Aliya Of Crestwood

Based on observation, interview, and record review, the facility failed to implement individualized fall prevention intervention for a resident identified at risk for falls, failed to prevent falls during provision of ADL (activities of daily living) care, and failed to ensure oxygen tanks were secured in the storage room. These failures affected two (R4 and R8) residents and have the potential to affect all 17 residents in Unit C Wing. Findings include: 1) On 04/20/2026 at 1:33pm, R8 stated the CNA (who was later identified as V40 – CNA) was changing him and she put him on his side facing the window and she was pushing something on his side and the next thing he knew he was on the floor, naked. R8 stated (V40) left him for about 35minutes. She came back with other staff (who was later identified as V17 – CNA, V25 (Licensed Practical Nurse), and V41 CNA) and they picked him up on the floor. R8 stated he informed (V16 – Licensed Practical Nurse) the next day that he fell; and she told him he needed to go the hospital. On 04/22/2026 at 9:46am, V40 (Certified Nursing Assistant) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that staff ordered and administered medications to a newly admitted resident (R156) and failed to ensure that a witnessed fall was documented in the resident's electronic health record (R8). R156 was admitted to the facility on [DATE] between 1:30 and 2:00PM and did not receive any medications till the morning of 4/21/2026. These failures affected two (R8 and R156) of two residents reviewed for quality of care. Findings include: 1.R156 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history, chronic obstructive pulmonary disease, hypokalemia, alcohol abuse with withdrawal, rheumatoid arthritis, tobacco abuse counseling, hypothyroidism, noninfective gastroenteritis, chest pain, etc. admission evaluation dated 4/20/2026 documented that R156 is alert and oriented x3, can make needs known and communicate with a clear speech. After visit summary dated 4/20/2026, scanned in resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy and procedures to ensure residents received showers in accordance with professional standards of practice. This failure applies to one (R4) of four residents reviewed for receiving showers in the facility. Findings include: R4 is [AGE] years old, female, admitted to the facility 08/14/2025, diagnoses including but not limited to: Dementia, metabolic encephalopathy, cerebral ischemia, and gait and mobility abnormality. R4's (MDS) Minimal Data Set assessment of 08/21/2025, section C, the BIMS (Brief Interviewed Mental status) score was 10/15, which means moderately impaired cognitively. R4's MDS of 8/21/2025, GG section for Shower/bathe self, R4 requires Substantial/maximal assistance - Helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the effort.On 9/29/2025 at 1:00 PM, R4's family member said, I went on vacation in the middle of the month, and when I came back to visit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their medication administration policy by not administering scheduled pain medication within the hour timeframe as ordered and failed to notify the physician of the missed dose for one (R1) out of three residents reviewed for medication administration in a total sample of four.R1 is a [AGE] year old with the following diagnosis: idiopathic neuropathy, chronic pain syndrome, and venous insufficiency.On 8/5/25 at 3:08PM, R1 said on 7/19/2025 she did not receive the scheduled morning medications at any time during the day shift (7:00 AM - 3:00 PM). R1 said the day shift nurse (V4) did not come into R1's room the whole shift. R1 stated that V4 did not check vitals and did not ask R1 for her pain level. R1 said the CNA (V10) had gotten R1 up from bed around 10:30 AM that morning. R1 said her family members came to visit her from 12PM to 3:00 PM. R1 said at approximately 3:00 PM she asked the evening nurse why she hadn't received her day time…

