Warren Park Health & Living Ctr

Based on interviews and record reviews, the facility failed to follow their Vaccination of Resident Policy. Failed to administer three [R23, R46, R113] residents their Covid Vaccine after consenting for the vaccine reviewed in a sample of 26. Findings includeReviewed the facility's immunization report provided by V27 [Infection Control Preventionist]. Noted R23, R46, and R113 consented for the Covid Vaccination, and was not administered per documentation provided.On 12/10/25 at 10:00 AM, R23 stated, I asked for the Covid Vaccine months ago, and I have not received the vaccine.On 12/10/25 at 10:38AM, R46 stated, I want the Covid Vaccine, but they would not give it to me.On 12/10/25 at 1:40 PM, R113 stated, I told the nurse I wanted the Covid Vaccine, but she never gave it to me.On 12/10/25 at 12:30 PM V27 [Infection Control Preventionist] stated, R23 consented to receive the Covid Vaccine on 2/6/25, R46 consented to receive the Covid Vaccine on 4/4/25, and R113 consented to receive the Covid Vaccine on 5/8/25. R23, R46 and R113 did not receive the Covid Vaccine, because I did not set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews facility failed to follow their policy to ensure residents are free from sexual abuse for 1 (R4) out of 3 residents reviewed for sexual abuse in a sample of 8.Findings include:R5's Facesheet documents in part: R5 is a [AGE] year-old man with a medical diagnosis of schizoaffective disorder and bipolar disorder. R5's Minimum Data Sheet Section C (07/02/2025) documents in part: R5 have a Brief Interview of Mental Status (BIMS) of 11. R5 is moderately cognitively intact.R4's Minimum Data Sheet Section C (07/10/2025) documents in part: R4 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.R3's Minimum Data Sheet Section C (08/22/2025) documents in part: R3 have a Brief Interview of Mental Status (BIMS) of 14. R4 is cognitively intact.On 09/18/2025 at 10:30 AM, surveyor observed R3 in her room. R3 stated that her boyfriend is R5. R3 stated that R5 usually gropes R4 but sometimes its consensual between R4 and R5. They will fool around…

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

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests. This has the potential to affect all residents residing on the 2nd and 3rd floor. Findings include: On 2/18/25 mouse droppings observed on the toilet room floor of R6's room on 2nd floor. On 2/18/25 mouse droppings were observed in corner on floor next to wardrobe dresser of R7's room on 2nd floor. On 2/18/25 numerous mouse droppings (100 plus) observed on the floor next to wardrobe cabinet of R9's room of 3rd floor. On 2/18/25 at 10:05AM, R3 stated I haven't seen mice in my room but R6's room has mice in it. On 2/18/25 at 10:07AM R4 stated yes there are mice in the building. On 2/18/25 at 12:48PM R9 stated yes there are mice in my room. About two days ago I stomped and killed one with my foot. I am leaving this place today because I have an apartment. On 2/18/25 at 12:35PM R8 stated yes there are mice. If you go across the hall in R9's room there are mice in his room. On 2/18/25 at 1:45PM V5 (Maintenance Director) stated we have…

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

Based on observations, interviews, and record reviews, the facility failed to discard expired food based on use by guidelines and labeled use by date, failed to ensure food items were labeled and dated with use by date, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 123 residents receiving food prepared in the facility's kitchen. Findings include: On 12/09/24 at 9:15 AM, V19 (Dietary Manager) stated all items should be labeled with an open and use by date and prepared items should be thrown out after seven days. V19 stated day one is the day the item was prepared and day seven is the date the item must be discarded on. V19 stated the purpose of labeling, dating, and discarding items after seven days is to ensure food is safe for the residents to eat and that there is a potential to make residents sick if they are served expired foods. On 12/09/24 at 9:45 AM, during initial kitchen tour observed found container of tuna salad dated 11/03/23 in the reach-in refrigerator. The tuna salad had areas of white…

