Pearl Of Hillside,the

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to re-screen residents with mental disorder for two of five residents (R95, R105) reviewed for pre-admission screening in a sample of 31. Findings include: 1. R95 is a [AGE] year-old male initially admitted in the facility on 04/20/2024 with diagnoses of not limited to Major Depressive Disorder and Bipolar Disorder. R95's Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome dated 04/12/2024 indicated R95 is authorized to stay in the NF (nursing facility) 30 days or less. It also indicated that re-screening must occur by or before the 30th day if the individual is expected to remain in the NF beyond the authorization timeframe. On 03/26/2025 at 11:35AM during interview with V20 (Regional Director of Social Work), V20 stated that a new screening should have been requested for R95 before the 30 days had ended. Review of R95's admission Record dated 03/27/2025 indicated R95 was initially admitted on [DATE]. Review of R95'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 ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 3 of 5 residents (R34, R87, R91) reviewed for PASARR in a total sample of 31. Findings Include: On 3/26/2025 at 10:30AM, V20 (Regional Director of Social Work) stated there was no PASARR completed for R87 prior to admission. A Level I was requested this morning. On 3/27/2025 at 9:30 AM, V1 (Administrator) stated PASARR needs to be completed prior to resident admission and if Level I is positive, Level II will have to be completed to ensure residents will receive appropriate services. R87's admission Record indicated an admission date of 10/29/2024. Diagnosis Information include Schizoaffective Disorder, Unspecified. Care Plan report state, Focus: R87 uses psychotropic medications r/t (related to) Behavior management, dementia, schizoaffective disorder. Review of Notice of PASARR Level I Screen Outcome, Notice 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 ensure to provide nail and foot care to dependent resident. This deficiency affects three (R60, R117, and R130) residents in the sample of 31 reviewed for Activities of Daily Living (ADL) Program. Findings include: On 3/25/25 at 10:30AM, Observed R117 lying in bed uncovered. Fingernails on both hands are long and dirty with black matter inside the fingernails. Toenails on both feet are long, curved, and have thick yellowish-brown discoloration. Bilateral lower extremities have dry scaly skin. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said that Certified Nurse Assistants (CNAs) should provide nail care as part of ADL care. R117 has an admission date of 3/22/24 with diagnosis listed in part but not limited to Encephalopathy, Chronic kidney failure, Human Immunodeficiency Virus, Hospice care. Comprehensive care plan indicated she has an ADL self-care performance deficit secondary Impaired mobility, decreased in ADL, Physical limitations. She has a terminal prognosis, in hospice…

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 comprehensive restorative nursing evaluation and ongoing assessment is completed for a resident with limited range of motion/ contractures to upper extremities. This deficiency affects two (R60 and R79) of three residents in the sample of 31 reviewed for Restorative program. Findings include: 1. On 3/25/25 at 10:45AM, Observed R60 up in wheelchair in activity room. He is awake but nonresponsive. He has flexion contractures on his right hand. No splint applied. Showed observation to V10 (Nursing Supervisor/Infection Preventionist). V10 said she does not know if he has an order for a splint. R60 has a re-admission date of 2/8/22 with diagnosis listed in art but not limited to End stage renal disease, dependence on renal dialysis, Type 2 Diabetes Mellitus with diabetic neuropathy, Aphasia following cerebrovascular disease, Cerebral infarction, Memory deficit, Anorexia. Physician order sheet indicated Caregiver will don/doff palm…

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 the resident's environment is free of accident hazards and failed to perform ongoing smoking assessments for a smoking resident for two of three residents (R46, R95) reviewed for accidents in a sample of 31. Findings include: 1. R46 is a [AGE] year-old female initially admitted in the facility on 03/03/2023 with diagnoses of not limited to Nicotine Dependence, cigarettes, and other seizures. R46's most recent smoking risk assessment was completed on 08/09/2024. On 03/27/2025 at 9:45AM during record review with V3 (Social Worker), R46's most recent smoking risk assessment was noted on 08/09/2024. On 03/27/2025 at 9:45AM during interview with V3 (Social Worker), V3 stated that R46's smoking risk assessment should have been completed quarterly and should have a smoking risk assessment on November 2024 and February 2025. V3 stated that smoking risk assessment is done to determine if the resident is still safe to smoke independently…

