Wentworth Rehab & Hcc

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review the facility failed to follow policy procedures and failed to develop a comprehensive care plan for one of three residents (R4) reviewed for abuse. Findings include: On 2/20/25, the State Agency received allegations that V7 (Certified Nursing Assistant) has been having an intimate relationship with R4 for the past two months, and this is abuse. R4 was admitted to the facility on [DATE]. R4's comprehensive care plan (received 2/26/25) excludes risk for abuse. On 2/26/25 at 11:32am, surveyor inquired when comprehensive care plans are developed V3 (ADON/Assistant Director of Nursing) stated The initial is on new admission. [R4 was admitted roughly 5.5 months ago]. On 3/3/25 at 12:27pm, surveyor inquired if R4 has an abuse care plan V3 reviewed R4's electronic medical records and responded I (V3) just see that he's (R4) an identified offender. I don't really see a care plan that he's at risk for abuse. Surveyor inquired if abuse should be included in resident care plans due 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 upon record review and interview the facility failed to follow policy procedures and failed to review/revise comprehensive care plans for two of four residents (R1, R5) reviewed for falls and pass privileges. Findings include: On [DATE], the State Agency received allegations concerning resident medical records not being updated to reflect current condition. On [DATE] at 11:32am, surveyor inquired when care plans are required to be reviewed and/or revised V3 (ADON/Assistant Director of Nursing) stated It's every 3 months and if it's a change or something new comes up. R1's care plans include the following: ([DATE]) Risk for falls, Goal Target Date: [DATE] [expired 2.5 months ago]. ([DATE]) Resident has been evaluated to be placed on a level one of the behavioral health pass program, Goal Target Date: [DATE] [expired 2.5 months ago]. On [DATE] at 12:01pm, surveyor inquired about concerns with R1's ([DATE]) fall care plan V3 (ADON) reviewed R1's electronic medical records and stated, I actually don't see…

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 record review and interview the facility failed to follow their abuse policy for one resident (R1), out of three residents reviewed abuse. This failure resulted in R1 falling to the floor during a behavior episode when a staff member who was not appropriately trained on Crisis Prevention Interventions (CPI) attempted to assist with the behavior. Finding Include: R1's care plan reads: R1 has difficulties managing her anger/frustration as evidenced by verbal and physical aggression. During periods of increased agitation, move resident to a quiet location, and intervene as appropriate. 10/26/2024 08:40 R1 Behavior Note Text reads: Writer witness resident grab food rack from staff and shove and throw (it) down, at her, and other residents in facility. Writer responded asking resident to calm down, attempting to redirect. Resident then refused and said, you can't touch me, and you will be next if you don't shut up talking to me. Resident then walked east and around towards room shouting, stop talking to me. 10/26/2024 14:14 R1 Nurses Note Text reads: resident was exhibiting…

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 special eating equipment and appropriate assistance for one (R3) resident out of three residents reviewed, in a total sample of three residents. This failure has the potential to affect the resident's ability to maintain or improve their ability to eat or drink independently. Findings include: R3's current face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dementia in other diseases classified elsewhere, muscle weakness (generalized). On 11/06/2024, 12:16 PM, R3 in dining room using her left-hand appears having difficulty grabbing food off the plate with a spoon. Observed dropping food off the spoon as she lifted to feed herself slowly. On 11/06/2024, 12:20 PM, R3 sitting in dining room not eating. Staff preparing meal trays, cook serving the meal plates, CNAs (certified…

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 maintain medical records for one resident (R1) in accordance with its policy and accepted professional standards of practices that are complete and accurately documented. This failure affects one of three residents reviewed for records, in a total sample of three residents. Findings include: During record review of R1s' electronic health record on 11/06/2024, at approximately 1:30 PM, R1s' most recent community survival assessment dated [DATE], documents that R1 is not capable of unsupervised outside pass privileges at this time. R1s' community survival skills assessment dated [DATE] and signed by V29 (Behavioral Health Counselor/BHC), documents that R1 is not sufficiently oriented and coherent affording her the potential for independent pass privileges. R1s' assessment also documents that R1 is not capable of unsupervised outside pass privileges. Surveyor requests a copy of R1s' most recent community survival assessment from V7 (Director of Behavioral…

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 the fall prevention interventions as stated in the care plans for residents with Dementia who are also at risk for falls. This failure has the potential to affect 4 residents, R8, R9, R10, and R11, reviewed for proper footwear as a fall prevention intervention. Findings include: On 10/9/24 between 10:45am and 10:55am during observation on the fourth floor, the following were observed: R11 was observed walking in the hallway and by the nursing station with red socks that are smooth on the bottom; V5(Memory Care Director) stated She's supposed to wear non-skid socks. R10 was observed in the day room in the wheelchair with black socks that are smooth on the bottom. R9 was observed in the day room with grey socks that are smooth on the bottom. R8 was observed in the day room sitting with other residents at the table with socks that are smooth on the bottom. The surveyor inquired about R8, R9, and R10, from V14 (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, interview, and record review, the facility failed to ensure that the large community shower room on the fourth floor East-Wing is maintained in a sanitary manner free of drain/sewer back-up. This failure has the potential to affect all 37 residents on the fourth floor East-Wing. Findings include: On 10/7/24 at 10am after the entrance conference, V1(Administrator) presented the census that shows as follows: Fourth Floor Unit A - 19 residents; Fourth Floor Unit B - 18 residents; total of 37 residents on the East wing of the fourth floor. On 10/7/24 at 10:40 am, with V10 (Assistant Director of Nursing), observed the East-Wing Community shower room with a wet towel covering the black liquid oozing out of the drain. Surveyor inquired from V10 if it was okay to have the drain like that; V7 stated They used the towel to cover it because they could not use it. I will notify maintenance. The Maintenance logbook did not document anything about the clogged shower room floor drain. On 10/9/24 at 11:22am, V12 (Maintenance Director) stated Somebody told me about it…

