Renwick Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label and date medications once it was opened to determine the expiration date, and failed to remove or dispose narcotic medications that were in a broken sealed container. This applies to 10 residents (R56, R81, R9, R64, R76, R69, R24, R46, R62, R57) reviewed for medication storage and labeling. The findings include: On [DATE], at 9:45 AM, the medication room of the 100 and 200 halls was inspected with V25 (Nurse). R56's Insulin Lispro Kwik Pen was opened and not dated. The Pharmacy audit assistance service shows this medication expires 28 days after it was opened. R81's Insulin Glargine-YFGN was opened and not dated. The Pharmacy audit assistance service shows this medication expires 28 days after it was opened. R9's Novolin R Flex Pen was opened and not dated. The Pharmacy audit assistance service shows this medication expires 42 days after it was opened. On [DATE], from 3:40 PM to 3:55 PM, the medication carts of the 300 and 400 halls…

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

Based on observation, interview and record review, the facility failed to serve portion sizes as shown on the menu spreadsheets for the pureed diets. This applies to 6 of 6 residents (R23, R27, R42, R57, R61and R79) reviewed for pureed diets in the sample of 19. The findings include: Diet spreadsheet for Spring Summer Menu 2024 (cycle day 2) included braised pork chop, carrot raisin brown rice and broccoli for the lunch meal. The same spreadsheet showed to use #8 scoop for the pureed carrot raisin rice and pureed broccoli. For the pureed breaded pork, scoop size was not shown. Pureed recipe for Pork Chop braised with apples included portion with one #6 scoop and top with 1 fluid ounce pureed apples. On October 21, 2024, at 9:20 AM, V6 (Cook) was noted to puree chicken instead of pork chop for the residents on pureed diets. V6 stated that some residents on the pureed diets do not like pork so he prepared pureed chicken instead. On October 21, 2024, at 12:30 PM, during the lunch meal tray line service, V9 and V10 (Dietary aides) were platting the food on the steam table. V10 put out 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 assess and provide splint and therapy services to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 3 residents (R23 and R32) reviewed for range of motion in the sample of 19. The findings include: 1. R32 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and left-hand contracture, based on the face sheet. R32's quarterly MDS (minimum data set) dated September 25, 2024, showed that the resident was cognitively intact. The MDS showed that R32 had functional limitation in ROM on one side of her upper extremity. The same MDS showed that R32 required maximum to total assistance from the staff with her ADL's (activities of daily living). On October 21, 2024, at 11:07 AM, R32 was in bed, alert, oriented and verbally responsive. R32 had weakness on her left arm and her left hand, wrist and fingers had limited ROM because she was not able to move her left wrist, open her left hand and extend her left fingers…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow up on dental care recommendations of a resident who was experiencing tooth pain for over 6 months and required tooth extractions. This applies to 1 of 1 resident (R3) reviewed for dental services in the sample of 19. The findings include: R3's electronic medical record showed her to be an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Cerebral Infarction affecting right dominant side, rheumatoid arthritis, and poly neuropathy. On 10/21/2024 at 11:03 AM, R3 was alert and oriented and stated her mouth and teeth hurt. R3 stated she has been seen by the dentist three times since she has been at the facility, but they did not do anything. R3 stated her teeth hurt and some of her teeth are broken. R3 stated, she ate some of her broken teeth mistakenly. R3 stated she had a mouth full of teeth when she was admitted to the facility two years ago. R3 stated it hurts when she chews. On October 23, 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.