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 physician oxygen orders for 1 of 2 residents (R141) reviewed for oxygen administration in a total sample of 31. Findings Include: On 3/25/2025 at 10:30 AM, R141 is laying flat in bed with oxygen on per nasal cannula. R141 stated he likes to lay flat in the bed even with oxygen on. Oxygen concentrator positioned at bedside with a setting of 4 liters (L)/minute. On 3/25/2025 at 10:35 AM, V25 (Licensed Practical Nurse/Agency) checked R141's physician order and indicated Oxygen (02) @ 2 Liters/Minute per nasal cannula/mask. V25 proceeded to R141's room and adjusted oxygen concentrator setting from 4L to 2L. V25 stated R141 should be on 2L per physician order. On 3/26/2025 at 9:00 AM, V2 (Director of Nursing) said oxygen administration should be followed according to physician order and raised head of bed at least 30 degrees. Review of admission Record (date: 2/8/2025) Diagnosis Information include CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), UNSPECIFIED, CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE,…

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 medication storage facility policy for 2 of 6 residents (R115, R79) reviewed for medication labeling and storage. Findings include: 1. R79 physician order sheet shows orders for Xalatan ophthalmic solution 0.005% (latanoprost), instill one drop in both eyes at bedtime related to glaucoma, order start date 6/7/2023. On 3/26/25 at 11:46am during a survey tour of the medication cart on the (unit) assisted by V2 (Director of Nursing), medication latanoprost 0.005% noted with R79's name, the box had one date of 3/15/25. V2 stated that 3/15/25 was the open date for the eye drops, V2 said the eye drops should be labeled with a second date for expiration. V2 said eye drops expire 30 days after opening. 2. R115 physician order sheet shows orders for Lokelma oral packet 10 GM (grams), give one packet by mouth one time a day for hyperkalemia, order start date 5/2/2024. On 3/27/25 at 8:22am during medication administration observation with V31 (Licensed Practical Nurse-LPN), V31 prepared and administered…

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 grant the resident or his or her representative the right to rescind the arbitration agreement within 30 calendar days of signing it. This failure affected three (R7, R37, R67) out of three residents reviewed for arbitration agreement in the sample of 31. Findings include: On 03/27/25 at 10:30 AM, V4 (Business Office Manager), said that all residents are offered arbitration upon admission. Surveyor reviewed the facility arbitration agreement with V4. V4 said that according to the facility arbitration agreement in section five, residents may cancel the agreement within seven (7) days. V4 said that after seven days, the agreement becomes binding. Review of the signed arbitration agreement by R7, R37 and R67 indicated that on section five: right of cancellation, these residents were only granted the right to rescind the agreement only within seven (7) days instead of 30 calendar days. R7 is a [AGE] year old male admitted on [DATE] with diagnosis not…

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 most recent hospice plan of care specific to each resident is available and accessible to facility's staff for collaborated and coordinated care. This deficiency affects three (R24, R82 and R117) residents in the sample of 31, reviewed for Hospice care services. Findings include: On 3/25/25 at 10:15AM, V14 Registered Nurse (RN) said that R24, R82 and R117 are on hospice care. On 3/25/25 at 10:48AM, V10 (Nursing Supervisor/Infection Preventionist) said that hospice services provided hospice residents with binders for all their documentation. Reviewed R117's hospice folder. Observed hospice initial comprehensive admission assessment dated [DATE] in chart. No admission Plan of care (POC) upon admission and no updated POC. V10 said that Social Services is the one responsible for coordination with hospice care. Reviewed R82 and R24 hospice medical records with V10. R82's hospice service binder indicated Plan of care (POC) start of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents are provided with the opportunity to receive annual dental exams as well as routine monitoring to identify any changes in dental care needs to the extent covered under the State health plan. This failure applied to five (R1, R4, R5, R6, and R7) of seven residents reviewed for dental services. Findings include: R1 has been a resident at the facility since 8/3/2019. Review of R1's medical record documents last dental visit and exam on 7/18/23; no additional dental visits within the past year and no documentation to show that R1 declined to have any dental services provided by the facility. R1's primary payor source is Medicaid. R4 was originally admitted to the facility on [DATE]. Review of R4's medical record does not have any documented dental visits while in the facility nor was there any documentation to show that R4 declined to have any dental services provided by the facility. R4's primary payor source 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 prevent a resident from developing a catheter associated urinary tract infection (UTI) which required transfer to a local hospital for treatment. This failure affected one (R5) of three residents reviewed for incontinence care. Findings include: R5 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: hypospadias, diabetes and neuromuscular dysfunction of bladder. According to Minimum Data Set, dated : 7-16-2024(MDS) indicates a Brief Interview for Mental Status (BIMS) score of 3/15 suggests severe cognitive impairment. R5 is dependent on two staff members for toileting, hygiene, and showers. On 8-17-2024 at 9:50am R5 was observed to be in bed, sitting up eating breakfast. R5 said, I am ok, no concerns voiced. V3 (Assistant Director of Nursing) in the room, uncover R5 lower part of his body, noted to have bilateral lower extremities contracted, it's very difficult to clean R5's urinary…