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 effective pest control for seven [R1, R2, R6, R7, R8, R9, R10] residents in the sample of 10. These failures have the potential to affect all 51 residents residing on the third floor. Findings include, On 8/20/24 at 10:20 AM R2 stated, I came to this facility because at my old facility, the staff was abusing me there too, and they stole my money. When I came here on 7/1/24, I moved into my room there was bugs crawling over me, the bed and privacy curtain. I told the nurse about it the next morning. I was in the day room, and someone came to me and said, 'you have to move to another room it has to be fumigated for bugs.' I was so embarrassed with my peers staring at me like I was nasty. I did not bring any bugs with me; the bugs were already here. On 8/20/24 at 10:48 AM, R6 stated, I been here since 2021. I know R2. I eat all my meals and participate in activities in the day room, but I keep getting bed bugs in my room. This 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 a resident's mammogram, ultrasound appointment refusal was addressed and failed to ensure further attempts to reschedule the appointment for 1 (R2) of 3 residents reviewed for Quality of Care. Findings Include: R2 was admitted to the facility on [DATE] with diagnoses not limited to Chronic Sinusitis, Asthma, Constipation, Heartburn, Urinary Incontinence, Pain, Insomnia, Essential (Primary) Hypertension and Schizoaffective Disorder. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Transfer paperwork from previous facility dated 05/14/24 02:46 PM document in part: R2 complained of a lump under the left breast. Order given to do ultrasound of left breast. 9:01 PM performed ultrasound to left breast. 05/16/24 4:20 PM R2 has left breast US (ultrasound) which found 4.9 x 4.0 x 3.7 cm (centimeter) hypoechoic solid tumor mass with intralesional mild vascular doppler signal, highly…

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 administer medications as ordered by the physician and failed to document the reasons for not administering medications as ordered. These failures affected 5 residents (R1, R2, R3, R4, and R5) of 5 residents, reviewed for medication administration, missed medications, and documentation of medications not given. Findings include: On 6/12/24 at 10:45am, R1 was observed in bed and interviewed regarding his missed medications. R1 stated that a few times, the nurse did not give him his medications. R1 explained that each time he was not given his medications, the nurse gave reasons like the computer was down, the medication was not available, or she could not find the keys. R1's BIMS (Basic Interview for Mental Status) dated 5/9/24 shows a score of 15 (Cognitively Intact.) On 6/12/24 at 12:05pm, V2 (Director of Nursing) presented the MAR (Medication Administration Records) and POS (Physician Order Sheets) for R1-R5 for May 2024. The MARs had several missing entries that were blank without any chart codes. The physician 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and sanitation, failed to utilize measuring utensils when mixing ingredients, failed to follow the recommended portion size for the menu, and staff failed to wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. This has the potential to affect all 180 residents in the facility. On 5/28/2024 at 9:30AM surveyor arrived at facility. Conducted kitchen observation observed one cook, four dietary aides and a dietary manager. V17 observed without hair net while preparing food in food designated areas. Surveyor notified staff of inspection. V8 reminded V17 she needed a hair restraint on. On 5/28/2024 at 9:35AM surveyor observed in main fridge, one crate with six cartons of eight-ounce carton of milk with no expiration date or used by dates labeled. On 5/28/2024 at 9:37AM surveyor observed expired potato salad with receive…

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 adequate staffing for one out of four floors of the facility. This failure affects all the residents that reside on the second floor. Findings include: On 05/30/2024, at 10:57 AM, V28 (Staffing Coordinator) stated, The facility has a total of five nurses on each shift. There is at least one RN (Registered Nurse) for the morning. There are a total of fifteen aides a day. Aides work eight-hour days. Nurses work twelve-hour days. Fourth floor has four aides every day, including weekends. One nurse on the fourth floor. Third floor has two aides. One nurse on the third. Second floor has two nurses and six aides. The second flood is my highest acuity floor. First floor is one nurse and two aides. Nursing staff is based on the census and acuity. We replace call offs. I am here at 6:00 AM. I have a phone 24 hours a day, seven days a week. I try to get someone to stay over or get someone to come in when there is a call off. The restorative nurses can work, and restorative aides can also work. Holidays I try to over 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 administer resident's prescribed medications in a timely manner according to the physician orders. This failure affects twelve (R63, R65, R68, R71, R83, R86, R107, R131, R134, R135, R143, R159) residents in a total sample of 35 residents. Findings include: On 05/28/2024 at 9:29AM, surveyor located on the first floor of the facility with V3 (Registered Nurse/RN). V3 states to surveyor that she was scheduled to start her shift at the facility at 7:00AM. V3 states she started her shift at the facility today at approximately 8:20AM. V3 states she began administering medications to residents at approximately 9:00AM. On 05/28/2024 at 10:09AM, V3 states that she is running a little behind and the resident's electronic medication administration record/eMAR will now turn red in color for resident's medication. V3 states the red color on the resident's eMAR will turn red to indicate that the medication to be administered is considered late. V3 states the time frame to administer resident's medication is one hour before…