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 reusable cloth incontinence briefs intended for resident use were in good condition, this failure has the potential to affect 40 incontinent residents residing in the facility. Findings include: On 12/10/2024 at 12:23PM, a tour of the laundry room was conducted with V13 (Laundry Aide). Surveyor observed the following inside of the laundry room in the basement of the facility: One cloth incontinence brief with multiple, permanent dark colored stains folded on a linen cart intended for resident use. V13 stated she is aware that she should throw the stained incontinence briefs away when the facility receives new cloth incontinence briefs. V13 stated she washed the cloth incontinence brief twice and since it is not ripped/torn, she assumed it was okay for residents to continue to use it. On 12/10/2024 at 12:47PM, V14 (Housekeeping Director) now located in the laundry room and observes the multiple, permanent dark stains on the incontinence brief. V14 states the permanent stains on the incontinence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refer four (R41, R66, R72, R90) residents with serious mental illness to the appropriate state-designated authority for PASARR (Pre-admission Screening and Resident Review) level II evaluation and determination in a total sample of 25 residents reviewed. Findings Include: R41s' Face sheet documents that R41 was admitted to the facility on [DATE] with diagnoses not limited to: bipolar disorder and anxiety disorder. R41s' PASARR screening dated 05/25/2005 titled OBRA-1 Initial Screen documents that there is reasonable basis to suspect a mental illness for R41. There is no documentation to show that R41 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R66s' Face sheet documents that R66 was admitted to the facility on [DATE] with diagnoses not limited to: schizophrenia, schizoaffective disorder, and bipolar disorder. R66s' PASARR screening dated 10/28/2013 titled Assessment Summary Information…

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 medications were locked and secured while unattended. This failure has the potential to affect all 68 residents residing on the 1st and 3rd floors. Findings Include: On 12/09/2024 at 11:15AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart unlocked and unattended with medication cart keys left inside of the medication carts' lock. V6 (Registered Nurse/RN) states she is responsible for the unlocked and unattended medication cart. V6 states this medication cart stores medications for residents on the 1st and 3rd floors of the facility. V6 states she must have gotten busy with other things and forgot to lock the medication cart and retrieve the keys. V6 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. V6 states residents could potentially overdose, have an adverse reaction, or other life-threatening complications if they get access to the medications. Surveyor observes inside of V6s' medication cart…

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 shared equipment was cleaned and decontaminated between each use for 4 [R27, R92, R104, R116] of 6 residents reviewed for medication administration observation. Findings included: On 12/9/24 at 9:38 AM, V23 obtained R116's blood pressure with a wrist blood pressure cuff device. V23 placed the device on R116 left wrist, blood pressure measured 134/99, heart rate 90. After use, V23 did not sanitize the blood pressure device, placed the device inside the top drawer of the medication cart and proceeded to prepare R116 medications. On 12/9/24 at 9:52 AM, V23 obtained R104's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device. V23 placed the blood pressure device on R104's left wrist, blood pressure measured 127/87, heart rate 82. After use V23 did not sanitize the device and placed it on top of the medication cart. On 12/9/24 at 10:10 AM, V23 obtained R92's blood pressure with same wrist blood pressure device. Prior to use, V23 did not sanitize the device 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 observations, interviews, and record reviews, the facility failed to provide dignity for two (R41, R226) residents in a total sample of 25 residents reviewed. Findings include: 1. On 12/09/2024 at 10:19 AM, R226 observed lying in bed inside of his room in a left lateral position. R226 observed with a shirt on with a white blanket half-way covering the mid-section of his body. R226 is observed without any under briefs on and his buttocks exposed. R226 states a staff member took his incontinence briefs off because they were too small. R226 states the facility does not have any incontinence briefs that are his size to place on him. On 12/09/2024 at 10:22AM, V4 (Certified Nursing Assistant/CNA) now located inside of R226s' room. V4 observes that R226 is not wearing any incontinence briefs. V4 stated she offered to place reusable incontinence briefs on R226 but R226 stated that he was not comfortable wearing the diaper. V4 stated the facility uses reusable incontinence briefs for residents who are mostly bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to correctly set air loss mattress based on weight for one (R75) of 8 residents reviewed for pressure wound treatment services in a total sample of 25 . Findings include: On 12/09/24 at 1:25 PM, R75 was observed lying in bed on an air loss mattress. Air loss mattress dial setting was in the middle of the 240-320-pound weight per the low air mattress' display panel. Surveyor felt the pressure of R75's low air loss mattress and it was hard and very firm to touch. On 12/09/24 at 1:30 PM, V2 (Director of Nursing) stated the low air loss mattress is set based on the resident's weight. V2 observed R75's low air loss mattress setting and stated R75 must weigh between 240-320 pounds since that is what the air loss mattress is set at. On 12/11/24 at 8:40 AM, V31 (Restorative Nurse/Fall Coordinator/Wound Coordinator) stated the purpose of low air loss mattress is to eliminate pressure from concentrating in one area so the pressure is distributed 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, interview and record review, the facility failed to provide adequate assistance and supervision to 2 (R50, R84) out of 2 high fall risk residents reviewed for accidents and hazards in a final sample of 25. Findings Include: On 12/09/24 at 12:05 PM, R50 was sitting in [R50's] wheelchair in the dining room alert and able to verbalize needs. R50 stated R50 has pain everywhere. R50 stated [R50] went to the bathroom by himself around 9:00 AM this morning, and while [R50] was washing [R50's] hands, R50 slipped and hit [R50's] head on the sink. R5 stated [R50] was able to lift himself back up and went back in bed. R50 stated [R50] notified the nurse but does not know the name of the nurse. On 12/9/24 At 12:10 PM, Surveyor notified V9 (Registered Nurse) of what was reported by R50. V9 stated that V9 was not made aware of R50's incident. V9 stated, I will assess and send [R50] out. On 12/9/24 At 12:31 PM, interviewed V33 (Certified Nursing Assistant) and stated that R50 can go to the bathroom on his…