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 on hair restraints for staff working in the kitchen. This failure have the potential to affect 141 residents eating from the facility's kitchen. Findings Include: On 01/24/24 at 10:05 AM, during initial tour with V7 (Food Service Director), V8 (Dietary Aide) and V9 (Dietary Aide) did not have their hair nets on. V7 said V8 and V9 are supposed to have their hair nets on. On 1/25/2024 at 10:06 AM, V2 (Director of Nursing) said staff that are working in the kitchen should have their hair covered, and don on apron and gloves. Dietary Department Sanitation & Safety Operation HAIR RESTRAINTS/JEWLRY/NAIL POLISH POLICY: To reduce the spread of microorganism, employees shall use effective hair restraints, avoid excessive jewelry and wear nail polish or acrylic nails only with precautions. PROCEDURE: Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated if needed.

Based on observation, interview, and record review, the facility failed to have oxygen in use signs for four residents (R31, R50, R98, and R198) and failed to provide humidification for one resident (R98) receiving continuous oxygen at 5L/min (liters per minute) of six residents reviewed for respiratory therapy in the sample of 30. Findings include: 1. On 1/23/24 at 11:00 AM, R98 was receiving oxygen at 5L/min via nasal cannula. There was not a humidifier bottle attached to R98's oxygen concentrator or the tubing. R98 said, I had a water bottle on that when I first came in, but I haven't had one in days now. There was no sign on R98's door indicating that oxygen was in use in the room. On 1/23/24 at 1:40 PM V22 (LPN-Licensed Practical Nurse) said, She should have a water bottle attached to the oxygen. Whoever set up the oxygen is responsible. On 1/23/24 at 1:45 PM, there is no sign on the door indicating oxygen in use for R31, R98, and R198. The Order Summary Report for R31 indicates aerosol to tracheostomy at 21% (use 2 liters if Spo2 (oxygen saturation) below 92%. The Order…

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 put open dates on multi-dose medications and store according to pharmacy recommendations. This failure has the potential to affect all 40 residents in Transition Care Unit. Findings include: On 01/24/2024 at 11:48AM, Transition Care Unit Medication Cart 1 was observed with the following: 1. one opened and undated Insulin lispro pen 2. one opened, undated and unrefrigerated Tuberculin Purified Protein Derivate (PPD) vial - label reads Refrigerate. Manufacturer box reads Once entered, vial should be discarded after 30 days. 3. one opened and unrefrigerated Tuberculin Purified Protein Derivate vial - label reads Refrigerate. Manufacturer box reads Once entered, vial should be discarded after 30 days. On 01/24/2024 at 11:50AM, V22, Licensed Practical Nurse, stated opened insulins and PPD vials should be dated when it was opened. V22 also said she is unsure if PPD vials should be refrigerated. On 01/24/2024 at 1:17PM, V15 (Assistant Director of Nursing) stated all nurses are expected to put an open date on all…