Based on observations and interview the facility failed to maintain resident room temperature at a comfortable setting to provide homelike environment. This applies to 6 of 6 residents (R17, R30, R43, R86, R245, R346) reviewed for environment in the sample of 19. The findings include: On October 21, 2024, at 10:33 AM, R346 stated I do not have heating or cooling in my room. It gets to 58 degrees in my room at nighttime. I bought a thermometer for my room. My family bought me extra blankets so I can stay warm at night. I put some blankets by the windows to block to cold air from coming in the room. They put this [heating and cooling] unit in the room since I came here but it doesn't work. Administration just keeps saying they are working on it. They tried to move my room, but I asked if it had heat, and it did not. R346's thermometer that was on nightstand showed 66 degrees Fahrenheit. On October 23, 2024, at 8:54 AM, R346's room temperature was checked with facility digital thermometer by V11 (Maintenance Director) and showed 72.4 degrees Fahrenheit. Facility digital thermometer was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide proper infection control practices for 55 residents (R2 - R56) after a positive COVID-19 exposure and failed to follow their COVID-19 policy. Findings include: On 7/23/24 at 10:45 AM there was no sign on the facility's front entry door showing that the facility was currently in an outbreak status for positive COVID-19. On 7/23/24 at 2:05pm R1 stated that she had not been tested for COVID-19 after she was informed that the facility had positive cases. On 7/23/24 at 2:15 pm R2 stated that she had not been recently tested for COVID-19. On 7/23/24 at 2:22pm R3 stated that she had not been tested for COVID-19 after she had been notified that there were positive cases in the facility. On 7/24/24 at 9:10 AM, V12 (CNA/certified nursing assistant) stated that she came to work on 7/2/2024 at 6:00 PM. V12 stated that from about 6:30pm - 10pm she was helping the other CNAs do work, getting water for the residents, doing laundry, 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 administration failed to provide oversight and leadership to ensure hot weather policies and procedures were followed when the facility's air conditioning was not functioning properly. V1 (Administrator) was aware the facility did not have functioning air conditioning and did not ensure temperature and humidity levels were being checked as shown in the policy This applies to all 98 residents residing in the facility. The findings include: The Facility Data Sheet dated June 12, 2024, shows the facility census as 98 residents. On June 12, 2024, at 11:42 AM, V1 (Administrator) was not present in the building. V2 (DON-Director of Nursing) stated, They are still working on the air conditioning situation. We have some portable air conditioners in the hallways and fans. On June 12, 2024, at 12:00 PM, V3 (Maintenance Director) stated he uses an infrared temperature gun to measure surface temperatures. V3 continued to say he does not have a thermometer to measure air temperatures or a device to measure humidity. V3 was not aware…

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 administer medications within the required timeframe. The facility also failed to obtain Physician's Orders to administer medications late. This applies to 25 of 27 residents (R1, R3, R5, R9, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, 31) reviewed for timely medication administration. Findings include: 1. On 3/28/24 at 2:02pm R3, who is oriented to person, place, and time, said that on 3/17/24 she did not get her evening medications on time. R3 said she did not get her medications until after 11:30pm. R3 said she stayed up waiting to get her medications because she was afraid if she didn't get them, she would have a stroke because her blood pressure would go up too high. R3 said after she got her medications, she had a difficult time falling asleep and her hands were shaking. R3's electronic medical records showed she has diagnoses including congestive heart failure, atrial fibrillation, hypertension, hypothyroidism, depression, atherosclerotic heart disease,…

