Arcadia Care Jacksonville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide proper assistance with ambulation and transfers for 2 of 4 residents (R24 and R43) reviewed for accidents in the sample of 38. Findings include:1. On 3/3/2026 at 11:18AM V14 Certified Nursing Assistant (CNA) and V28 CNA secured strap of sling to mechanical lift. V14, CNA operated the lift with V28 CNA holding onto R43 in sling, once up in air V28 CNA removed hands from sling. V28 CNA with back to R43 in the sling, moved reclining wheelchair to position under R43. V28 then put hands back on sling to guide R43 in sling to chair.R43's care plan dated, revision 1/5/2028 documents R28 has an Activity of Daily Living (ADL) self-care performance deficit relate to Dementia. R43's care plan documents interventions; transfer: R28 requires full mechanical lift and 2 assist to transfer between surfaces. R43's face sheet dated 3/3/2026 documents a diagnosis in part of weakness.2. On 3/3/2026 at 11:30AM R24 exits room with V29 CNA beside R24. R24…

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 a Registered Nurse (RN) 8 hours a day, seven days a week for 18 of 18 days reviewed for RN coverage from 11/1/2024-11/18/2024. This failure has the potential to effect all 75 residents at the facility. Findings include: On 11/18/2024 at 9:00AM, an RN was not observed to be on duty. On 11/19/2024 at 10:14 AM, V2 Director of Nurses, stated the facility does not employ any full time RN's at the facility. V2 stated they are unable to provide RN coverage 8 hours a day. V2 stated the facility has 3 RN's who work per diem. The facility daily staffing schedule dated 11/1/2024-11/18/2024 documents no RN for 8 hours a day 7 days a week. On 11/19/2024 at 12:30PM V2, DON stated the facility does not have policy for staffing, V2 stated the facility follows Central Management Services (CMS) guidelines. The CMS 671 Long Term Care Application for Medicare and Medicaid documents a census of 75 residents at the facility.

Based on interview and record review the facility failed to provide 12 hours of Certified Nursing Assistant (CNA) training on a yearly basis for 3 of 5 CNA's (V13, V31 and V36) reviewed for training. This failure has the potential to affect all 75 residents residing at the facility. Findings include: The Facility's trianing records did not document on V13, V31 and V36 CNA's training record they received 12 hours of annual competency training. On 11/25/2024 at 9:42AM V35, Human resources director stated V36, V31, and V13 did not receive required in-service training of 12 hours for CNA's. V35 stated she provides staff with the training site they are to utilize and the log in . V35 stated she does not provide oversight to ensure the training is completed. V35 stated it is the expectation that staff completed required training. The facility policy, policy on training of Employees and documentation of such training dated 9/2023 documents the facility will train all members of its workforce on its policies and procedures with respect to protected health information, as necessary and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify residents and representatives, in writing, prior to being transferred to the hospital, for 6 of 6 (R7, R12, R17, R36, R54, R72) residents reviewed for discharge transfer notice requirements in a sample of 35. Findings include: 1. On 11/20/2024 at 09:14 AM, R17 stated that he didn't know why he was going to the hospital nor was he given a document explaining why he was sent to the hospital on [DATE], 12/31/2024, and 1/1/2024. R17's Progress note, dated 12/18/2023 at 11:27 AM, documented, Resident being sent to (Emergency Department) for evaluation related to altered mental status, resident is unaware of who we are, low BP (blood pressure), not following commands as normal, (Nurse Practitioner) aware and resident agreeable for ambulance to take to hospital, resident also was seeing things in his bed that were not there. R17's Progress noted, dated 12/31/2023 at 5:10 pm documented, (4:50 PM)- labs received from (Regional Hospital). Emailed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to perform hand hygiene, change gloves when soiled, wear Personal Protective Equipment, and sanitize a multi-use blood glucose monitor to prevent cross contamination for 10 of 16 residents (R1, R4, R16, R20, R22, R24, R31, R57, R61, R71) reviewed for infection control in the sample of 35. Findings include: 1. On 11/19/24 at 09:11 AM, While toileting R20, V28 Certified Nurses Aide (CNA) and V21 CNA both donned gloves without hand hygiene. 2. On 11/19/24 V26 Licensed Practical Nurse, (LPN) was observed giving morning meds during the medication pass. At 7:33 AM, V26, Licensed Practical Nurse LPN was outside of R22's room with her medication cart. V26 donned gloves without hand hygiene, gathered the blood glucose monitoring machine, and the blood glucose test strip, alcohol pad and entered R22's room to obtain a blood glucose level. V26 wiped R22's finger with alcohol, pricked R22's finger and obtained the needed blood sample. The blood glucose…