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 influenza and Pneumococcal immunization as required for four of five residents (R7, R84, R104 and R142) reviewed for immunizations in a sample of 30 residents. Findings Include: On 1/24/24 at 11:45 AM, V3 (Infection Preventionist) and V15 (Assistant Director of Nursing) both stated all immunization refusals should be documented. V3 stated she is responsible for checking residents' immunizations are up to date once admitted into the facility. On 1/25/24 at 10:15 AM, V2 (Director of Nursing) stated V3 is responsible for keeping resident's immunizations up to date. On 1/25/24 at 10:00 AM, R7's, R84's, and R104' s immunization records had no documentation to indicate these residents received Pneumococcal vaccine or refused, R142's immunization record had no documentation to indicate he received or refused the influenza or Pneumococcal vaccination. Facility policy, dated 6/1/23, reads: Infection Control- influenza and Pneumococcal Immunizations for residents. Intent: It is the policy of the facility to ensure that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light is accessible to three (R15, R57, R91) of seven residents reviewed for call light accessibility in the sample of 30. Findings include: 1. R15 is a [AGE] year old female admitted on [DATE], with diagnoses not limited to morbid obesity, polyneuropathy, chronic obstructive pulmonary disease, and hypertension with heart failure. R15's care plan, with a revision date of 1/9/2023, documents the following: Focus: The resident is at risk for falls related to decreased mobility, impaired cognition, and psychotropic med use. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance On 01/23/24 11:25 AM, R15's call light was not within her reach. R15 said she is always trying to reach for her call light, but she can not reach the call light most of the time. On 01/23/24 at 11:56 AM, V13…

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 enter the code status and order for one resident (R6) of eight residents reviewed for code status in the sample of 30. Findings include: R6 is a [AGE] year-old resident whose diagnoses include heart failure, acute respiratory failure with hypoxia, and peripheral vascular disease. A progress note of [DATE] by V29 (Social Worker) indicated Advanced Directives code status is DNR (do not resuscitate) per daughter. A progress note of [DATE] by V29 indicates DNR form was signed (education provided). The form was signed by V30 (family member of R6). On [DATE] at 12:20 PM, the code status on R6's health record banner was blank. There was no form in the electronic medical record that indicated the code status of R6. The orders did not contain a directive such as Full Code or DNR (Do Not Resuscitate). On [DATE] at 11:35 AM, V16 (LPN-Licensed Practical Nurse) said, There's is no code status in here. (indicating electronic medical record in the computer). She…

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 assistance to residents who are unable to shave themselves safely for two of three residents (R9, R23) reviewed for activities of daily living in a sample of 30. Findings include: 1. R23's order summary report, dated 01/25/2024, indicated admission date of 09/19/2022, and diagnoses of not limited to unsteadiness on feet and other lack of coordination. R23's Minimum Data Set (MDS), dated [DATE], indicated Brief Interview of Mental Status (BIMS) Summary Score of 11, and need for partial/moderate assistance on personal hygiene. R23's Care Plan, revised on 11/14/2023, indicated R23 has an ADL (activities of daily living) self-care performance deficit secondary to impaired mobility, decrease in ADLs, physical limitations, balance problems, gait, strength and endurance, and interventions include assisting with ADLs. On 01/23/2024 at 10:59AM, R23 was observed in her room sitting on her wheelchair with observable clusters of facial hair…

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 it is free of medication error rate of five percent or greater. During medication administration observation, two medication errors were observed out of 25 opportunities, resulting in an eight percent medication error rate. This deficiency applies to two (R9, R21) of six residents observed for medication administration. Findings include: R21's order summary report, dated 01/24/2024, indicated admission date of 06/23/2023, diagnosis of not limited to unspecified dementia, and order for Sennosides 8.6mg tablet 1 tablet with order date of 06/23/2023. R9's order summary report, dated 01/24/2024, indicated admission date of 06/21/2023, diagnoses of not limited to Alzheimer's disease, unspecified dementia and major depressive disorder, and order for Lexapro (Escitalopram Oxalate) 5mg 0.5 tablet with order date of 01/15/2024. On 01/24/2024 at 8:55AM, V24 (Agency Licensed Practical Nurse) was observed preparing the oral medications for R21, and V24 put one tablet of Sennosides-Docusate sodium 8.6…