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 grooming, timely incontinence care, and assistance with transferring out of bed for residents who require assistance with ADLs (Activities of Daily Living). This applies to 3 of 3 residents (R1, R6 and R3) reviewed for ADL care in the sample of 7. The findings include: 1. Face sheet shows that R1 is [AGE] years old with multiple diagnoses including multiple sclerosis, morbid obesity, hemiplegia of left dominant side, neuromuscular dysfunction of the bladder, and neurogenic bowel. R1's MDS (Minimum data Set) dated October 1, 2023, showed R1 to be cognitively intact. R1's MDS also showed R1 to be dependent on staff for transfers and toileting. R1's ADL care plan dated 10/31/2022 shows R1 requires a mechanical lift and is dependent on staff for transfers and ADL care. On February 26, 2024, at 12:08 PM, R1 stated he has been in the same incontinence brief for 22 hours. R1 stated he is usually up in his wheelchair between 8:00 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide physical therapy to R1. This applies to 1 of 1 resident (R1) reviewed for physical therapy in the sample of 6. The findings include: R1's face sheet shows he is a [AGE] year-old man admitted to the facility on [DATE], after staying at the hospital for 11 days. R1's nursing admission/re-admission nursing note dated January 17, 2024, shows, B. Initial Goals/Discharge Plans: 1. Initial plans: discharge to community . 2. Therapy ordered on admission: physical therapy (PT) and occupational therapy (OT), 2a. Therapy Care Plan: Focus: Resident has a goal to IMPROVE PHYSICAL FUNCTIONING and will be receiving Physical, Occupational, and/or Speech therapy . R1's order summary report provided by the facility on February 13, 2024, does not show any orders for physical therapy or occupational therapy. On February 13, 2024, at 12:01 PM, V6 Physical Therapist stated, he did not do a full evaluation on R1 when he was admitted . He screened him. He stated, R1'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 that the ambient air temperatures in the building remained within a comfortable range during a heating system breakdown. This failure affected 30 residents (R1 and R3-R33) reviewed for comfortable environment. The findings include: On 1/21/24 at 9am, during tour of the facility, the facility air felt very cold to this surveyor. Residents were ambulating in the hall wearing jackets and or sweaters. Some staff were also observed wearing sweaters and or jackets. On 1/21/24 at 9:00am V3 Housekeeping Director stated, The heats been going out off and on for about a couple of weeks. They started handing out these space heaters to help about a week ago. On 1/21/24 at 9:20am V4 Maintenance Director stated, the dining room is closed right now. We only have one boiler that is working. The company we were working with was not getting the problem fixed so we started using a new company. I do not write the temperatures down when I take them. If 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.

Based on interview and record review, the facility failed to provide an oral antibiotic as ordered. This applies to 1 of 3 residents (R4) reviewed for medication administration. Findings include: R4's admission Record dated 01/04/2024 documents R4 with diagnoses to include hemiplegia and hemiparesis and diarrhea. R4's Laboratory Results Report dated 01/08/2024 at 05:40 PM documents R4 tested positive for toxigenic Clostridioides difficile (C. diff). The Progress Note for R4 dated 01/09/2024 at 11:51 AM documents Writer relayed resident's lab result to (V10 Nurse Practitioner). He ordered resident to be on Vancomycin 125mg by mouth every 6 hours for 10 days for C-diff. Order entered accordingly and POA/family notified. R4's Medication Administration Record dated 01/04/2024-1/11/2024 documents that R4 did not receive Vancomycin until the 01/11/2024 06:00 AM dose. On 01/10/2024 at 11:00 AM V7 Registered Professional Nurse stated The supply here was gone. The Pyxis was out of the medication. I called and faxed the pharmacy. The medication hadn't arrived when I came in for the next…

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 properly label, date, seal, store and serve food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 12/12/23 documents that the total census was 91 residents. On 12/13/23 at 11:54 AM, V25 (Cook) said 1 resident is NPO (Nothing by Mouth) and does not eat from the facility kitchen. On 12/12/23 from 10:02 AM to 10:49 AM, the facility kitchen was toured in the presence of V25 (Cook) and the following items were found: Dry Storage: 1. an opened 32 ounce confectioners cane sugar, opened and undated 2. an opened, unsealed 160 ounce bag of wheat semolina pasta 3. opened 14 ounce bag of chicken gravy undated and not sealed 4. opened undated 14 ounce bag of chicken gravy 5. 18 quart bucket of undated, unlabeled large, not sealed bag of broken up candy pieces 6. 5 lb (pound) bag of blueberry…

