer and uses a manual wheelchair for mobility. On 02/01/2025, at 1:33 PM, R1 stated that last year (no date provided) during a mechanical lift transfer, staff hurt her knee and she thought staff did it intentionally, therefore R1 called emergency services because she was in pain,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 in the walk-in cooler/freezer was labeled with a date indicating when the item was placed into the walk-in cooler/freezer. This failure has the potential to affect all 174 residents in the facility who are receiving an oral diet. The findings include: On 6/23/2024 at 9:50am while inside the walk-in cooler, observed one 48-ounce package of chopped spinach not in a case and not labeled with the date it was placed in the walk-in cooler and one opened box (10 cans in the box) of non-diary whipped topping not labeled with a date it was placed in the walk-in cooler. On 6/25/2024 at 2:15pm V5 (Dietary Supervisor) stated the purpose of labeling/dating the food containers in the walk-in cooler and freezer is so that staff can monitor when to use the foods that are put into the walk-in cooler and freezer. V5 stated the staff has 30 days to keep the food items in the walk-in cooler and freezer once the food items have been dated with an in- date. V5 stated the cooks and dietary aids are responsible for…

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

Based on observation, interviews and records reviewed, the facility failed to ensure residents on enhanced barrier precautions (EBP) had EBP signs posted at their rooms, that staff were using Personal Protective Equipment (PPE) when providing care for residents and that the residents' PPE bins were available and stocked. These failures affected 4 (R24, R43, R83, R165) residents and has the potential to affect all 174 residents in the facility. Findings include: On 06/23/2024 at 11:14 am, observed V12, Certified Nursing Assistant (CNA) with no gloves or gown on, adjusting R43's diaper, under pad and sheets. R43 observed with indwelling foley catheter. There was no Enhanced Barrier Precaution sign on the door of R43's room. The was no Personal Protective Equipment (PPE) bin outside R43's room. On 06/23/2024 at 11:20 am, V12 (CNA) stated Enhanced barrier isolation is pretty much when you gown and glove up. We use isolation when there is a sign on the door, or the nurses will let us know who to use isolation on. The resident R43, that I was just caring for is not on isolation. Normally…