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, observations, and record reviews the facility failed accommodate a resident's preference to eat in his room for 1 of 5 residents, (R8), reviewed for Resident's Rights in a sample of 35. Findings include: R8 was admitted to the facility on [DATE] with diagnosis of, in part, multiple sclerosis (MS), quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. R8's Care Plan dated 10/18/24, documented he is dependent on staff for Activities of Daily Living (ADL's); he is able to move only neck/head, has a diagnosis (Dx) of end stage MS, has muscle spasms extremities involuntarily jerk, prefers to use safety belts on the electric wheelchair (w/c) to promote positioning and enhance mobility. R8 is unable to stand and has little use or movement in is extremities and per his request, R8 refuses to come to the dining room at times. R8's Care Plan further documented he isolates in his room a majority of the time. R8's Minimum Data Set (MDS) dated [DATE] documented R8 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 interviews, observations, and record reviews the facility failed to report changes in condition to the physician for 1 out of 2 residents, (R30), reviewed for notification of changes in a sample of 35. 1. R30's admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. On 11/18/24 at 3:58 PM, R30 is in the hallway walking. R30 has very spastic jerky movements of the arms, legs, head, tongue, and mouth. R30 has involuntary backward arching of the back, shuffling of the feet sidewise and forward motion. R30 tripped over her feet and fell into surveyor. V9, Licensed Practical Nurse, (LPN) who was steps away came and assisted R30 to regain her footing by grabbing her under her…

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 abuse for 1 of 3 residents (R52) reviewed for abuse in the sample of 35. Findings include: R52's admission Profile, print date of 11/19/24, documents that R52 was admitted on [DATE] and has a diagnosis of Schizoaffective Disorder. R52's Minimum Data Set, dated [DATE], documents that R52 cognitively intact. R52's General Note, dated 11/7/24, documents, On 11/7/24 @ 3:08 pm Staff reported an allegation of a res (resident) to res physical altercation. Resident has no injuries outside of some redness on the right hand. No complaints of pain. Investigation initiated. Resident/staff interviews initiated. Physician/Resident Representative/Ombudsman notified. Follow up report will be sent. BIMS (Brief Interview of Mental Status): 13/15 Dx (diagnosis): COPD (Chronic Obstructive Pulmonary Disease), Emphysema, Schizoaffective Disorder, Bipolar Type, Bipolar II Disorder, Mild Intellectual Disabilities Investigation initiated. Resident/staff interviews…