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

Based upon observation, interview, and record review the facility failed to follow policy procedures and failed to ensure that 8 of 25 residents (R8, R10, R11, R13, R14, R16, R17, R18) remained free from significant medication errors. Findings include:1. R10’s POS (Physician Order Sheets) include Escitalopram (Antidepressant) 20mg (milligrams) give 1 tablet one time a day. Special instruction: take with 10mg tablet for total dose of 30mg daily (start date: 11/21/24). On 7/15/25 at 8:30am, V11 (LPN/Licensed Practical Nurse) dispensed (1) 20mg (milligrams) Escitalopram tablet in R10’s medication cup (with scheduled 8am medications) and affirmed she was prepared to administer them however the prescribed dose is 30mg. Surveyor inquired what R10’s Escitalopram order states V11 accessed R10’s EMAR (Electronic Medication Administration Record) and stated, “Escitalopram 20 milligrams give 1 tablet 1 time a day and take with a 10-milligram tablet.” Surveyor inquired about R10’s Escitalopram prescribed dose V11 responded “30 milligrams.” R10’s Escitalopram 20 milligram tablet (not 30…

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

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that medication orders received include a prescribed dose, and failed to maintain a medication error rate below 5%. There were 4 medication errors out of 37 opportunities, resulting in a 10.81% medication error rate. Three of three residents (R7, R10, R12) in the medication administration sample were affected. Findings include:1.R10's POS (Physician Order Sheets) include Escitalopram 20mg (milligrams) give 1 tablet one time a day. Special instruction: take with 10mg tablet for total dose of 30mg daily (start date: 11/21/24).On 7/15/25 at 8:30am, V11 (LPN/Licensed Practical Nurse) dispensed (1) 20mg Escitalopram tablet in R10's medication cup (with scheduled 8am medications) and affirmed she was prepared to administer them however R10's prescribed Escitalopram dose is 30mg. Surveyor inquired how much Escitalopram was dispensed in R10's medication cup V11 checked the single dose package and affirmed it was 20mg. Surveyor inquired what R10's Escitalopram order states…

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 incontinence care timely for a resident who was identified as dependent on staff. This affected one of three residents (R2) reviewed for incontinence care. Findings Include: R2's minimal dated set (MDS) section C brief interview for mental status dated 6/27/25 documents: a score of fifteen which indicates cognitively intact. Section H (bowel/bladder) dated 6/30/25 documents: frequently incontinence. Section GG (functional ability) documents: toileting- dependent. R2's Minimum Data Set, dated [DATE] documents: roll left and right. The ability to roll from lying on back to left and right side and return to lying on back ln the bed documents substantial/maximal assistance. On 7/1/25 at 10:48pm, R2 who was assessed to be alert and oriented to person, place and time said, she was left soiled and saturated with urine for 3.5 hours on one occasion and over two hours on another. R2 said, being left in saturated urine made her feel stressed, frustrated…

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 follow their policy and provide a written notice of room change with and explanation of the room change for one of one resident (R2) reviewed for written room change notice. Findings include: On 2/27/25 at 10:39am V1 (R2's sister/ POA-Power of Attorney) said the facility did not discuss R2's room change with her. V1 said she did not get a copy of the room change notice. On 2/27/25 at 4:40pm request was made to V4 (Director of Nursing) V5 (Administrator) and V7 (Social Service) to review the written notice of room change for R2. On 2/28/25 upon exit of this survey V5 (Administrator), V4 (Director of Nursing), and V7 (Social Worker) did not present a copy of the written notice of room change and explanation of room change for R2, the facility did not present documentation denoting a written notice was given to R2's family/poa/ resident representative Facility policy dated 11/1/2023 denotes in-part room change/transfer within facility. To assure residents and/ or their representatives are appropriately notified of 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 on interview and record review the facility failed to follow their abuse prevention policy and report an allegation of abuse to the abuse coordinator and or Director of Nursing on 2/21/25 for one of one resident (R1) reviewed for abuse reporting. Findings include: R1 face sheet denotes R1 has diagnosis of dementia. On 2/27/25 at 4:19 pm V3 (Registered Nurse) said V1 (visitor) approached him on 2/21/25 and said that V2 (Certified Nursing aide/CNA) slapped R1 on the knee. V3 said he did not report the allegation to V4 (DON) or V5 (Administrator). On 2/27/25 at 4:25 pm (Director of Nursing) said he was not aware of the allegation of abuse for R1. Facility policy titled abuse prevention dated 3/2022 denotes in-part, internal reporting requirements and identification of allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure proper integrity of the facility roof that resulted in ceiling cracks in two residents' rooms and ensure dust free ventilatory outlets in all residents' rooms throughout the facility. This failure has a potential to affect all 131 residents residing in the facility. Findings include: On 02/18/2025 at 09:45 AM Surveyor was provided with facility census listing 131 residents residing in the facility. On 02/18/25 between 11:00 AM and 2:00 PM Surveyor completed initial observations that revealed: - abundant collection of black/dark grey, powder like particles on the ceiling, around and in the ventilatory outlet and smoke detector in room [ROOM NUMBER] - cracked plaster on the ceiling with rusty discoloration in room [ROOM NUMBER], water collection bucket underneath the crack in the ceiling - cracked plaster on the ceiling with rusty discoloration in the bathroom room [ROOM NUMBER] - abundant collection of dark grey/white, powder like…