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 a.) ensure that multi-use blood pressure cuff devices and pulse oximeters were properly cleaned and disinfected in between resident use for ten (R12, R20, R27, R29, R83, R98, R124, R126, R159, R161) residents, b.) ensure that its staff follow the facility's policy to demonstrate proper hand hygiene while performing peri-care to one resident (R14), and c.) post a contact isolation precaution sign for one resident (R157) identified as having a physician order for contact isolation precautions in a total sample of 35 residents reviewed for infection control. Findings include: On 05/29/24 9:49 AM R14 agreed for surveyor to observe V15 (CNA) provide peri-care to R14. V15 cleaned R14's peri-area. V15 proceeded to apply a new brief on R14. V15 gently moved R14's right leg over his left leg to turn on his left side. V15 turned R14 back on his back, V15 secured brief. V15 applied oil on R14's arms, legs. Then V15 proceeded to cover R14 with towel,…

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 within reach for two residents (R14, R17) reviewed for environment/accommodations of needs in a total sample of 35 residents. This failed practice placed the resident at risk for not being able to call for help, if needed. Findings include: On 05/28/24 10:54 AM observed R17 in bed lying down, head of bed elevated, observed with limited movement to her right arm, noted slightly contracted. R17 states that she has had a history of bad strokes. Surveyor observed R17 's call light under her right arm, on her lower right side of her stomach. Surveyor questioned resident if she can reach her call light, observed R17 attempt to reach the call light with her left hand. R17 observed having difficulties attempting to reach her call light. Resident states that she is unable to reach it because she states that she doesn't have the strength. R17 states that this is not the first time that she is unable 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 refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This failure affects two of two residents (R58 and R88) reviewed for PASSR (Preadmission Screen and Resident Review) in a total sample of 35 residents. Findings include: R88 is a [AGE] year-old man. R88's face sheet lists R88's diagnosis as bipolar disorder. R88 was admitted to the facility on [DATE]. R88's OBRA (Omnibus Budget Reconciliation Act) initial screen dated 08/17/2020. The screen notes that there is not a reasonable basis for suspecting MI (Mental Illness). PASRR (Preadmission Screen and Resident Review) Outcome Explanation Notice dated 08/16/2022, notes R88 does not need more screening unless you have a serious mental illness or experience a significant change in treatment needs. R88 was diagnosed with bipolar disorder 07/21/2023. On 05/30/2024, at 12:11 PM, V9 (Psychosocial Coordinator) stated, When a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers to a resident who is unable to maintain good personal hygiene. This failure affects one of three residents (R174) reviewed for activities of daily living in a total sample of 35 residents. Findings include: R174 is a [AGE] year-old female resident. R174's face sheet notes medical diagnoses as pressure ulcer of sacral region stage four, pressure ulcer of right heel stage 3, pressure ulcer of other site stage 3, dementia, Alzheimer's disease, high blood pressure, visual disturbance, and wasting syndrome. R174's MDS (Minimum Data Set) dated 04/04/2024, notes R174 is not alert. R174's MDS also notes that R174 requires substantial/maximal assistance with showers and bathing R174. R174's care plan notes R174 has an ADL (activity of daily living) functional performance deficit with decreased functional ability. Staff must assist with ADL tasks as needed and assist with personal hygiene as needed. R174 demonstrates impaired cognitive…

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 catheter changes for a resident that requires an indwelling catheter. This failure affects one (R174) of three residents reviewed for catheters in a total sample of 35 residents. Findings include: R174 is a [AGE] year-old female resident. R174's face sheet notes R174's diagnoses as pressure ulcer of sacral region stage four, pressure ulcer of right heel stage 3, pressure ulcer of other site stage 3, dementia, Alzheimer's disease, high blood pressure, visual disturbance, and wasting syndrome. R174's MDS dated [DATE], notes R174 is not alert. R174's care plan notes R174 has an ADL (activity of daily living) functional performance deficit with decreased functional ability. Staff must assist with ADL tasks as needed and assist with personal hygiene as needed. R174 demonstrates impaired cognitive functioning related to Alzheimer's disease dementia. On 05/28/2024, at 11:21 AM, R174 was seen in bed with a catheter. R174's urine was very…

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 medications were administered as ordered by the residents' physician for one (R83) resident in a total sample of 35 residents. Findings Include: On 05/28/2024 at 9:29AM, surveyor located on the first floor of the facility with V3 (Registered Nurse/RN). V3 states she is unable to locate R83's medications in the medication carts. V3 is observed opening and closing drawers and searching in both medication carts on the first floor. V3 states she will have to call the pharmacy to inquire about R83's medications. On 05/28/2024 at 10:21AM, V3 is observed calling the facility's contracted pharmacy and places the call on speaker. Pharmacy representative states to V3 that R83 has experienced a loss of insurance and R83's medications cannot be shipped to the facility due to insurance issues. Pharmacy representative states to V3 that R83 should be enrolled in a Medicaid insurance plan. Pharmacy representative states to V3 that the pharmacy…