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, observations, and record reviews the facility failed to protect a resident while smoking for 1 out of 1 residents, (R8), reviewed for smoking safety and accident prevention in a sample of 35. Findings include: R8 was admitted to the facility on [DATE] with diagnosis of, in part, multiple sclerosis (MS), quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. R8's Minimum Data Set (MDS) dated [DATE] documented R8 is cognitively intact. R8's MDS also documented that he has impairment to both sides of his upper extremity and is dependent on staff to assist him with all self-care abilities including eating and oral hygiene. R8's care plan dated 10/18/24 documented a plan for smoking with interventions for a smoking apron to be worn while smoking. R8 refuses to wear the smoking apron and instruct him about the facility policy on smoking: locations, times, safety concerns. R8's care plan further documented he is dependent on staff for Activities of Daily Living (ADL'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 interview, observation, and record review, the facility failed to provide complete incontinent care for 3 of 7 residents (R16, R31, R43) reviewed for incontinent care in the sample of 35. Findings include: 1. R16's admission Record, print date of 11/21/24, documents that R16 was admitted on [DATE] and has a diagnosis of Multiple Sclerosis. R16's Minimum Data Set, (MDS), dated [DATE], documents that R16 is severely cognitively impaired, is always incontinent of bowel and bladder, and dependent on staff for toileting and personal hygiene. On 11/20/24 at 1:43 PM, V33, Certified Nurse Aide (CNA), entered R16's room to provide incontinent care. V33 removed R16's wet incontinent brief. With soapy wash cloths, V33 cleansed the groin, labia, and meatus. R16 was rolled over and the left buttock and rectal area were cleansed. V33 dried the buttocks and put on a new incontinent brief. V33 failed to rinse or dry R16's peri-area. R16's peri-area was wet and had soap suds left. V33 failed to rinse R16's buttocks. 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 interview, observation, and record review, the facility failed to recognize a nonfunctioning Gastrostomy tube for 1 of 4 residents (R16) reviewed for Gastrostomy tube in the sample of 35. Findings include: R16's admission Record, print date of 11/21/24, documents that R16 was admitted on [DATE] and has a diagnosis of Multiple Sclerosis. R16's Minimum Data Set, dated [DATE], documents that R16 is severely cognitively impaired and has a feeding tube. On 11/19/24 at 12:55 AM, V19, Licensed Practical Nurse, donned a gown and entered R16's room to do her tube feeding. V19 washed her hands and put on gloves. V16 using a large disposable syringe attempted to aspirate residual liquid from R16's stomach to verify the Gastrostomy tube (G-tube) placement. V19 was unable to pull back the plunger anymore than an approximate 0.25 to 0.5 centimeter (cm). While V19 was attempting to pull back the plunger, the G-tube was visibly closing in on itself at the top and the bottom near the abdomen. V19 stated that sometimes…

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, observation, and record review, the facility failed to provide medications as the Physician Ordered. There were 37 opportunities with 6 errors resulting in a 16.22% medication error rate. The errors affected 2 residents (R70 and R44). Findings include: 1. On 11/19/24 at 7:54 AM, V26, Licensed Practical Nurse, (LPN) administered R70's morning medications. V26 administered 10 milligrams (mg) of Lexapro. R70's Physician Order, dated 11/20/24, documents, Escitalopram Oxalate 20 MG Tablet Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE 2. On 11/19/24 at 8:05 AM, V26 prepared and administered medications to R44. 1. Baclofen 10 mg 1/2 tablet given. 2. Fluconase Nasal Spray 50 microgram (mcg) 1 spray in each nare given 3. Breo Ellipta 100-25 mcg not given by V26. V26 stated that the medication was not available and she would need to order it from the pharmacy. On 11/20/24 at 10:30 AM, V26 stated that R44's Breo Ellipta did not come in from the pharmacy on 11/19/24 so R44 never did receive his dose for 11/19/24. V26 stated, 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 interview, observation, and record review, the facility failed to provide diets as ordered by the physician for 1 of 16 residents (R30) reviewed for quality of care in the sample of 35. Findings include: R30's admission record, print date of 11/21/24, documents that R30 was admitted on [DATE] and has diagnoses of Psychosis, Schizoaffective Disorder, Drug Induce Subacute Dyskinesia, and Schizophrenia. R30's Minimum Data Set, dated [DATE], documents that R30 is severely cognitively impaired, requires setup or clean up assistance for eating, supervision or touching assistance for sitting and walking. R30's Care Plan, revision date of 10/04/2022, documents, (R30) is at increased nutritional risk r/t (related to) DX (diagnosis): COPD (Chronic Obstructive Pulmonary Disease), Hypertension, Anxiety, Bipolar. Intervention: I use adaptive equipment to ensure my safety: plastic silverware therapy request her to get plastic do to resident poking herself so get plastic for a safety Date Initiated: 11/18/2024.…