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 their policy and procedures for dietary food storage, cleaning, and hand hygiene practices by not ensuring stored foods were free of contaminated substances, not ensuring stored foods were properly labeled, not ensuring coolers and freezers were clean and free of contaminated items, not ensuring food items not intended for resident use were discarded, and not performing hand hygiene after handling contaminated items. This failure applies to all 123 residents receiving food from the facility. Findings include: On 02/18/2025 at 10:18 AM In the facility's main kitchen observed a strong foul odor in the cooler along with two large boxes of meat with a red substance spilled on them. V26 (Dietary Aide) stated she observed the strong odor, and it could be spoiled food or something spilled and the cooler needs to be cleaned. Observed a container with a burger patty labeled black bean burger partially covered with plastic wrap with no labeled dates. Observed a large box of tomatoes, a large box of lettuce, and 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 follow the pharmacy policy by not storing unopened Insulin in the medication refrigerator and documenting open date labels for three of three (R439, R127, R82) residents reviewed during medication storage and labeling in the sample of 32. Findings include: On 02/19/2025 at 12:15PM Surveyor conducted an inspection of the 1st floor (Unit 2-C) medication cart. Surveyor observed undated insulin pen medications not labeled opened, and unopened insulin not properly stored in facility/medication refrigerator for two residents: R439 Novolin R Flex Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. R127 Lispro Kwik Pen 100unit/ML - No open date written on label. Not stored in appropriate facility/medication refrigerator per pharmacy policy for all unopened insulin should be refrigerated. On 02/19/2025 at 12:50PM Surveyor conducted an inspection of the 1st floor (Unit 1-C) 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 interviews and record reviews, the facility failed to follow its skin prevention policy and notify one resident's (R1) family regarding a new facility acquired wound timely. This affects one of three (R1) resident reviewed for change in condition notification. Findings include: On 1/23/25, V3 (wound care nurse) stated that R1 was at high risk for skin breakdown. V3 stated that R1 developed a facility acquired MASD (moisture associated skin damage) sacral wound due to loose stools, moisture in brief due to sweating, and loose skin (on 12/23/24). V3 stated that the was an overall decline in R1's medical condition. V3 stated that while R1 was in the hospital, R1 was started on dialysis treatments three times a week. V3 stated that since R1 was re-admitted from the hospital, R1's overall condition has declined. V3 stated that on 12/17 she discussed with R1's family that R1's multiple comorbidities and risk factors could cause skin impairments. V3 stated at that time, R1 did not have any skin alterations. V3 stated that on 12/30 V3 did R1's wound care treatment in the presence…