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, facility failed to follow their policy to ensure medications that are outdated are to be immediately removed or disposed, for 2 (R54 and R81) out of three residents reviewed for medication storage and labeling in the sample of 35. Findings include: On 05/28/2024 at 11:00 AM, surveyor observed the medications on cart #1 and cart #2 on 3rd floor. V5 (Licensed Practical Nurse) stated that she is the only nurse on the 3rd floor, and she manages Cart #1 and Cart #2. On cart #1 surveyor observed a budesonide formoterol fumarate dihydrate inhaler for R54. There was a label on the inhaler which stated when the medication was first given and when it is expired. The label on the inhaler had written on it that the date opened was 2/13/2024 and date the date expired was 5/13/2024. On 05/28/2024 at 11:05 AM, surveyor asked V5 what do these two dates mean. V5 stated that those are the dates when the medication was opened and first given and when it expires. V5 stated that the date that the inhaler for R54 was opened on 2/13/2024 and it expired 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 observations, interviews, and records review, the facility failed to provide a meal to one (R85) of five residents reviewed in sample of 35. This failure resulted in R85 experiencing hunger. Findings include: R85's current face sheet documents R85 is a [AGE] year-old individual with medical conditions that include but not limited to: End stage renal disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, displaced fracture of shaft of second metacarpal bone, left hand, subsequent encounter for fracture with routine healing, history of falling, type 2 diabetes mellitus without complications. R85's MDS (Minimum Data Set) dated [DATE], documents R85 has a BIMS score of 15/15, indicating R85 has intact cognation, MDS section GG -Functional Abilities and Goals documents R5 needs supervision or touching assistance and partial to moderate assistance with Activities of Daily Living (ADL) care. On 5/28/2024 at 11:35am, R85 was observed in her 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.

Based upon record review and interview the facility failed to revise care plans with appropriate interventions for three of three residents (R1, R2, R3) reviewed for falls. Findings include: On 5/21/24 at 1:32pm, surveyor inquired about resident fall prevention interventions (post fall). V10 (Restorative Nurse) stated We want to put in an intervention based off of what we observed to prevent this from happening again or prevent injury. The intervention is in the care plan, we update the care plan. The facility fall log affirms R1 fell on 4/12/24. R1's (4/5/24) care plan states resident is at risk for falls. Interventions: (4/12/24) Send resident to hospital for further evaluation and treatment status/post fall. On 5/21/24 at 1:43pm, surveyor inquired about R1's (4/12/24) fall. V10 stated While she (R1) was in the room and provided ADL (Activities of Daily Living) care, she had a fall. She was injured, she hit her head. Surveyor inquired if R1's care plan interventions were revised on or about (4/12/24) V10 responded Yes and affirmed that Send resident to hospital for 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.

Based on observation, interview, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a sanitary, orderly, and comfortable interior for two residents (R7, R11) of 3 residents reviewed for clean, sanitary, and homelike environment. Findings include: On 3/19/2024 at 10:32am, Surveyor team smelled odor coming from a room on unit four upon arrival to unit. Observed large yellow urine stain on the floor under bed two and three of R11's room. In R11's room, observed (R11) bed with three urinals, two on bedside table and one on dresser. R11 was laying down on low bed with walker at bedside. R11 alert and verbally responsive. On 3/19/2024 at 12:37pm R7 observed leaving dining room area to her room. R7 approached room and started yelling my bed not made up, the other beds are made and there is boo boo on my floor. I can't get to the bathroom with this on my floor. Observed dried feces on floor in R7 room extended from beds to the door. R7 informed V6(restorative aide). Observed V6 trying to clean the feces up with sanitation…

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 reviews the facility failed to provide the necessary care and services to ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, oral and incontinent hygiene care affecting one resident (R8) out of three residents reviewed for incontinent care. Findings include: On 3/19/2024 at 11:00am observed R8 on fourth floor dementia unit inside the dining room sitting in his wheelchair at the table with safety harness on. R8 observed talking to self and speaking to individuals as they walked by. R8 was yelling, I got to go to the bathroom. R8 noted with catheter tube and privacy bag connected to wheelchair. R8 continue to have conversations to himself and saying I have to go pee. On 3/19/2024 at 11:00am-11:56am observed. R8 continued to ask for assistance to the bathroom. V6 (restorative aide) then came to the dining room were R8 was siting and removed him. V6 notified V7 (certified nursing assistant/CNA), and they took R8 to his room. On 3/19/2024 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 notify physician of x-ray result revealing right hip fracture immediately. This failure affected one (R2) of 3 residents reviewed for resident injury. The findings include: R2's health record documented admission date of 5/24/23 with diagnoses not limited to Malignant Neoplasm of Liver, Pressure Ulcer of Sacral Region Stage 4, Pressure Ulcer of Left Elbow Stage 3, Xerosis Cutis, encounter for palliative care, Gastro-Esophageal Reflux Disease without Esophagitis, Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture With Routine Healing, Urinary Tract Infection, Hyperkalemia, Hypo-Osmolality And Hyponatremia, Acute Kidney Failure, Cardiac Arrest, Elevation of Levels of Liver Transaminase Levels Transaminitis, Altered Mental Status, Hypotension, Acute Respiratory Failure with Hypoxia, Tachycardia. R2 is under hospice care since admission. On 9/19/23 at 10:51 am observed R2 lying in bed, alert and verbally responsive, lying 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.