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 adhere to good hand hygiene practices, and cleaning and disinfection of resident-care equipment during medication administration for two of six residents (R21, and R9) reviewed for medication administration in a sample of 30. Findings include: On 01/24/2024 at 8:50AM, during medication administration observation, V24 (Agency Licensed Practical Nurse) was observed checking R21's blood pressure. After checking R21's blood pressure, V24 went back to the medication cart and proceeded in preparing R21's medications without performing hand hygiene. At 9:20AM, V24 was observed checking R9's blood pressure, without disinfecting the blood pressure cuff prior to use. After checking R9's blood pressure, V24 went back to the medication cart and proceeded in preparing R9's medications without performing hand hygiene. On 01/24/2024 9:35AM, V24 stated she should have performed hand hygiene after resident contact and before preparing the medications for R21 and R9. V24 also said she should have disinfected the blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure transportation was provided for a resident to a scheduled hip surgery (R3) and to a diagnostic procedure (R2) for 2 of 4 residents reviewed for quality of care in the sample of 12. The findings include: 1. On 10/6/23 at 9:40 AM, V3, Nursing Supervisor, said R3 was all set up for hip surgery on 8/16/23. V3 said she set up transportation with the local ambulance service the day prior to R3's surgery. On the day of V3's surgery, transportation was running late and the surgeon said R3 was too late, and they had to cancel and reschedule R3's surgery. On 10/6/23 at 10:42 AM, V9, Transportation Coordinator, said the local ambulance company was scheduled to transport R3 to her surgery appointment on 8/16/23, but they came late and they had to cancel her surgery. V9 said the ambulance company requests at least 24 hours notice for a transportation appointment, but they call anyway and hope they get to the facility in time for the resident to get to their…

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

Based on observation, interview, and record review, the facility failed to ensure the Daily Nurse Staffing was posted daily. This failure affected all 136 residents residing in the facility. Findings include: The (10/24/2022) facility census was 136. On 10/24/2022 at 12:21pm, the Daily Nurse Staffing Form located right across the reception area and right by the conference room was dated 10/22/22. V1 stated, This should be changed on a daily basis. This was from Saturday. This is probably the easiest thing to do in the facility. The (10/27/2022) email correspondence with V1 documented, in part The facility doesn't have a more specific policy regarding nurse staffing posting.