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 its skin care prevention policy and develop a person-centered care plan with interventions to prevent or reduce the risk of developing skin breakdown. This affects one of three residents (R1) reviewed for care plan development. Findings include: On 1/23/25 at 10:00AM, V3 (wound care nurse) stated that R1 was at risk for skin breakdown. V3 stated that R1 developed a facility acquired MASD (moisture associated skin damage) sacral wound due to fragile skin, loose stools, moisture in brief due to sweating, and loose skin. V3 stated that there was an overall decline in R1's medical condition since R1 was re-admitted from hospital stay in November. On 1/23/25 at 12:00PM, V4 CNA (certified nurse aide) stated that R1 is dependent for all ADLs (activities of daily living). On 1/23/25 at 12:35PM, V7 LPN (licensed practical nurse) stated that stated that R1 was able to make slight movements, but not able to reposition self. R1's comprehensive care plan does not note a risk for an alteration in skin integrity or actual skin…

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 its tube feeding policy and check the resident's gastrostomy tube for residual prior to administering medications and bolus feeding. This failure affected one resident (R1) out of three residents reviewed for gastrostomy tubes in a sample of 5. Findings include: On 1/22/25 at 4:30PM, this surveyor observed V10 RN (registered nurse) administer medications and bolus feeding for R2. V10 was not observed checking R2's G-tube (gastrostomy tube) for any residual or checking placement prior to administering R2's scheduled medications. V10 was observed administering 150ml (milliliters) of water prior to initiating R2's bolus G-tube feeding. On 1/23/25 at 12:20PM, V6 LPN (licensed practical nurse) stated that the resident's G-tube should be checked for residual before administering medications and bolus feedings via G-tube. On 1/23/25 at 12:35PM, V7 LPN stated that the resident's G-tube should be checked for residual before administering medications and bolus feedings via G-tube. V6 stated that if 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 observations, interviews, and record reviews, the facility failed to follow its enteral tube medication administration policy and administer water in between each medication administered and administer scheduled medications per physician orders for one resident (R1) out of three reviewed for medication administration in a sample of 5. Findings include: On 1/22/25 at 4:30PM, this surveyor observed V10 RN (registered nurse) prepare R2's medications for administration. V10 crushed R2's medications and placed each medication in a separate medication cup. V10 was observed dissolving each medication in water. V10 administered R2's medications via gastrostomy tube. V10 was not observed flushing the gastrostomy tube with 5-10ml of water in between each medication administered. On 1/22/25 at 4:30PM, V10 stated that R2's omeprazole was not present in the medication cart. V10 did not inform R2 that R2 was not receiving this medication. On 1/23/25 at 9:45AM, R2 complained of his stomach bothering him to V3 LPN (licensed practical nurse). R2 denied nausea or vomiting, but 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 observation, interview, and record review, the facility failed to monitor its call light system and answer call lights within a timely manner for four residents (R2, R3, R4, R6) out of six residents reviewed for call light response times. Findings include: On 09/07/2024 at 9:58AM, V13 (R2's Family Member) states he lives in another state but came to visit R2 once V13 was informed that R2's health was declining and R2 was in the process of expiring. V13 states he was located inside of R2's room approximately two weeks ago and R2 appeared to be in pain. V13 states he located R2's call light and pressed it because he is not sure if R2 could use the call light on her own. V13 states he waited 45 minutes for someone to come to R2's room to answer R2's call light. V13 states he waited for so long that he went to the nurses' station to go and find a staff member to help assist R2 with her needs. V13 states he also made V1 (Administrator) aware that he waited a long time for someone to answer R2's call light.…

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 treatment as ordered by physician for resident who has swollen bilateral feet. The facility also failed to ensure ongoing assessment, identify, document, and obtain physician order for rashes on entire upper back, lateral, medial upper arm, and open wound on upper back This failure affects two (R34 and R90) of three residents in the sample of 22 reviewed for Quality of care. Findings include: 1. On 4/2/24 at 10:20AM, Observed R34 lying on bed wearing socks with noticeable tightness due to bilateral edema. She is alert and responsive with periods of forgetfulness and confusion. She said that her both feet/able has been swollen and it hurts at times. On 4/2/24 at 10:38AM, V2 DON (Director of Nursing) and V5 (Unit 2 Manager) said that R34 is alert but confused. Both said that she has Dementia. V2 DON provided copies of R34's active medical records including face sheet, physician order sheet and care plan. R34 is re-admitted on [DATE]…