Based on interviews and record reviews, the facility failed to ensure complete medical records by failing to have weights and wound treatments charted for two (R2, R3) out of a total sample of 11 residents. Findings include: R3's July 2023 Treatment Administration Record (TAR) documents in part an order to cleanse R3's sacral wound with normal saline then apply foam daily and as needed. Blank charting/no charting for 7/6, 7/7, and 7/10. July 2023 TAR also documents in part an order for Medihoney Wound/Burn Dressing Paste (Wound Dressings) Apply to sacrum topically everyday shift for [wound care] after cleansing with [normal saline] and applying MediHoney and adaptic or calcium alginate then cover with foam dressing. Blank charting for 7/16 and 7/17. Additional order documents in part Optifoam Gentle Ex 6 X 6 External Apply to sacrum topically every day shift for [wound care] cleansing with [normal saline] and applying MediHoney and adaptic or calcium alginate. Blank charting for 7/16 and 7/17. Attempted telephone interviews with V42 (Former Wound Care Coordinator) on 9/20/2023 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 follow the residents' comprehensive care plan to ensure their call lights were within easy reach for 4 (R4, R16, R22, R317) of 4 residents reviewed for call lights in a total sample of 32 residents. Findings Include: On 6/13/23 at 10:54 AM, R16 was sitting on the side of R16's bed. R16 stated that R16 is legally blind and only see movements. R16's call light was observed on the floor by R16's bed and not within reach of R16. R16 stated that R16 goes up to the nurse's station when help is needed. R16 stated, I don't know where it is. At 11:21 AM, R317 lying in bed alert and able to verbalize needs. R317 stated that R317 is new to the facility and just came from an acute hospital for rehabilitation. R317 stated, I don't know. I don't have a call light, since I came here. I can't call for help. Observed R317's room and only found a call light connected to the wall in the bathroom but nothing by R317's bed. At 11:27 AM, V5 confirmed that R317…

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 policy and procedures for advance directives by not addressing on the resident's care plan for one (R96) resident. The facility also failed to ensure in obtaining physician order for five (R1, R53, R96, R152, R155) of five residents. These failures can potentially affect 5 residents in a sample of 32 reviewed for advance directives. Findings include: R152 admission date was on [DATE] with diagnoses not limited to Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, Essential Hypertension, Type 2 diabetes mellitus, Anemia, Vitamin D deficiency, Hyperlipidemia, Ataxia, Cocaine abuse. R155 admission date was on [DATE] with diagnoses not limited to Malignant neoplasm of connective and soft tissue of thorax, Chronic and other pulmonary manifestations due to radiation, Encounter for antineoplastic chemotherapy, Type 2 Diabetes Mellitus, Anemia, Long term use of systemic steroids, Vitamin D deficiency, Elevated…

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 revise 4 (R1, R96, R155, R267) of 5 residents' comprehensive care plan to address their current psychotropic medications use in a sample of 32 reviewed for psychotropic medications. Findings Include: R1's clinical records show an admission date of 5/24/06 with listed dx not limited to schizoaffective disorder, type 2 diabetes mellitus, heart failure, and anxiety disorder. R1's physician order sheet (POS) shows R1 is taking scheduled psychotropic medications Haloperidol, Sertraline, and Quetiapine. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R1 received antipsychotic, antianxiety, and antidepressant medications. R1's comprehensive psychotropic care plan date initiated on 6/9/22 does not address R1's current psychotropic medications use. The care plan focus reads, R1 is receiving anti-anxiety medication Buspirone, anti-depressant medication Doxepin and anti-psychotic medication Haldol, to manage symptoms related to a diagnosis…

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 smoking assessment and safety protocol policy and procedure by not developing a care plan for one (R72) resident and not evaluating residents who smoke on a quarterly basis for five (R30, R72, R113, R116, R152) residents. These failures can potentially affect five (R30, R72, R113, R116, R152) of five residents reviewed for smoking in the sample of 32. The findings include: R30 admission date was on 10/11/21 with diagnoses not limited to Unspecified protein-calorie malnutrition, Alcohol abuse, Unspecified Asthma, Disorder of kidney and ureter, Vitamin D deficiency, Hypertensive chronic kidney disease, Anemia in chronic kidney disease, Solitary pulmonary nodule, Tobacco use, Essential hypertension, Bilateral age-related cataract. R72 admission date was on 3/22/23 with diagnoses not limited to Cerebral infarction due to embolism of bilateral anterior cerebral arteries, Low back pain, Essential hypertension, Atherosclerotic heart disease, Embolism and thrombosis of unspecified artery, Hyperlipidemia,…

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 follow their policy by not obtaining consents for psychotropic use prior to initiating the medications and failed to limit as needed psychotropic medications to 14 days for 4 (R96, R108, R133, R267) out of 5 residents reviewed for unnecessary medications. Findings include: On 06/13/2023 at 12:26 PM, Reviewed R96's physician order sheets. R96 had an order for RisperiDONE ordered 05/02/2023. R96's Medication Informed Consent Form for Risperidone has a date of 06/14/2023 4:30 PM. Facility did not provide a consent dated for when medication was ordered. On 06/13/2023 at 12:50 PM, Reviewed R108's physician order sheets. R108 had orders for QUEtiapine ordered 06/01/2023 and OLANZapine every 6 hours as needed for agitation ordered 4/19/2023 with an end date of Indefinite. R108's Medication Informed Consent Forms for Quetiapine and Olanzapine have a date of 06/15/2023 10:00 AM. Facility did not provide consents dated for when the medications were ordered. On 06/14/2023 at 9:30 AM, Reviewed R108's progress notes. No behavioral…