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

Based on observations, interviews, and record review the facility failed to ensure that the residents indwelling catheter drainage bag is covered. This failure affected one resident (R165) reviewed for dignity in the sample of 59 residents. Findings Include: R165's admission record includes diagnoses of malignant neoplasm of colon, colorectal cancer, malignant neoplasm of rectosigmoid, and diabetes. R165's (5/11/24) Minimum Data Set documented, in part Section C. Cognitive Patterns. BIMS (Brief Interview for Mental Status) score is 15. R165 is cognitively intact. Section H. Bladder and Bowel: H0100. Appliances check all that apply: A. Indwelling catheter. On 6/23/24 at 10:40 am, R165 indwelling catheter drainage bag was hanging from the bed frame facing the hallway not covered with a privacy bag. On 6/23/24 at 10:50 am, V24 LPN (License Practical Nurse) stated that the urinary drainage bag should be covered with a privacy bag for dignity. On 6/25/24 at 10:00am, V4 DON (Director of Nursing) stated that the urinary drainage bag should be covered in a privacy bag to allow privacy and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to rescreen a resident to determine if specialized services under the Preadmission Screening and Resident Review requirements are necessary. This failure affected 1 (R153) resident reviewed for PASRR screening in the total sample of 59 residents. Findings include: R153's ([DATE]) Notice of PASRR (pre-admission screening and resident review) Level I Screen Outcome documented, in part PASRR Level Review Date: [DATE]. PASRR Level I Determination: Convalescence Categorical. Approval period: 60 days. Suspected or confirmed PASRR condition(s): Mental Health Disability. PASRR outcome explanation. Notice of criteria met for convalescence categorical-no PASRR Level 2 required. Your Level one screen shows you have evidence of serious mental illness. Further PASRR evaluation is not required because you meet criteria for a short term convalescence admission. This means you may stay for a limited number of days in a Medicaid certified nursing facility without further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clean and correctly log refrigerator temperatures for one resident's (R135) personal refrigerator. Findings include: On 06/23/2024 at 11:15am observed a black colored refrigerator in R135's room. Observed a temperature log affixed on the front of the refrigerator door. The temperature log was missing the documentation of a temperature reading for the following dates: 6/14/2024, 6/20/2024 and 6/21/2024. Observed a black substance on the thermometer located on the top shelf inside the refrigerator. The refrigerator contained two Styrofoam cups with drinks inside and a bottle of water. On 06/23/2024 at 12:15pm R135 stated the staff clean the refrigerator in my room once a month and the staff check the temperature in the refrigerator once a month. On 06/25/2024 at 10:29am R135 stated staff have not told me I need to clean my personal refrigerator. R135 stated I don't know what that black stuff is on the thermometer in the refrigerator. 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 ensure a resident's adaptive equipment was functional. This failure affected 1 (R68) resident reviewed for adaptive equipment in the total sample of 59 residents. Findings include: On 06/23/24 at 12:16pm, R68 was sitting on a wheelchair. R68 stated I (R68) have an issue with my (R68) wheelchair. The brakes are both broken. I (R68) got the wheelchair a couple of months ago. This surveyor requested R68 to engage the brakes; the brake on the right was not touching the rear wheel and the brake on the left was loose. The wheelchair moved while the brakes were engaged when R68 propelled the wheelchair. On 06/23/24 at 12:23 PM, this surveyor requested V8 (Assistant Director of Nursing) to check R68's wheelchair and R68 stated the wheelchair brakes are not tight; the one on the right is loose and the one on the left need's adjustment. We (facility) are going to provide a new wheelchair immediately. The purpose of the wheelchair brakes is to steady the wheelchair; for safety, to prevent falls. It is a concern. 