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

Based on observation, interview and record review, the facility failed to implement an effective pest management program by not maintaining a clean kitchen dry storage area which resulted in live ants and mice droppings being observed which has the potential to affect all 104 residents that participate in dining services. Findings include: On 11/2/23 at 12:17PM, Kitchen dry storage area was observed with fifteen cylindrical dried small dark brown pieces on top of a flying insect light trap adhered to the middle of the wall. V34 (kitchen manager) confirmed that it was mice droppings and unsure how long it had been there. On 11/3/23 at 2:55PM, V34 (kitchen manager) tour of dry storage room observed multiple large open shelving units, with more than ten small ants crawling along the shelves edge with boxes of powdered sugar and brown sugar bags. In addition, one large clear storage bin with multiple small containers of syrup with more than 10 small ants crawling around the sides and inside of the container. On another shelve there was a large binder of recipes that had ants crawling…

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 inform the primary care physician of the change of condition for one of one resident (R21) reviewed for change of condition in a sample of 10. Findings include: On 01/11/2024 at 10:30AM during record review, R21's Progress Notes by V21 (nurse practitioner/NP) dated 12/19/2023 indicated R21 was seen and examined with pain of 7/10 on both lower extremities (BLE) especially to the ankle and knee and R21 said that she slipped off her commode and fell with complaint of (c/o) tenderness to touch on the outer lateral ankle which was also swollen. The same progress note indicated that V21 notified the nurse, recommended to administer any needed medication (prn) as soon as possible (ASAP) and to also inform the primary physician about the fall. Review of R21's Progress Notes dated 12/19/2023 to 12/20/2023 did not indicate any communication or notification to primary physician related to swollen and tender ankle. R21's Progress Notes by V21 dated 12/21/2023 indicated R21 complained of pain at 6/10 (pain scale) on BLE (bilateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident who was identified as a maximum assist with activities of daily living prior to discharge and recommended 24-hour care was safely discharged back to his home. This affected one of three residents (R6) reviewed for sufficient preparation for transfer on the sample list of 21. This failure resulted in R6 being discharged home alone without 24 hour care to assist with incontinence care and lead to R6 being sent back to local emergency room with stage 1 pressure sore to buttocks six days after discharge. Findings include: R6 was admitted to the facility on [DATE] with a diagnosis of unspecified fracture of left wrist and hand, parainfluenza virus pneumonia, chronic obstructive pulmonary disease, congestive heart failure, difficulty walking, major depressive disorder, morbid obesity, seizures, diarrhea, anxiety, peripheral vascular disease, hypertension, and urinary tract infection. On 10/20/23 at 3:45Pm, R6 who was alert and oriented to…

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

Based on interview and record review, the facility failed to revise the care plan after a change of condition for one of one resident (R21) reviewed for care plan in a sample of 10. Findings include: Review of R21's Progress Notes dated 12/22/2023 at 6:30PM indicated R21 returned from hospital with diagnosis (Dx) of fracture of left ankle and on non-weight bearing status. R21's care plan indicated last reviewed/revised on 12/21/2023 did not address the fracture and non-weight bearing status. On 01/11/2024 at 10:30AM during record review, R21's comprehensive care plan dated 12/21/2023 indicated no new problem, goal or approach after R21 came back from the hospital. At 3:00PM, R21's care plan was reviewed with V2 (Director of Nursing) and confirmed that no additional problem, goal or approach were noted on the comprehensive care plan. On 01/11/2024 at 3:00PM during interview with V2, V2 stated that the care plan should have been revised and updated after R21 came back from the hospital. On 01/11/2024 at 12:48PM during interview with V14 (Restorative Nurse), V14 said that R21's care…