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 its policy and offer pneumonia vaccines prior to or upon admission to the facility. This failure affects three (R9, R72, R75) out of five residents reviewed for pneumonia vaccines in a total sample of 25 residents. Findings include: R9s' Facesheet documents that R9 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses not limited to: Chronic Obstructive Pulmonary Disease/COPD, Anemia, unspecified open wound to left leg, and chronic multifocal osteomyelitis. Review of R9s' electronic health record/EHR reveals that there is no documentation to show that a pneumonia vaccine was administered to R9. Facility is unable to provide documentation to show the pneumonia vaccine was offered to R9 prior to 11/20/2024. R72s' Facesheet documents that R72 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses not limited to: Stage 4 Chronic Kidney Disease, Diabetes Mellitus, dependence on renal dialysis, anemia, 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, facility failed to follow their policy to report the appearance of suspicious bruise, lacerations, or other abnormalities as unknown origin as soon as it is discovered for one (R1) out of three residents reviewed for reporting of unknown injury. Findings include: R1 is a [AGE] year-old female. R1's medical diagnoses are but not limited to schizophrenia, bipolar disorder, unspecified psychosis not due to a substance or known physiological condition, seizures, and rectal prolapse. R1's BIMS (Brief Interview for Mental Status) dated 03/14/2024, notes interview for mental status was not conducted because R1 is rarely or never understood. R1's care plan documents that R1 had a fall on 2/16/2023 and 4/17/2023. On 06/04/2024 at 11:18 AM, V3 (Nurse Practitioner) stated that she was R1's nurse practitioner when R1 was here. V3 stated that R1 hurt her head a while back due to a fall. V3 stated that R1 fell on 4/18/2024. R1 refused to go to the hospital. R1 is alert and oriented x2. V3…

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 establish and implement interventions for one resident (R5), with a behavior of urinating and defecating in a waste basket. This failure has affected two residents (R5 and R6) and has the potential to affect 54 other residents who reside on the second floor. Findings include: R5 is [AGE] year-old with diagnoses including but not limited to: Catatonic Schizophrenia, Unspecified Psychosis, Depression, and Anxiety Disorder. R6 is [AGE] year-old with diagnoses including but not limited to: Chronic Diastolic Heart Failure, Peripheral Vascular Disease, Osteoarthritis, Hypothyroidism and Type 2 Diabetes Mellitus. R6 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. R5 and R6 are roommates on the second floor at the facility. On 01/22/2024 at 10:25 AM, Surveyor exited the elevator on the second floor and noted a strong odor of urine. At that time, Surveyor inquired about the odor. On 01/22/2024 at 10:27…