Based on observation, interview, and record review, the facility failed to respond to call lights in a timely fashion for 3 residents (R45, R70 and R103), and to ensure the call light is within reach for one resident (R67). This failure affected 4 residents out of a sample of 46. Findings include: 1. R45 has a BIMS (Brief Interview of Mental Status) score of 12 (suggests moderately impairment), but R45 able to answer and respond to all questions. Call light Ability Screen for R45 states, in part, resident is able to use the call light, which was completed today, 10/27/2022. 2. R67 has a BIMS (Brief Interview of Mental Status) score of 03 (suggests severe impairment), but R67 able to answer and respond to simple questions. Call light Ability Screen for R67 states, in part, resident is able to use the call light, which was completed today, 10/27/2022. On 10/24/2022 at 10:25am, R67's call light was tied to the left side rail hanging to the floor. R67 stated she does not know where it (call light) is, but would use it (call light) if she could find it (call light). On 10/24/2022 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 ensure residents who depend on staff assistance for their ADL (Activities of Daily Living) and grooming receive shaving and nail care. This affected four residents, (R61, R67, R90, and R334), in the sample of 46 residents reviewed for ADL care and grooming. Findings include: 1. R61's face sheet documents R61 has the following diagnoses including, but not limited to: Unspecified lack of coordination, unspecified injury of head subsequent encounter, anxiety disorder, and legal blindness. R61's Minimum Data Set (MDS), dated [DATE] section C for Cognitive Patterns documented, in part, the Brief Interview for Mental Status (BIMS) score is 3, indicating R61 has memory impairment. R61's MDS, dated [DATE] section G for Functional Status: G0110: Activities of Daily Living (ADL) Assistance: J. documents in part R61 requires extensive assist for personal hygiene care. On 10/24/22 at 10:33 am, R61 was in bed, not shaved, with facial hair. R61 had 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: implement individualized fall prevention interventions for residents identified to be at risk for falls; failed to ensure that oxygen tank was placed in a holder; and failed to ensure that floor tiles on the units were even and not sinking. These failures have the potential to affect R19, R28, R38, R47, R336, and 49 other residents on three units of the second floor, reviewed for hazards and prevention of falls with injuries. Findings include: 1. R19's care plan, dated 10/23/2020, states R19 is at risk for falls due to her needs for total assistance. Intervention states to ensure resident is positioned correctly in bed after providing care. R19'S Fall Risk Assessment, dated 10/27/22, states R19 is at risk for falls. R28's Care plan, dated 4/7/2020, states R28 is at risk for falls related to visual impairment, muscle weakness etc. Intervention states to ensure resident is positioned correctly in bed after providing care. R28'S Fall Risk Assessment, dated 8/16/22, states R28 is at risk for falls. R38'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 discard expired medication, dispose of loose pills in the medication carts, and to label open and expiration dates on open medications. These failures have the potential to affect (R5, R7, R14, R85) and all residents receiving medications from Parkview1 medication cart 1 on 1st floor, Heritage Place medication cart 1A/1B on the 2nd floor, Transitional Care Unit medication cart 1 and 2 on the 1st floor. Findings Include: On 10/24/22 at 1:30pm, V22, LPN (License Practical Nurse), review of 1st floor Park View 1 medication cart 1(rooms 171-187): *R5's bottle of Humalog Insulin, with an open date of 9/10/22, and an expiration date of 10/7/22. V22 stated, This (Insulin bottle) is expired and should have been thrown away. V22 held the expired insulin bottle and stated, I will throw the bottle away. *Multiple loose pills in drawer 2 and in drawer 3 in the Parkview 1 medication cart. (rooms 171-187). On 10/26/22 at 2:40 pm, V3 (Assistant Director of Nursing, ADON) stated, When a new bottle of Insulin is opened 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 observation, interview, and record review, the facility failed to ensure two residents (R22 and R119) received privacy in regards to urine collection bags. This failure affected two residents (R22 and R119), whose urine collection bags were not covered for privacy and was visible from the hallway, in the sample of 46 residents. Findings include: 1. On 10/24/22 at 10:48 am, R119 was observed in bed awake and alert, with R119's urine collection bag not provided with privacy. R119's urine collection bag had approximately 200 milliliters of urine hanging from the bed frame of R119's bed, visible to the hallway public area without privacy. On 10/24/22 at 12:40 pm, V3 (Assistant Director of Nursing, ADON) V3 stated the urine collection bag should be covered. For dignity and privacy of the resident. 2. R22's admission record includes a diagnosis of Diabetes, Kidney Failure, Heart Failure, Dementia, Alzheimer, Bilateral BKA (Below knee Amputation) Atherosclerotic Heart Disease, and Hypertension. R22's Minimum…

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 document the code status in the resident's electronic medical record which affected one resident (R108) in a sample of 46. Findings include: R108 has BIMS (Brief Interview of Mental Status) score of 03 (suggests severely impaired). R108's original admission date was 06/14/2022. On 10/24/2022 at 1:17pm, surveyor reviewed R108's profile screen and orders, and there was nothing listed on the profile screen or in the orders. On 10/24/2022 at 2:30pm, surveyor reviewed R108's profile screen that showed a code status of Full Code and a Code Status order dated 10/24/2022 at 2:27pm, indicating it was just put in the system. On 10/26/2022 at 2:15pm, V28 (Registered Nurse) stated code status should be included on the profile screen, or in the orders. V28 stated the admission coordinator updates the code status on the profile screen. On 10/26/2022 at 2:53pm, V3 (Assistant Director of Nursing) stated, You can find the code status in the electronic medical record and in the orders and it should be displayed at the top…

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

Based on interview and record review, the facility failed to ensure that a resident's midline was flushed before and after administration of medication and during the time the resident's midline was not in use. This failure affected 1 (R15) resident reviewed for professional standard of care in the total sample of 46 residents. Findings include: On 10/24/2022 at 12:32pm, R15 has a midline in R15's right arm. V14 (Licensed Practice Nurse/LPN) stated, I don't know when (R15) will be finished with (R15)'s antibiotic. On 10/24/2022 at 12:34pm, R15 stated, I have this (pointing to the midline) a couple of weeks ago. On 10/24/2022 at 12:35pm, V14 checked what was written for R15's IV antibiotic, per this surveyor's request, and stated, The order is Meropenem 500mg via IV per 100ml/hr every 8 hours x 11 days. Order was on 10/10/22. On 10/24/2022 at 12:36pm, R15 stated, I've been telling them that since they are not giving the medication, to remove this. R15 was pointing to the midline. On 10/25/2022 at 2:11pm, surveyor inquired about flushing protocol for midline not in use. V3 stated, The…