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 incontinence care at least every two hours, and failed to ensure a shower or bath was provided at least two times a week. This affected two of three residents (R7, R10) reviewed activities of daily living care on the sample list of 21. This failure resulted in R7 being left and saturated in urine, and R10 receiving 1 staff provided bath in approximately 15 days. Findings Include: 1) R7 has the diagnosis of Cerebral Infarction. Minimal data set section C (cognitive patterns) dated 9/21/23 documents a score of eight which indicates moderate impairment. Section G (functional status) documents: R7 requires extensive assistance with one person physical assist with toilet use. Section H (bladder and bowel) documents: R7 is frequently incontinent (seven or more episodes of urinary incontinence.) On 11/16/23 at 2:42pm, R7 who was assessed to be alert to person and situation, was observed sitting in her wheelchair with wet areas in between her inner thighs. R7 was asked, why her pants were wet, R7 replied, I…

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

Based on interview and record review, the facility failed to assess and monitor the resident after a fall for one of one resident (R21) reviewed for accidents in a sample of 10. Findings include: Review of R21's Progress Notes by V15 (Licensed Practical Nurse) dated 12/18/2023 indicated R21 had a fall, with no visible injury, and an NP (nurse practitioner) was informed with no new orders and to monitor R21. On 01/11/2024 at 3:00PM during record review with V2 (Director of Nursing), R21's progress notes and observations did not indicate any follow up monitoring and assessment of R21 after the fall on 12/18/2023 at 12:40PM until 12/21/2023 at 9:00AM. R21's Progress Notes by V21 (nurse practitioner/NP) dated 12/19/2023 indicated R21 was seen and examined with pain of 7/10(pain scale) on both lower extremities (BLE) especially to the ankle and knee and R21 said that she slipped off her commode and fell with complaint of (c/o) tenderness to touch on the outer lateral ankle which was also swollen. R21's Progress Notes by V21 dated 12/21/2023 indicated R21 informed V21 that no diagnostics…

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 their policy and procedures related to ensuring that open/leftover foods were properly stores and labeled/dated; they failed to follow their cleaning and sanitation schedule to ensure the kitchen was kept in a sanitary/cleanly manner; and failed to ensure that residents were served meals that were of appropriate temperature. This failure has the potential to affect 96 residents that are currently receiving meals from the food service department. Findings include: Per facility diet tally sheet, the facility currently has four residents that are NPO (nothing by mouth). Per resident census report, the facility has 96 residents currently residing. On 4/10/23 at 9:40AM, initial observations of the kitchen were made with V15 (Dietary Manager). Observed walk-in cooler to have debris on the floor. V15 says the walk-in cooler should be kept in a more cleanly manner. V15 said she does not have anyone to put stock away and she is having a hard time hiring people. Noted an opened pack of cookies, container of…

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

Based on observation, interview, and record review, the facility failed to have an effective pest control program to address insects and rodents in the facility. This failure has the potential to affect all 96 residents currently residing in the facility. Findings include: On 4/10/23 at 9:40AM, it was observed that the walk-in cooler in the kitchen had three bags of uncooked pasta. V15 (Dietary Manager) said we store the dry pasta in here because we have had a problem with rodents getting into our food in the dry storage room. On 4/11/23 at 9:25AM, it was observed to have over ripened, brown/black banana in kitchen. V15 said, V15 saw a couple gnats flying around the bananas and they need to be thrown out. At 9:45AM, V16 (Cook) and V17 (Cook) were interviewed regarding rodents. V17 said we started seeing mice in the kitchen about a year ago. We would see them in the storeroom and started noticing food and package that would be chewed through and rodent droppings. We would have to throw out food. That is why we started putting certain products in the cooler because it is contained. We…