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 insulin pens were stored properly to prevent cross contamination in 2 of 4 medication carts reviewed for medication storage and labeling. Findings Include: On 06/14/23 at 12:15 PM the third-floor East medication cart was checked with V5 (Licensed Practical Nurse). Six Insulin pens were observed stored in a Styrofoam cup without bags in the medication cart drawer. R76 Order dated 04/24/23 document: Lantus Solostar Solution Pen-injector 100 UNIT/ML (Milliliters) (Insulin Glargine) Inject 53 unit subcutaneously at bedtime. Insulin pen observed in the medication cart reads: Lantus Solostar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 50 unit subcutaneously twice a day. R76 Order dated 06/12/23 document Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 14 unit subcutaneously with meals. Insulin pen observed in the medication cart reads: Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 10 unit subcutaneously three times…

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 serve foods under sanitary conditions by not ensuring serving utensils were sanitized before using to serve foods to the residents. This failure affected all 46 residents on the third floor receiving regular textured diet. Findings Include: On 6/13/23 at 12:19 PM, during dining observation on the 3rd floor for lunch, observed V9 (Dietary Aide) dropped three serving utensils on the floor. V9 picked them up and washed them briefly with soap and water at the nearby handwashing sink. V9 set the three wet serving utensils aside for approximately one minute and then placed one of the serving utensils in the plain pasta container and the other two serving utensils in the salad containers. V9 then started serving the residents the salads using the un-sanitized serving utensils. On 6/14/20 at 11:07AM, interviewed V6 (Food Service Supervisor) and stated that all dishwares are supposed to be sanitized before use. V6 stated that V6 expects that all dietary staff should sanitize all dishwares and utensils first before…

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. [A] the facility failed to follow their infection prevention and control policy when staff entered the room of one [R146] of two [R22] on transmission-based precautions without wearing the appropriate personal protective equipment (PPE) [B] failed to have Enhanced Barrier Precautions signage, have available and accessible Personal Protective Equipment (PPE), and wear PPE during high-contact resident care activities for one (R154) resident who had a urinary catheter and [C] failed to ensure the glucometer and reusable medical equipment was cleaned and disinfected between resident use. This failure has the potential to affect 6 (R22, R33, R67, R75, R91, R136) out of 7 (R97) residents reviewed during medication administration. Findings include, On 06/13/23 10:45 AM, R146 was resting in bed. Observed V8 [Social Service Director] walked directly into R146's room without applying any PPE and touched R146's linen as he spoke to R146. V8 exited the room without handwashing or using alcohol. On 6/13/23 at 10:47 AM, V8 stated, I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and provide discharge instructions to a resident (R166) who chose to discharge Against Medical Advice (AMA) who was reviewed for discharge in a sample of 32. Findings include: R166 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Dependence on Renal Dialysis, History of Falling and Asthma. Document titled Against Medical Advice (AMA) Form: Release from Responsibility for Discharge signed and dated 05/08/23. Progress note dated 05/08/23 document in part: Late Entry: MD (Medical Doctor) notified resident discharge AMA. There was no additional information documented in the Electronic Medical Records. 06/15/23 at 08:18 AM V2 (Assistant Administrator) stated VR166 will not have a discharge summary or assessment because R166 left AMA. It was not a proper discharge. 06/15/23 at 10:56 AM V15 (Licensed Practical Nurse) stated I was the nurse on duty when R166 left AMA. R166 woke up 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 an air mattress used for pressure reduction was on the correct settings, for 1 (R22) of 3 (R4, R85) residents reviewed for pressure ulcers, in a sample of 32. Findings Include: R22 has diagnosis not limited to Respiratory Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Tachypnea, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side and Diaper Dermatitis. R22 weights dated 06/08/23 document: 120.0 Lbs. (pounds), 05/25/23 119.8 Lbs., 05/18/23 119.2 Lbs. and 05/11/23 120.8 Lbs. Care plan document in part: Actual alteration in skin integrity, sacrum, right buttock, right arm cast, Hx (history) of pressure ulcer R ischium, L Hip Date Initiated: 03/25/23. Interventions: Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed Date Initiated: 05/25/23. On 06/13/23 at 11:20 AM Entered R22 room and observed R22 laying in the bed on a low air loss mattress. The low air loss mattress setting was observed…