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 that the treatment cart was safely locked up when not in the vicinity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all 28 residents residing on the 2nd floor of the facility. Findings include: On 02/28/24 at 11:13am, one treatment cart was noted in the hallway unlocked and not in the visual vicinity of the nurse. V5 RN (Registered Nurse) was made aware of this observation and when asked about the facility protocol/policy on medication cart storage; V5 identified the cart as a treatment cart and stated I (V5) don't know why the cart is not locked. V5 called V8 (Care Plan Manager) the floor supervisor and showed the treatment unlocked cart to V8. V8 stated the treatment cart is broken after checking the cart and stated we must rectify this because the cart must be locked always when not in use. At 4:05pm, when this observation was brought to V2 DON (Director of Nurses) attention and was asked about facility policy/protocol on medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident environment remains free of accidental hazards and the environment is free of sharp objects that could harm the residents. This failure affected R5 and R18 who has sharps stored on their bed side table and has the potential to affect all 31 residents residing on the 4th floor of the facility. Findings include: On 02/28/24 at 11:45, in R5's room on the bedside table observed 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. At 11:46am, V12 LPN (Licensed Practical Nurse) restorative nurse who stated that she is the medication nurse and in charge of the floor was made aware of the observation and shown the 23 disposable shaving razor sticks, 1 pair of scissors and two nail clippers. V12 counted the razora with the surveyor and stated it's 23, I'm not sure why (R5) would have this many razors. V12 counted and stated five (5) of the razors were used and they should be thrown away in the dirty utility room in the sharp container and the clean shaving razors are kept in 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, interviews and record reviews, the facility failed to follow their policy to ensure correct food temperatures were maintained prior to delivering food to residents for three (R1, R3, R4) out of three residents reviewed for dietary services. Findings include: On 1/30/24 at 11:06 AM R1 stated that the food is never warm. On 01/30/24 at 11:25 AM R3 stated that the food is cold occasionally. On 01/30/24 at 1:18 PM R4 stated the food is cold nine times out of ten. R4 stated that she eats her meals in the dining area and the food is always cold and arrives thirty to forty minutes late. R4 stated that she has personally told dietary department about the cold food. R4 reported that once she brought it up the following day, her food was hot or warm, but it returned to being cold after two days. On 1/31/24 at 11:25 AM surveyor observed the dietary staff on tray line. V6 (Dietary Manager) stated that dietary staff will be starting to serve trays for all residents. On 01/31/24 at 12:38 PM, surveyor observed the last meal tray that was handed out to the resident. 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 observation, interview, and record review, the facility failed to provide sufficient nursing coverage per their assessed staffing needs to ensure adequate care and support. This failure has the potential to affect all 176 residents that reside in the facility. Findings include: On 01/02/2024, V21 (Staffing Coordinator) provided surveyor with the nursing staff schedules dated 09/01/2023 to 12/31/2023. On 01/03/2024 at 10:49AM, V21 stated this was the entire nursing staff schedule which reflects the actual names and amount of nursing staff who worked in the facility during that time frame. V21 states whenever there is a change to the schedule, she updates it as soon as possible to ensure an accurate schedule. V21 states the facility does use agency staff to supplement staffing at the facility. V21 also states the facility no longer utilizes resident aides/RAs since November 2023. V21 states she staffs according to the budget that is given to her from V1 (Administrator) and V2 (DON). V21 states this is how…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to follow their abuse policy to protect residents from physical and verbal abuse for three (R1, R5, R11) residents reviewed for abuse in a sample of six. Findings include: On 01/02/2024 at 10:55 AM, surveyor observed R1 walking from the elevator to the dining area. R1 stated that she had somebody scream at her yesterday. R1 stated that it was V18 (Activity Aide). R1 stated that she hasn't had a chance to tell anybody yet, but she will today. R1 stated that V17 screams at us routinely. R1 stated that V19 (Activity Aide) swears and screams at her all the time. R1 stated that she always says, I'm not putting up with her bullshit. On 01/02/2023 at 11:20 AM, R13 stated that he has heard V19 (Activity Aide) swear at residents all the time. On 01/02/2023 at 11:28 AM, R14 stated that he has heard V19 swears at other residents. R14 stated that he has heard V17 (Certified Nursing Assistant) yell and swear at residents. On 01/02/2023 at 10:00 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to follow their policy for Misappropriation of Resident Property and Exploitation. This failure resulted in three (R6, R7, R8) residents' being exploited by V11 (Former Certified Nursing Assistant), who took/borrowed their money, and did not buy them stuff or refund them their money as promised. Findings include: Facility Reported Incident Report (FRI) dated 