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 their policy and procedure for ensuring the facility's environment was clean and homelike. This failure applied to seven of seven (R16, R18, R23, R25, R60, R83, R90) residents reviewed for environment. Findings include: On 04/10/23 at 11:06 AM, V9 (Licensed Practical Nurse/LPN) stated to R18 and R23 why are your meal trays still in your room? Observed R18's and R23's breakfast trays were still left in their room. On 04/10/23 at 11:32 AM, observed R90's shared bathroom toilet with fecal spatter. On 04/10/23 at 11:43 AM, observed R83's bathroom floors and baseboards in poor condition, observed heavy buildup on wall vent, paint peeling from wall its baseboards peeling from wall. On 04/10/23 at 01:23 PM, observed R25's raised toilet seat in her bathroom with heavy build up, rust & some feces on the surface. Observed her bathroom floor vent with heavy build up, rust and chipped and warped paint around base of walls. On 04/10/23 at 03:34 PM, observed R60's bathroom vent with heavy build up and rust, base…

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 their policy and procedures for ensuring residents receive necessary care and services to maintain good grooming and hygiene. This failure applied to six of six residents (R7, R9, R18, R75, R90, and R95) reviewed for activities of daily living. Findings include: On 04/10/23 at 11:37 AM, observed R90 yell out in pain when V8 (Licensed Practical Nurse/LPN) adjusted his blanket. R90 stated that he has an ingrown toenail that is hurting him, and he has not seen the podiatrist in two to three months. On 04/11/23 at 9:56 AM, observed R18's fingernails to be long, yellow, and dirty. R18 stated he asked for his nails to be cut yesterday, but they couldn't because they didn't have any nail clippers. On 04/11/23 at 10:28 AM, observed R7's fingernails to be long. R7 stated his nails get clipped every now and then. On 04/11/23 at 3:25 PM, observed R90's fingernails to be very long. R90 stated he has not seen the podiatrist in months and has been asking. Observed R95's feet to be scaly and his toenails to be long…

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 sufficient staff to meet resident needs for assistance with Activities of Daily Living (ADLs). This failure has the potential to affect all 23 residents currently residing on unit two of the facility. Findings include: 04/11/23 09:32 AM, R2 was observed in her room awake, alert and oriented and stated that the facility does not have enough staff, especially CNAs and sometimes you must wait for a long time before your call light is answered. 04/10/23 12:05PM, V5 (Registered Nurse/RN) pulled the surveyor aside and said that he needs to report that the workload in unit two is too much for one nurse. They used to have two nurses in the unit and recently they started scheduling only one. V5 added that they used to have agency nurses, but lately they stopped using them, and sometimes they have admissions and discharges in that unit, and one nurse must do that in addition to taking care of the residents. 04/12/23 at 11:46AM, V34 (Licensed Practical Nurse-LPN/Unit Manager) said that she has been complaining…

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 notify a resident or family of a reason for a room change and failed to provide any documentation of such notice in the resident's medical record. This failure affected one (R2) of one resident reviewed for room change. Findings include: R2 is a [AGE] year old female who has resided at the facility since 1/4/2023, with past medical history including, but not limited to unspecified asthma, heart failure, acute and chronic respiratory failure, essential primary hypertension, muscle wasting, etc. 04/11/23 09:32 AM, R2 was observed in her room awake, alert and oriented and stated that she was moved from a different room to this room, she was in a room by herself previously and now she has a roommate who is always cold and R2 is always hot, the facility did not inform her prior the move and did not give her a choice of roommate. Reviewed resident's record and did not see any documentation that resident or her family member was notified of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident who are dependent on staff receive timely incontinence care. This failure applied to two of two residents (R12 and R18) reviewed for incontinence care. Findings include: R12 is a [AGE] year-old female with diagnoses history of Bed Confinement Status and Stage IV Pressure Ulcer of Lower Back who was admitted to the facility 10/18/22. On 04/11/23 at 10:37 AM, R12 stated she was last changed last night. R12 stated she doesn't request to be changed. R12 stated they just come and change her at times. On 04/11/23 at 11:45 AM, observed V33 (Certified Nursing Assistant/CNA) pull R12's brief that she just removed from her from the garbage. Observed R12's brief to be heavily saturated. Observed V33 pulled R12's sheets out from under her that she had been lying on just before receiving incontinence care to be heavily saturated. V33 stated R12's sheets are wet and will be changed. V33 stated she spilled some water on R12's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify changes in the nutritional needs of a resident who is at nutritional risk. This failure applies to one of one resident (R18) reviewed for nutrition. Findings include: R18 is an [AGE] year-old male with a diagnoses history of Partial Paralysis and Contracture who was admitted to the facility 06/17/2015. On 04/10/23 04:10 PM, R18 stated they leave his breakfast and don't help him eat. Observed R18's meal ticket, which stated that he requires tray set up. R18 stated they also don't leave his bedside table with his meal over him, and he is unable to access it. On 04/11/23 at 9:20 AM, observed R18's breakfast tray left with him and no one assisting him with his meal. On 04/11/23 at 9:39 AM, observed R18's meal ticket states he requires tray set up. Observed his breakfast included cut up sausage, scrambled eggs, oatmeal, English muffin. Observed R18 spilling food on himself. On 04/11/23 at 9:54 AM, observed V33 (Certified Nursing…