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, observation, and record review, the facility failed to wear personal protective equipment (PPE) to prevent the potential spread of COVID-19. This failure has the potential to affect all 81 residents residing in the facility. Findings include: 1. On 8/16/24 at 8:55 AM, R2's room was observed with a sign on the outside of the door indicating R2 was on droplet/contact precautions. Gown, gloves, N95 and face shield/goggles are required when entering room. Gloves and masks are observed on carrier hanging on the door. No gowns were observed. Surveyor had to ask to get a gown prior to entering room. R2 stated she was admitted to the facility short term for therapy, she didn't come out of her room for the first two weeks and then only came out once to get her weight. After that, she tested positive for COVID a couple of days later, so she knows someone brought it in the facility. R2 stated she has a cough and gets short of breath easily. R2 stated she feels that they are treating her a certain way…

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, observation and record review, the facility failed to maintain an effective call system to ensure residents can communicate to staff when they need assistance. This failure has the potential to affect all 81 residents residing in the facility. Findings include: 1.On 8/16/24 at 8:55 AM, R2 was observed in her bed with a large cow bell and air horn at bedside. R2 stated the call lights are not working and haven't been for a while. R2 stated they are telling her that the part has been ordered and when it comes in, it will be installed but they haven't given her a time frame for when that will occur. R2 stated they gave her a small bell to ring when she needed something, that didn't work, staff didn't come, so they gave her a pressure pad alarm to press to get staff's attention, that didn't work, staff still didn't come, so they gave her a larger cow bell and the staff still don't respond so she bought an air horn. R2 stated the staff don't come in her room unless they must, the only time she can…

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, observation and record review, the facility failed to employ a Registered Nurse, (RN), for eight hours per day. This failure has the potential to affect all 73-resident residing in the facility. Findings include: On 3/28/24 at 11:55 AM, there were 2 Licensed Practical Nurses, (LPN), observed working. On 3/29/24 at 8:20 AM, there were 3 LPNs observed working. The Nursing Schedule from 3/3/24 through 3/29/24 with no RN coverage. On 3/29/24 at 8:25 AM, V2, Director of Nurse, (DON), stated, she is the only RN employed by the facility. On 3/29/24 at 11:02 AM, V7, LPN, stated they need more RNs. On 3/29/24 at 11:40 AM, V1, Administrator, stated they do not have a policy on staffing, they follow the guidelines set forth by the State. On 3/29/24 at 11:40AM, V11, Regional Director, stated they are currently trying to recruit RNs on a daily basis by going through different hiring websites, offering sign on bonuses and utilizing sister facilities when needed. The Census Report, dated 3/27/24, documents there are 73-residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to maintain a medication error rate of less than 5% when 2 medications were unavailable, and 6 medications were administered incorrectly to 2 of 5 residents (R6, R7). This resulted in 8 medication errors out of 31 opportunities resulting in a medication error rate of 25.80%. Findings include: 1. R6's admission Record, print date of 3/26/24, documents that R6 was admitted on [DATE] and has a diagnosis of Multiple Sclerosis. R6's Physician Orders, dated March 2024, documents, Magnesium Gluconate Oral Tablet 27.5 mg (milligram) on time a day for supplement, start date of 3/11/24. Ozanimod HCL Oral capsule 0.92 mg. Give 1 capsule by mouth one time a day related to Multiple Sclerosis, start date of 3/12/24. On 3/26/24 at 8:25 AM V15, Licensed Practical Nurse, (LPN), prepared and administered R6 morning medication. V15 was unable to give the Physician Ordered Magnesium Gluconate 27.5 mg or the Ozanimod HCL 0.92 mg. On 3/26/24 at 8:27 AM, V15…

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, observation and record review, the facility failed to complete wound care as ordered and document wound descriptions/observations in 2 of 3 residents (R1, R2) reviewed for wound care in the sample of 3. Findings include: 1. On 1/9/24 at 8:40 AM, R2 was observed in her room, up in the wheelchair. R2 had dressings in place to her bilateral lower extremities (BLE). The dressings were undated, both loose and the wounds were exposed. The dressings were soiled with yellow and bloody drainage. Areas to the BLE that were visible, were dry with scaly skin, red and swollen. R2 stated she has pain everywhere and her BLE itch. R2 stated she has seen a wound care doctor and wants to know what is causing the wounds. R2 stated they change her dressings every day but only once a day, regardless of if they are soiled or need changed. On 1/9/24 at 11:00 AM, R2's BLE were observed with V3, Assistant Director of Nurses, (ADON), and V6, Registered Nurse (RN), with the following noted: the old undated dressings…