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 perform appropriate hand hygiene practices when providing catheter care, handle the catheter bag and tubing in accordance with infection control standards of practice, and provide complete catheter care in a timely manner for 1 (R154) resident out of a total sample of 32 residents reviewed for improper nursing care. Findings include: R154 is a resident of the facility. R154's face sheet documents in part medical diagnoses of benign prostatic hyperplasia and retention of urine. R154's comprehensive care plan contains a focus initiated on 05/04/2023 that documents in part R154's need to use a suprapubic catheter related to benign prostatic hyperplasia. Interventions initiated 05/04/2023 document in part: Catheter care per orders, Position collection bag below the level of the bladder, and Provide catheter care. R154's physician order sheets document in part: Catheter: Indwelling urinary catheter care daily and PRN [as needed]. On 06/13/2023 at 10:46 AM, R154 was sitting up in a wheelchair in the day 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 a.) ensure oxygen tubing was labeled and stored to prevent contamination for 2 (R4, R67) of 2 residents and b.) ensure a resident received the correct oxygen flow rate for 1 (R67) resident in a sample of 32. Findings Include: R67 has diagnosis not limited to Type 2 Diabetes Mellitus, Pneumonia Due to Streptococcus Pneumoniae, Acute Respiratory Distress Syndrome, Acute Respiratory Failure with Hypoxia and Dependence on Supplemental Oxygen. Order Summary Report dated 06/14/23 document in part: Respiratory: Oxygen per nasal cannula @ 4 liters per minute continuous every shift for respiratory symptoms. R4 was admitted to the facility on [DATE] with diagnosis not limited to Chronic Kidney Disease, Chronic Pulmonary Emboli, Mood (Affective) Disorder, Contracture of Muscle Unspecified Site, Muscle Weakness (Generalized), Encounter for Palliative Care, Protein Calorie Malnutrition, non - Pressure Chronic Ulcer of Unspecified Part of Left leg with…

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

Based on observation, interview, and record review the facility failed to ensure a resident was free from a significant medication error related to insulin administration for 1 (R97) of 6 (R22, R33, R67, R75, R136) residents reviewed for medication administration. Findings Include: R97 has diagnosis not limited to Type 2 Diabetes Mellitus and Morbid Obesity On 06/14/23 at 12:00 PM V5 (Licensed Practical Nurse) stated R97 blood glucose was 350 and she will receive 10 units of insulin. V5 retrieved the Novolin R Injection Solution 100 UNIT/ML (Milliliters) (Insulin Regular (Human)) and applied a needle to the insulin pen. V5 proceeded to R97 room setting the insulin pen at 10 units. V5 injected the insulin into R97 right upper arm. V5 stated I prime the needle the first time using the insulin pen but when I use it again, I usually don't prime it. I thought holding the insulin pen against the skin is the reason that you get the right amount of insulin. An air bubble was observed in the insulin pen. Upon priming the needle, V5 did not see any insulin at the tip of the needle. After…

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 Nurse Staffing information was posted daily and failed to ensure the Nurse Staffing information was accurate. These failures affected all residents residing in the facility. Findings include: On 8/21/2022 the facility census was 167 residents. On 8/21/2022 at 9:04am surveyor observed the Nurse Staffing posted in front of the receptionist window with a date of 8/18/2022, there was no daily staffing sheet posted for 8/21/2022. At about 12:40pm surveyor observed the Nurse Staff sheet with a date of 8/18/2022 and surveyor inquired from V10 (Receptionist) about how often the Staffing sheet is changed. V10 said, I usually change it and it should be changed every morning when I come in at 7:00am, but the printer isn't working. On 8/22/2022 multiple observations were made between 9:04am and 3:23pm and surveyor did not observe any Nurse Staffing Sheet for 8/22/2022 posted in the reception area. On 8/23/2022 at 12:02pm V2 (Director of Nursing) stated that the receptionist is responsible for updating and displaying 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.

Based on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated, and stored; walk-in refrigerator clean; and failed to clean, sanitize, and air-dry cooking equipment after use to prevent food borne illness. These failures have the potential to affect all 158 residents receiving oral diets from the facility's kitchen. Findings include: On 08/21/22, V32 (Food Service Manager) provided a list of residents on various diet consistencies, which documented 8 residents have NPO (nothing by mouth) status, and that 158 residents receive oral diet from the kitchen. On 08/21/22 at 9:45 AM, during the initial tour of the kitchen with V32, the following items were observed in the walk-in refrigerator: 1.) large pan half filled with lettuce covered in plastic wrap - not labeled or dated. 2.) 2-5-pound containers of Low-Fat Cottage Cheese labeled with manufacturer use by date of 08/19/22. Surveyor asked V32 if she (V32) would serve the cottage cheese to the residents. She (V32) stated, it is not good anymore and she (V32) would throw the 2…

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 menu for residents on pureed diet. This failure affected 11 residents (R4, R9, R10, R25, R34, R71, R81, R87, R127, R135, and R141) reviewed for food and nutrition services in the sample of 64 residents. Findings Include: On 08/21/22, during lunch meal rounds the following observations were noted. Facility spreadsheets dated 8/21 list lunch meal as follows for general diets: Pork Roast, Garlic Mashed Potatoes, Mixed Vegetables, Dinner Roll or Bread, Margarine, [NAME] Cake with Chocolate Frosting, Beverage of Choice. Facility spreadsheets for lunch for pureed diets list items as follows: Pureed Pork Roast (#8 scoop), Garlic Mashed Potatoes (1/2 cup), Pureed Mixed Vegetables (#10 scoop), Pureed Cake (#10 scoop), pureed bread (#20 scoop), Margarine (1 each), Beverage of Choice. R4, R9, R10, R25, R34, R71, R81, R87, R127, R135, R141 on pureed diet received the following items for lunch on 08/21/22: #8 scoop pureed pork roast, #8 scoop mashed potatoes, #8 scoop pureed mixed vegetables, 1/2 cup applesauce.…