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

Based on observation, interview, and record review, the facility failed to ensure that controlled medications are accurately reconciled and properly stored for two (R155 and R256) of two residents reviewed for medication storage and labeling. Findings include: On 04/11/23 at 11:01 AM, during inspection of medication cart A wing in Unit 2 with V6 (Licensed Practical Nurse/LPN), it was observed that R256's Tramadol tablets were counted as 14 in the medication dispensing card. In the controlled drug receipt/record/disposition form, the remaining tablets should be 15. V6 stated, One tablet is missing. R256 has an order of Tramadol HCL (Hydrochloride) tablet 50 mg (milligrams) one tablet by mouth every six hours as needed, per POS (Physician Order Sheet). Upon inspection of medication cart B wing in unit 2 also, one tablet of Oxycodone is missing in R155's medication dispensing card, leaving to 3 tablets only. In the controlled drug receipt/record/disposition form, 4 tablets should still be available. R155 has an order of Oxycodone tablet 20mg one tablet by mouth every 6 hours as needed…

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

Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were six medication errors out of 36 medication opportunities observed, resulting in a 16.67% medication error rate. This failure affected two (R39 and R65) of six residents observed during medication administration. Findings include: On 04/11/23 V9 (Licensed Practical Nurse/LPN) was observed to for medication administration from 9:10AM to 10:30AM. At 9:12AM, V9 was observed to provide medication to R65. V9 confirmed that all medications due for the morning shift we given during this observation. After reviewing the Medication Administration record for 4/11/23, the nurse omitted four medications, however, the nurse documented that they were given during the time observed. These medications included eye drops: Brimonidine 0.2%-1 drop to L eye three times a day; Dorzolamide 2% 1 drop to L eye twice a day; Timolol 0.5% gel 1 drop to L eye three times a day, and Guaifenesin tab 600mg twice daily. At 10:05 am. V9 (LPN) was observed to prepare 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 maintain infection control standards while administering intravenous (IV) medications and while providing direct resident care to all residents in C and D halls. These failures applied to one (R305) of one resident receiving IV medication and to all residents currently residing on halls C and D of the facility. Findings include: On 4/10/23 at 2:22PM, V8 (Licensed Practical Nurse/LPN) was observed administering IV medication Cefazolin to R305. During this observation, V8 attached Intravenous tubing to Cefazolin bag dated 4/10/23 at 5AM which was disconnected from the resident and hanging from the IV pole prior to this observation. The opening of the tubing was not capped or covered. V8 entered room and did not wash hands with soap and water. V8 put on gloves and went to the bed side of R305 and began to administer the medication. V8 held the insertion point while cleaning the IV port R8 wiped the port quickly with an alcohol swab and flushed the tubing slowly. V8 then connected the tubing to R305. The tubing…

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.