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

Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions for two residents with history of pressure ulcers, and at risk for further pressure ulcers. These failures affected two residents (R19 and R38) of three residents, reviewed for pressure ulcers and pressure ulcer prevention interventions, in a total sample of 46 residents. Findings include: 1. R19's care plan, dated 5/20/21, states R19 is at high risk for skin breakdown related to decreased mobility, incontinence, and diagnoses of Diabetes and Peripheral Vascular Disease. R19's Pressure Ulcer Risk Assessment, dated 5/10/2022, shows R19 scored 13 on the scale (moderate risk for pressure ulcer). R19's latest weight records, dated 10/12/22, shows R19 weighs 160 pounds. Again, on 10/24/22 at 12:30pm, R19's low air loss mattress was observed to be at the same 400 pounds weight. At this time, V17(LPN/Licensed Practical Nurse) was notified. V17 stated she does not know how the air mattress is supposed to bet set at the correct weight for the resident. V17 explained…

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 hand splints or other restorative devices were applied on resident's upper extremities as indicated in the assessments and care plans, to prevent further contractures. This affects one resident (R28) of three residents, reviewed for restorative care, in a total sample of 46 residents. Findings include: R28's care plan, dated 8/27/2020 with revision date 11/17/2020, states R28 has fixed right and left hand/wrist and provided splints, and R28 would benefit from splinting program. Intervention states in part: Apply bilateral hand splints upon awakening and off 2 hours later. Perform PROM (passive range of motion for 3-5 minutes before applying splint to right and left hand/wrist On 10/24/22 between 10:25am and 1:15pm, R28 was observed awake in bed with mild contractures on the upper extremities, without any restorative device to prevent further contractures. Again on 10/25/22 between 10:10am and 12:58pm, R28 was still without any splints or other restorative devices. On 10/25/22 between 10am and 12pm, R28…

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

Based on observation, interview, and record review, the facility failed to maintain an accurate account of controlled substance records for two residents (R15 and R33) reviewed for controlled substance in a sample of 46 residents. Findings Include: On 10/26/22 at 11:35am V28 (Registered Nurse) review of 1st floor Transitional Care Unit medication cart 1(rooms 101-117, and 24-27). V28 stated, Narcotic count is done at the beginning of each shift and at the end of each shift. On 10/26/22 at 11:50 am, R15's Oxycodone/APAP 5-325mg tablet, should be 13 tablets; observed 11 tablets. V28 stated, I gave that to (R15) this morning, I forgot to sign out the medication when I gave it. Surveyor observed V28 sign out the medication on the Controlled Drug Receipt/Record/Disposition Form. Dated 10/26/22, Time 9:00 am, Given 2 left 11 with V28 signature. On 10/26/22 at 11:52 am, R33's Oxycodone 10mg tablet should be 12 tablets; observed 11 tablets. V28 stated, I gave the mediation earlier and did not sign the medication out when I gave it. The medication is supposed to be signed out when given.…

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

Based on observation, interview, and record review, the facility failed to ensure the resident's midline dressing was not soiled ,and failed to ensure the IV (intravenous) medication bag and the IV tubing were labeled with date. These failures affected 1 (R15) resident reviewed for infection control in the total sample of 46 residents. Findings include: On 10/24/2022 at 12:29pm, there was a contact isolation sign by R15's door and PPE bin outside of R15's room. V14 (Licensed Practice Nurse) stated, (R15) has a wound on his (R15) scrotum. On 10/24/2022 at 12:32pm, R15's midline line dressing was heavily soiled. There was an IV pole by R15's bed. There was a bag of IV antibiotic hanging on the IV pole that was not dated. The IV tubing was also not dated. V14 stated, I don't know when (R15) will be finished with (R15)'s antibiotic. On 10/24/2022 at 12:34pm, R15 stated, I have this (pointing to the midline) a couple of weeks ago. On 10/24/2022 at 12:35pm, V14 checked what was written on R15's IV antibiotic bag, and stated, The order is Meropenem 500mg via IV every 8 hours x 11 days.…

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.