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 there were sufficient nursing staff in the facility to provide adequate care and assistance for residents including assistance with bathing. This failure has the potential to affect all 77 residents in the facility. Findings include: 1. On 11/5/23 at 8:50 AM (a Sunday), the facility was entered. The facility was running one CNA short because of a call off. 2. On 11/06/23 at 11:00 AM, Resident Council Meeting was held in the Activity Department with 13 residents in attendance (R8, R24, R2, R41, R11, R32, R10, R71, R5, R43, R53, R16, and R62). Meeting was over at 11:30 AM. Issues brought up at meetings: Number one complaint is the Facility Staffing. There were multiple residents speaking out with a consensus of the committee, that stated that there is not enough help at the facility to take care of their needs, including answering call lights and assisting them when needed. On 11/6/2023 at 11:00 AM R8, Resident Council President,…

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 water temperature of the dish machine was hot enough to sanitize the dishes to prevent food borne illness. This failure has the potential to affect all 77 residents living in the facility. Findings include: On 11/5/23 at 10:30 AM, the dish machine was being used. The temperature gauge was reading 80 degrees (?) Fahrenheit (F). V23, Dietary Manager, stated that she is going to have V14, Maintenance Director, come and check the machine out to see what is going on. On 11/5/23 at 11:00 AM, V1, stated that the water temperature is not getting hot enough and he is trying to figure out what is going on with it. On 11/5/23 at 11:10 AM, V1, Administrator stated that all of the dishes that were washed this morning are being rewashed and sanitized in the three-compartment sink. V1 stated that the machine was checked this morning and it was running 120 degrees and they are trying to figure out what is going on. On 11/6/23 at 9:00 AM, V14 stated that they have figured out that the problem is the hot water…

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 prevent a fly infestation through effective pest control. This has the potential to affect all 77 residents who reside in the building. 1. R16's Minimum Data Set (MDS), dated [DATE], documents that R16 is cognitively intact. On 11/5/2023 at 9:21 AM there were multiple flies on R16's heavily soiled dressing on right foot. A fly was on top of urine filled urinal and 1 fly floating in urine. 1 fly was on R16's arm. On 11/5/2023 at 9:39 AM R16 stated that the flies are bad. R16 stated that he doesn't have anything to kill them with. R16 stated that he does not like it and would rather not have them at all. On 11/6/2023 at 10:22 AM, R16 was lying in bed with 2 flies on R16 and flying around R16's feet and 1 fly on R16's arm. On 11/7/2023 at 12:42 PM R16 was lying in bed with flies on the bed and on R16's body. 2. R25's MDS, dated [DATE], documents that R25 is cognitively intact. On 11/5/2023 at 9:28 AM there was a fly on R25's arms and covers.…

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 resident-to-resident physical abuse for 4 of 24 residents (R2, R26, R45, R179) reviewed for abuse in the sample of 46. Findings include: R2's admission Profile, print date of 11/7/23, documents R2 was admitted on [DATE] and has diagnoses of Major Depression and Dementia. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 is severely cognitively impaired and is independent with ambulation. R2's Care Plan, dated 4/18/23, documents, The resident is / has potential to be physically aggressive r/t (related to) Dementia, History of harm to others. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/03/2022 Assess and address for contributing sensory deficits. Date Initiated: 02/03/2022. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 02/03/2022. R2's Care Plan, dated 1/25/23, documents,…