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 two dependent residents (R4 and R8) received showers as scheduled. This failure has affects two of five residents reviewed for ADLs (Activities of Daily living). Findings include: R4 is [AGE] year-old with diagnoses including but not limited to: Encounter for Antineoplastic Chemotherapy, Generalized Anxiety disorder, Low back pain and Type 2 Diabetes Mellitus with Diabetic Neuropathy. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R8 is [AGE] year-old with diagnoses including but not limited to: Muscle Weakness, Other Lack of Coordination, Alzheimer's disease, Hypothyroidism and Essential Hypertension. R4 and R8 are roommates on the first floor in the facility. On 01/24/2024 during unit rounds, Surveyor observed both R4 and R8 in their room in bed. On 01/24/2024 at 11:30 AM, R4 said, I really need a shower. I was supposed to have a shower on yesterday, but no one ever came to give me 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 post the daily nursing staffing. This failure has the potential to affect all 125 residents residing in the facility. Findings include: On 03/05/23 V1 (Administrator) present facility's census of 125 residents. On 11/12/23 at 9:10 am, upon entrance to the facility, the facility's daily staff posting was observed posted at the receptionist desk dated 11/9/23. On 11/14/23 at 1:40 pm V2 DON (Director of Nursing) stated, the staffing sheet should be posted daily. V2 stated, I (V2) give the staffing to the HR (Human Resource), and they are responsible for the posting for Monday to Friday. I do not know who HR give the sheets to for the weekends. On 11/14/23 at 1:50 pm, V33 (Receptionist) stated, the staffing sheets is given for the whole week, and I post the sheets daily. Surveyor inquired if V33 had the sheets for November 10th,11th, and 12, 2023. V33 stated, yes. I (V33) had the sheets for the whole week and the sheets are to be posted daily. On 11/14/23 at 2:34 pm, V39 HR (Human Resource) stated, I print 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 label/date food items, failed to store food items/goods six inches off the floor, failed to dispose of food items after the use by date, and failed to ensure staff kept personal belongings in appropriate location in an effort to prevent food borne illnesses These failures have the potential to affect all 124 residents receiving oral nutrition at the facility. Findings include: The (11/11/2023) Midnight Census report documented that there were 125 residents at the facility. The (undated) List of residents not taking oral nutrition indicated there was one resident on the list. On 11/12/23 9:29am, during the initial tour of the Kitchen with V7 (Cook); there were 2 bottles of Purified Drinking Water inside the reach in cooler. V7 (Cook) stated, these should not be here. The Reach in cooler is not for staff. On 11/12/23 09:35 AM, there was a pair of black shoes on the floor inside the dry storage room. V7 (cook) stated, these are not supposed to be here; the food in the kitchen might get contaminated. On 11/12/23…

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

Based on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed to prevent pest and rodents from migrating into the dumpster. This failure has the potential to affect all 125 residents at the facility. Findings include: On 11/12/23 at 10:00am, two out of 6 lids of the outside dumpster were open. V7 (Cook) stated, the dumpster should be closed at all times to avoid attracting bees, flies, cockroaches and rats. On 11/13/2023 at 10:26am, in reference to the outside dumpster's lids that were open, V17 (Dietary Manager) stated, the dumpster should be close at all times. There's food in the dumpster, food will attract rodents, insects, flies, and roaches to get into the dumpster. On 11/14/2023 at 10:33am, in reference to the outside dumpster, V27 (Maintenance/Housekeeping Supervisor) stated, the dumpster should be closed at all times so pest will not go there, pest like rodents. The (undated) facility provided document Safe food handling - Dumpster upon request of dumpster policy in reference to dumpster lids and overflowing garbage did…

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 room identifiers on residents' room in an effort to provide a safe environment to residents. This failure affected six (R24, R34, R43, R73, R101, and R323) residents reviewed for home like environment in the total sample of 58 residents. Findings include: On 11/12/23 10:46 AM, R34, R43, R101, and R323's room had no room number/identifier. On 11/12/23 10:47 AM, R24 and R73' room had no room number/identifier. On 11/12/23 11:02 AM, V9 (Certified Nursing Assistant) stated, that is room [ROOM NUMBER] and 104. The room numbers are missing. Maybe the maintenance put it somewhere. On 11/14/2023 at 10:20am, surveyor pointed out to V27 (Maintenance and Housekeeping Supervisor) R24, R73's, R34, R43, R101, and R323's room are missing room number/resident identification. V27 stated, someone stole the numbers 2-3 weeks ago. I (V27) informed (V1) already. I (V27) am not sure if she (V1) already ordered the 'room numbers'. On 11/14/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately don and doff personal protective equipment (PPE) for isolation rooms; failed to perform proper hand hygiene, failed to doff gloves in the hallway; failed to post the proper isolation sign for positive COVID 19 isolation rooms in efforts to prevent the spread of microorganism including COVID 19; failed to provide accessible PPE for isolation rooms; failed to properly transport COVID 19 isolation linen; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R2, R16, R18, R30, R33, R38, R94, R105, R107, and R118 and has the potential to affect all 50 residents on the first floor, all 57 residents on the second floor and all 18 residents on the third floor at the facility. Findings include: On 11/12/23 V2 (Director of Nursing, DON) presented the facility census of 125 residents. On 11/13/23, V18 (Infection Preventionist Licensed Practical Nurse, LPN) provided a document titled Updated Positive…