10/02/2023 documents on 09/26/2023, R6, R7, R8 reported they gave V11 a total of $226 to purchase snacks for them as follows: -R6 gave V11 $160, R7 gave V11 $44 and R8 gave V11 $22. Resident Concerns Forms dated 10/20/2023 documents R6 reported $160 stolen from him, R7 reported $25 stolen from him, and R8 reported $41 stolen from her. On 01/03/2024 at 11:25am V1(Administrator) said R6, R7, and R8 all reported at different times that they had given V11 some money to get them different things but V11 did not buy the items for the said residents and did not give them their money back. V1 said she asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interviews and records review, the facility failed to report and initiate an investigation of alleged abuse in a timely manner by failing to identify and ensure the reporting of a suspected abuse. This failure affected 2 residents (R1, R2) out of 3 residents reviewed for abuse. Finding include: R1's face sheet shows R1's diagnosis in part of hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, overactive bladder, and anxiety disorder. R1's Brief Interview of Mental Status (BIMS) dated 09/08/23 score 14 out of 15, indicating R1 has intact cognitive function. On 10/24/23 at 09:05 am R1 observed lying in bed, alert, oriented to self, place, time and situation. R1 says she can walk a little bit but uses the wheelchair for mobility, needs assistance with transfers and she uses an incontinence brief during the night. R1 says the incident happened in August, and it was about 3 am when a male Certified Nursing Assistant (CNA) came to her room. R1 says the CNA put his hands under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement their Involuntary Transfer and Discharge Process policy and failed to provide their bed hold policy upon discharge to hospital for one of one resident (R1), reviewed for involuntary discharge. Findings include: R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. R1's Petition For Involuntary/Judicial Admission dated 2.19.2023, completed and signed by V9 (LPN-Licensed Practical Nurse), documents in part: I assert that (R1) is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide their bed hold policy upon discharge to hospital for one (R1) of one resident reviewed for discharge. Findings include: On 8/10/23 at 11:30am, V1(Administrator) said, I am not aware of any abuse allegations involving R1. Residents are not denied to come back after involuntary petitions are given. R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. On 8/16/2023 at 11:32 AM, surveyor spoke with R1 via telephone. R1 said in part, she was not issued any paperwork, including the facility's bed hold policy, when she was petitioned to the hospital after an altercation with a nurse (V3-RN). R1 said, I wanted to return to the facility. Emergency Department Progress Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 permit a resident to return to the facility after hospitalization for one resident (R1) of one reviewed for discharge. Findings include: On 8/10/23 at 11:30am, V1(Administrator) said, I am not aware of any abuse allegations involving R1. Residents are not denied to come back after involuntary petitions are given. R1's medical record (Face Sheet, MDS-Minimum Data Set) documents R1 is a moderately cognitively impaired [AGE] year-old admitted to the facility on 2.8.2023 with diagnoses including but not limited to: Non-traumatic intracerebral hemorrhage in brain stem, Chronic obstructive pulmonary disease, Adult failure to thrive, and latent syphilis. On 8/16/2023 at 11:32 AM, surveyor spoke with R1 via telephone; the call took place at a homeless shelter where R1 currently resides. The doctor in the emergency room called the facility and was told they would not accept me back. The doctor in the emergency room said, we won't participate in whatever 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 follow proper food storage practices and label/date food items; failed to ensure staff's personal food items were not stored in the kitchen; failed to ensure the cleanliness of the stand-alone freezer; and failed to follow proper sanitation guidelines to prevent foodborne illness. These failures have the potential to affect all 173 residents receiving a meal tray from the kitchen. Findings include: On 5/15/23 at 10:04 AM, the garbage can under the hand-washing station sink had no trash bag in place. V8 (Dietary Director) stated that there should be a trash bag in the trash can to prevent a mess, bugs, and smell. On 5/15/23 at 10:08 AM, the stand-alone freezer in the kitchen appeared dirty with visible splash marks on the outside doors. Inside the freezer were 7 individual scoops of vanilla ice cream in small foam bowels wrapped with clear, plastic wrap that were not labeled. V8 stated, They didn't put the date on it. V8 added that there should be a label on the food item to indicate the date it was opened or…