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 of two residents (R414 and R415) reviewed for call lights in the sample of 64. Findings include: R414 is a new admission with a BIMS (Brief Interview of Mental Status) score of 11. R414 has a diagnosis of but not limited to Sepsis, Atrial Fibrillation, Chronic Embolism and Thrombosis of Deep Veins of unspecified Lower Extremity, Cerebral Infarction, and Pancytopenia. R415 is a new admission with a BIMS (Brief Interview of Mental Status) score that has not been determined. R415 has a diagnosis of but not limited to Encounter for Attention to Gastrostomy, Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4, Hypertension, Epilepsy, Cerebral Infarction and Adult Failure to Thrive. On 8/21/2022 at 12:50pm surveyor observed R414's call light on the left side of 414's bed not within reach of the resident. On 8/21/2022 at 12:58pm surveyor observed R415 trying to reach his (R415) call light. Surveyor observed call light hanging down to the floor on the right side…

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 residents who depend on staff assistance for their ADL's (Activities of Daily Living) receive shaving. This affects 3 residents (R30, R68 and R112) in the sample of 64 residents reviewed for ADL care and grooming. Findings includes: On 08/21/22 at 10:48 am, R112 was observed in bed awake alert with confusion unable to be interviewed. Surveyor observed R112 with facial hair to the upper lip area (mustache present), and chin area (beard present) unshaved. On 08/21/22 at 10:56 am, R68 was observed in bed awake alert with confusion. Surveyor observed R68 with facial hair chin area (beard present) unshaved. When Surveyor asked R68 if R68 prefers to have facial hair on R68's face and chin area shaved, R68 was not able to respond to the surveyor question and stated, I can't hear. On 08/21/22 at 10:57 am, R30 was observed in bed awake alert and oriented. Surveyor observed R30 with facial hair in chin area (beard present) unshaved.…

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

Based on observations, interviews and record reviews, the facility failed to ensure adaptive devices were applied to residents' hands to maintain and prevent further contracture for 3 (R71, R85, R141) residents reviewed for limited range of motion in the sample of 64 residents. Findings include: On 08/21/22 at 10:45 AM, observed R85 lying in bed, left hand noted with contracture without splint or hand protector. On 08/21/22 at 11:00 AM, observed R141 lying in bed, both hands noted with contractures without palm protectors. V15 (Assistant Director of Nursing) entered R141 room once surveyor was observing R141 and stated, R141 should be wearing palm protectors on both hands because he (R141) keeps hands in a ball. V15 stated, R141 cannot follow commands, is bed bound and is dependent on staff for activities of daily living (ADL). V15 stated, she (V15) will go to get the palm protectors and put them on R141 now. On 08/21/22 at 12:45 PM, observed R71 feeding self on 2nd floor dining room using his (R71) left hand. R71's right hand was contracted and without any type of splint or brace.…

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 have a five percent (5%) or lower medication error rate. There were 4 medication errors out of 36 medication opportunities, resulting in 11.11 percent medication error rate 3 residents (R122, R132, and R137) in the sample of 64 were affected when being reviewed for medications not administered as ordered. Findings include: On 08/21/22 at 12:00 pm, V12 (Registered Nurse, RN) was observed at the 2nd floor East medication cart preparing 12:00 pm, medications for R122. Surveyor observed V12 prepare and count 2 pills total that were administered to R122 via G-tube (gastrointestinal tube). Upon this surveyor reconciling of R122's medications as to what medications were ordered for administration and what medications were observed as administered and documented by V12 the following medication errors were identified: 1. Route error: Bisacodyl EC (enteric coated) tablet delayed release 5 mg give 1 tablet via NG-tube (Nasogastric tube) every 6 hours…

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 food that accommodates resident allergies and preference. This failure affected 2 residents (R85, R136) reviewed for food allergies and preference in the sample of 64 residents. Findings include: On 08/22/2022 at 9:00 am, R85 was observed eating breakfast in her (R85)'s room. R85 received scrambled eggs, 1 slice of toast w/jelly, 2 slices of bacon, hot cereal, and juice. R85's meal ticket indicated NO gravy onions under dislikes and allergy section was left blank. On 08/22/22 at 2:34 pm, R136 was observed in room with lunch tray on bedside table. R136 received spaghetti with 3 meatballs topped with tomato sauce. R136 had not consumed any of the lunch. R136's meal ticket indicated under allergy section shellfish, fish, tomatoes, strawberries, watermelon. R136 stated that he (R136) gets food he is allergic to all the time and I just don't eat it. On 08/22/22 at 2:44 pm, V31 (Licensed Practical Nurse) was shown the meal ticket and the tray of food R136 received for lunch. V31 stated, R136 should not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure required plate guard was provided to residents to facilitate self-feeding and promotion of dignity. This failure affected 2 residents (R71 and R85) reviewed for assistive device during mealtime in the sample of 64 residents. Findings include: On 08/21/22 at 12:40 PM, surveyor observed R85 feeding self from regular plate with food spilled from plate onto table. R85's meal ticket documents, in part: plate guard. On 8/21/22 at 12:55 PM, surveyor observed R71 feeding self from regular plate. R71's meal ticket documents, in part: plate guard. On 08/22/22 at 9:00 AM, surveyor observed R85 feeding self from regular plate. R85's meal ticket documents, in part: plate guard. On 08/22/22 at 9:05 AM, surveyor observed R71 feeding self from regular plate. R71's meal ticket documents, in part: plate guard. On 08/22/22 at 9:40 AM, V28 (Therapy Director, Occupational Therapist) stated, a recommendation for adaptive equipment such as a plate…

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.