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

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of roaches. This failure has the potential to affect all 125 residents in the facility. Findings include: On 11/12/23 at 10:00am, two out of 6 lids of the outside dumpster were open. V7 (Cook) stated, the dumpster should be closed at all times to avoid attracting bees, flies, roaches, and rats. On 11/13/2023 at 10:26am, in reference to the outside dumpster that was open. V17 (Dietary Manager) stated, the dumpster should be close at all times. There's food in the dumpster, food will attract rodents, insects, flies, and roaches to get into the dumpster. On 11/12/23 at 11:25 AM, there was a live roach inside the shower room. This observation was pointed out to V12 (Certified Nursing Assistant). V12 stated, there is a small live roach in shower 3. On 11/14/2023 at 10:22am, in reference to the live roach seen on the 1st floor shower room, V27 (Maintenance and Housekeeping Supervisor) stated, I (V27) just came in today and nobody told me (V27)…

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 call light device was within reach for one resident (R107) to call for staff assistance. This failure affected one resident (R107) in the sample of 58 residents reviewed for accommodation of needs. Findings include: R107 has a diagnosis of but not limited to Chronic Atrial Fibrillation, Protein-Calorie Malnutrition, Vascular Dementia, Low Back Pain, Age Related Osteoporosis, Cognitive Communication Deficit. R107's has a Brief Interview of Mental Status score of 10 that indicates moderate cognitive impairment. On 11/12/2023 at 11:25am surveyor observed R107's call light device on the left side of the pillow underneath another pillow where R107 could not reach. On 11/12/2023 at 11:26am R107 said, I ((R107) cannot reach it. Surveyor observed R107 attempting to reach for the call light, but R107 was unable to reach the call light. On 11/12/2023 at 11:28am V15 (CNA) stated, no R107 cannot reach the call light and it (referring to call light) should be attached to the resident. On 11/14/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a thorough physical abuse investigation which affected two (R49 and R70) residents in the sample of 58 residents reviewed for abuse. Findings include: On 11/12/23 at 11:14 am, R70 observed in wheelchair propelling self out of R70's room using R70's right arm to move the wheelchair wheel and right foot to move on floor. R70's left arm laying on R70's lap. This surveyor noted a healed, pink laceration, approximately 3 centimeters (cm) in length. When asked about the laceration, R70 stated, I (R70) fell and hit my head. R70 stated, it was in the basement in the dining room by the vending machine (on 10/12/23). R70 said, R49 and R70 were in the dining room with no one else there. R70 said, R70 doesn't remember exactly what R49 said to R70 but that all of a sudden, I (R70) fell and hit my head. R70 said, R70 yelled, and the nurses and CNAs came and helped R70. R70 stated, I (R70) was bleeding from above my eye pointing to R70's left eyebrow. R70…

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 document review the facility failed to maintain its nurse call system in full functioning condition on 3 of 3 resident floors. This affects all 123 residents in the facility. Findings include: On 10/14/23 at 10AM the facility nurse call system was tested. V2 Director of Nursing (DON) and V4 (Maintenance/Housekeeping Director) were present during observations. Room A corridor light above room door does not function when call is activated. R2 and R3 corridor light above room door does not function when call is activated. When R2 and R3 toilet room nurse call is activated for the following rooms R8's room, B, C and D rooms light up at the 2nd floor nurses station nurse call panel. When the room B room nurse call is activated rooms R8's room, B, C and D rooms light up at the 2nd floor nurses station nurse call panel. When R8's room nurse call is activated in rooms R8's room, B, C, D and E rooms light up at the 2nd floor nurses station nurse call panel. R2 and R3's corridor light above room door does not light when call is activated. Room F lights up…

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.