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 assist residents with incontinent care, bathing, grooming, hygiene, change of clothing, and eating assistance for residents who require assistance for 4 of 23 residents (R38, R63, R64, R69) reviewed for assistance with Activities of Daily Living (ADL) care in the sample of 46. The findings include: 1. R63's Face Sheet, undated, documents R63 was admitted to the facility on [DATE]. R63's Electronic Medical Record, documents R63's diagnoses include Neurocognitive disorder with Lewy Bodies, Chronic Obstructive Pulmonary Disease (COPD), Transient Cerebral Ischemic Attack (TIA), Atherosclerosis heart disease (ASHD), Cellulitis, Dementia, and Heart Failure. R63's Care Plan, dated 8/15/23, documents R63 has an ADL self-care performance deficit r/t (related to) Dementia, Hemiplegia. Interventions: Bathing/Showering: The resident requires assist of (#) staff member with bathing/showering, Bed Mobility: The resident requires assist of (#) staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide complete and timely incontinent care for 5 of 5 residents (R4, R17, R18, R33, R63) reviewed for incontinent care in a sample of 46. Findings include: 1. R33's Care Plan, dated 10/22/23, documents that R33 has bladder and bowel incontinence related to (r/t) Cognitive Impairment. It continues, Toilet before and after meals, upon rising in the AM and before bed at night. R33's Minimum Data Set (MDS), dated [DATE], documents that R33 is cognitively impaired, always incontinent of bowel and bladder, and totally dependent on 2 staff for toileting. On 11/6/2023 at 9:14 AM V5, Certified Nurse Aide (CNA), and V11, CNA, performed incontinent care. V5 and V11 assisted R33 in the bed using a full body lift. V5 and V11 then removed R33's pants revealing a soiled incontinent brief. V5 and V11 opened R33's brief and rolled the incontinent brief between R33's legs. V5 then, using a wet towel, wiped R33's groin and inner labia. V5 and V11 rolled R33…

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, provide gastrostomy tube (g-tube) feedings according to the facility policy, including correct resident positioning, and checking for placement and/or residual prior to administering tube feedings to the resident for 4 of 4 residents (R4, R18, R22, R70) reviewed for gastrostomy tube feedings in the sample of 46. The findings include: 1. R4's Face Sheet, undated, documents R4 was originally admitted to the facility on [DATE]. R4's Electronic Medical Record, documents R4's diagnosis (Dx) include Encephalopathy, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Dementia, Benign neoplasm of the brain, Traumatic brain injury, Dysphagia, Major depressive disorder, Contractures, COVID-19, Generalized anxiety disorder, Hyperlipidemia, Post traumatic seizures, Hypothyroidism, Hypertrophic pyloric stenosis, Anemia, Fibromyalgia, and Gastrostomy-Gastric Tube (G-Tube). R4's Care Plan, dated 10/24/23, documents R4 is on a NPO (nothing by mouth)…

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 properly store medication and label insulin for 4 of 5 residents (R14, R25, R34, R72) reviewed for medication labeling and storage in a sample of 46. Findings include: On [DATE] at 8:50 AM 100-Hall medication cart was inspected. The medication cart contained the following: R34's opened Humalog KwikPen 100 UNIT/ML (milliliter) Solution pen-injector was in the cart. There was no label on the pen as to when it was opened. V10, Licensed Practical Nurse (LPN) verified that the medication was opened, in use and no opened date was on the pen. R72's Novolog Pen FlexPen 100 UNIT/ML Solution pen-injector was in the cart. There was no label as to when it was opened. V10 verified that the medication was opened, in use and no opened date was on the pen. R14's Levemir FlexPen 100 UNIT/ML Solution pen-injector was in the cart. There was no label as to when it was opened. V10 verified that the medication was opened, in use and no opened date was on pen.…

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 perform appropriate hand hygiene, glove changes when soiled, and to ensure the wound care supplies were kept clean to prevent contamination and potential infection for 4 of 23 residents (R4, R16, R17, R63) reviewed for infection control in a sample of 46. Findings include: 1. On 11/6/23 at 9:35 AM, R4 was lying in bed with his sheet off, and his incontinence brief unfastened. V9, Certified Nurse Aide (CNA), entered with a handful of washcloths, a plastic bag, and new a new incontinence brief to clean R4. V8, CNA, entered to assist V9. V9 went into the restroom and wet the washcloths, donned gloves, then turned R4 to his side while V8 wiped once to R4's bilateral buttocks, bilateral groins, pubic area, and his penis all while using the same washcloth and did not dry R4. V8 then placed a clean depends on the front of R4 and tucked it between his legs. R4 was then rolled to his other side while V8 wiped once to R4's buttocks and anal area and did not dry R4. V8 and V9 then fastened the incontinence brief around…

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