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

Based on interview and record review, the facility failed to ensure that facility staff receive behavioral health training to safely and effectively respond to residents' behaviors and failed to have a process in place to track staff's participation in the training. These failures have the potential to affect all 124 residents in the facility who have diagnoses of SMI (Serious Mental Illness). Findings include: On 5/15/23 at 10:35am, V1(Administrator) presented the facility's census as 174 residents. Also, on 5/17/23 at 2:26pm, V14(Social Services Director/PRSD-Psychiatric Rehabilitation Services Director) presented a list of 124 residents out of the 174 residents that have diagnoses of severe mental illness (SMI) with behaviors. On 5/17/23 at 2:45pm, V1 presented the facility's records of resident-to-resident physical altercations within the past 3 months. A review of these records showed that there were seven residents to resident physical altercations between 1/9/23 and 4/7/23. V1 was asked if she(V1) thinks that Behavior Health Training could help reduce the incidents; V1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the walls and base boards of the fourth-floor dayroom, shower room, and hallway in good repair. This failure has the potential to affect all 29 residents on the fourth floor. Findings include: On 5/15/23 at 10am during the entrance conference, V1(Administrator) presented the facility's census that shows that 29 residents live on the fourth floor. On 5/16/23 between 11am and 1pm during observation of residents on the fourth floor, the following were observed: Dayroom/Dining Room radiator cover was broken, and the broken piece was left on the floor by the radiator close to one of the dining tables where residents were sitting. Broken drywall in the dining room; Peeling paint at the hallway entrance to rooms 403, 407, 410, and 411; Broken drywall and broken base board at the entrance to the shower room. On 5/17/23 between 10am and 11:45am, the above listed maintenance issues remained the same. On 5/17/23 at 11am, V30(Maintenance Director) was interviewed regarding the above listed issues. V30 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one resident's (R139) urinary catheter drainage bag was covered with a privacy cover and failed to provide dignity for one resident (R158) who was accused by facility staff of stealing in the presence of other residents, resulting in R158 feeling humiliated. These failures affected two residents (R139 and R158) in a sample of 58 residents. Findings include: On 5/16/2023 at 10:52 am R139's urinary catheter bag was observed hanging off the bed frame on the left side of R139's bed. R139's bed is the first bed upon entering the room and the urinary catheter drainage bag was visible upon walking past R139's room door when the door was open. On 5/16/2023 at 11:41am this observation was brought to the attention of V16 (RN/Registered Nurse). V16 stated the cover for the urinary catheter bag comes snapped to the bag. V16 stated the Certified Nursing Assistant must have taken the cover off the urinary catheter bag. V16 stated 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 a safe and functional homelike environment for one resident (R76) out of 7 residents reviewed in the total sample of 58 residents. Findings include: On 5/15/23 at 11:33 AM, R76, who was noted to be hunched over when ambulating, was observed attempting to hang his (R76) jacket inside the closet in his (R76) room but was having difficulty due to one of the sliding closet doors being noted off the hinges and fallen into the closet onto the clothes. R76 stated, It is broken. It does make it difficult. The surveyor inquired how long the closet door has been this way. R76 replied, Long time. Probably before I (R76) came in the room. On 5/15/23 at 11:47 AM, this observation was brought to the attention of V30 (Maintenance Director) who stated, It's off the hinges. I'll fix it right now. On 5/17/23 at 2:55 PM, V1 (Administrator) stated, They could get hurt by that. There could be an injury. V1 added that maintenance does rounds daily so she (V1) would expect the fallen closet door to be replaced or repaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that an accurate Community Access Observation was complete for one resident (R45), who was reviewed for timely and accurate assessments. This failure has the potential to affect all residents that reside at the facility. Findings include: R45 is [AGE] year old with diagnosis including but not limited to: History of COVID, Type 2 Diabetes Mellitus, Hyperlipidemia, Gastro-esophageal reflux disease and weakness. R45 has a BIMS (Brief Interview for Mental Status) Score of 15, which indicates cognitively intact. R45's face sheet documents an original admission date of 3/11/2009. On 5/17/23, R45 was observed sitting in the day room. Surveyor inquired about how R45's day was going. On 5/17/23 at 10:30 am, R45 said, They treat me like a slave in here (referring to the facility). My rights have been violated. I can't come and go as I please. I have been here for about 14 years, and can't get a grounds pass. I lost my grounds pass over 10 years ago and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to check placement of the Gastrostomy tube (G-tube), failed to check residual amount of enteral formula and failed to administer medications in accordance with Professional Standards for one resident R26. This failure affected one resident (R26) out of a sample 5 residents. Findings: R26 is a [AGE] year-old male with a diagnosis of Polyosteoarthritis, Schizoaffective disorder, Type 2 diabetes Mellitus, Chronic Respiratory failure with hypoxia, Gastrostomy Malfunction, and Dysphagia. R26 has a Brief Interview of Mental Status of 15 that indicates cognitively intact. On 5/15/2023 at 9:44am, surveyor observed V29 (LPN) crush R26's medications (Chlorpromazine HCL 200mg, Cyclobenzaprine tab 5mg and Finasteride tab) together and pour into one cup. Surveyor also observed V29 mix R26's Omeprazole and liquid Famotidine together and pour into one cup without cleaning and storing the medication syringe in a plastic bag. On 5/15/2023 at 9:57am V29 stated…

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

Based on observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R46) reviewed for oxygen equipment, in a total sample of 58 residents. Findings include: On 5/16/23 at 10:59am, surveyor observed R46 in bed awake and alert. R46 was observed with 2 liters oxygen via nasal cannula tubing in place unlabeled and not dated. When R46 was asked regarding R46's nasal cannula oxygen tubing, R46 stated, The nurse came in to change the tubing on yesterday (referring to 5/15/23). On 5/16/23 at 11:41am V16(RN/Registered Nurse) stated the nurse is to put a sticker on the oxygen tubing with the date the oxygen tubing was changed. V16 stated I usually place a piece of tape with the date the oxygen tubing was changed. V16 stated the nurse is responsible for changing the oxygen tubing every week or as needed. V16 stated the change of the oxygen tubing is usually done on the 3pm to 11pm shift. On 5/17/2023 at 1:13pm V2(DON/Director of Nursing) stated the nurses are responsible for changing the oxygen…

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