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 educate and offer COVID-19 immunizations to 5 of 5 residents (R1, R5, R18, R34, & R50) and staff reviewed for COVID-19 immunizations in a sample of 25. Findings include: On 12/14/23, R1, R5, R18, R34 & R50's electronic records were reviewed, and no documentation could be found for them receiving immunizations for the year of 2023. No documentation could be found for the facility providing COVID-19 screening for the staff or offering and providing COVID-19 vaccination to the staff. On 12/14/23 at 12:40 PM, V4 (Infection Preventionist) was unable to provide any COVID-19 immunization consent forms for: R1, R5, R18, & R50, and could only provide R34's COVID-19 consent form dated 5/26/22. V4 said that R18 had no documentation for immunizations but that R18 had COVID on 10/27/23. (R18's electronic health record showed that she was admitted to the facility on [DATE]). V4 said the facility did not give any vaccinations for the 2023 - 2024 year to R1, R5, R18,…

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 keep resident call lights accessible and provide adequately sized incontinence briefs to residents. This applies to 6 of 6 residents (R28, R69, R2, R84, R83, and R93) reviewed for accommodation of needs in a sample of 25. The findings include: 1. On 12/12/23 at 10:43 AM, R28 was lying in bed. R28's bed was pushed up against the wall on the left side. R28's call light was clipped onto the call light switch on the wall, located above the end of the bed, out of reach of the resident. On 12/13/23 at 08:57 AM, R28 was eating her meal in bed. R28's call light was still clipped onto the call light switch, and out of reach of the resident. On 12/14/23 at 08:25 AM, R28's call light remained clipped onto the wall input point and remained out of reach of the resident. On 12/14/23 at 08:41 AM, V8 (CNA/Certified Nurse Assistant) said R28 was able to use the call light and it should be within reach so if she needed help, she would be able to call 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 follow infection control measures while; providing medications for 3 residents (R12, R6, & R97), providing medical treatments/procedures for 1 resident (R97), providing resident care for 1 resident (R46), and failed to properly contain soiled linen and respiratory equipment for 1 resident (R12) in a sample of 25. The Findings include: Providing medications: 1. On 12/12/23 at 10:27 AM, V9 (Nurse) was observed putting 1 Hydrocodone APAP 5-325mg (Milligrams) tablet in her ungloved, uncleaned hand, and then she put the medication in a medication cup. The surveyor asked V9 if the medication was still clean after she put it in her hand. V9 said that it was not, and that it was contaminated medication. V9 then put some pudding in the cup and gave the contaminated medication to R12. On 12/12/23 at 10:49 AM, V9 said the medication was contaminated, but she gave it to the resident anyway because she didnt want to use up another narcotic. V9 said she should not have given it to the resident, because by giving 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 interview and record review, the facility failed to provide influenza and or pneumococcal immunizations for 5 of 5 residents (R1, R5, R18, R34 & R50) reviewed for immunizations in a sample of 25. Finding include: On 12/14/23, R1, R5, R18, R34 & R50's electronic records were reviewed, and no documentation could be found for them receiving immunizations for the year of 2023. On 12/14/23 at 12:40 PM, V4 (Infection Preventionist) provided Influenza Immunization Informed Consent forms and Pneumoncoccal Immunization Informed Consent forms for: R1 (dated 11/4/23), R5 (dated 1/12/23), and R34 (dated 11/3/22 & 1/12/23). V4 provided R34's COVID-19 Vaccine Informed Consent - Resident/Client form (dated 5/26/22). V4 did not provide R18 & R50's Influenza Immunization Informed Consent forms, Pneumoncoccal Immunization Informed Consent forms, or COVID-19 Vaccine Informed Consent. V4 said that R18 and R50 did not have the forms. V4 said that R18 had no documentation for R18 immunizations but that R18 had COVID on 10/27/23 and the hospital gave R18 her influenza vaccine on 10/1/23, but R18…

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 assess a resident for self-administration of medications and failed to obtain a physician's order for a resident to self-administer medications. This applies to 1 of 7 residents (R53) reviewed for medications in the sample of 25. Findings include: R53 is a [AGE] year old female admitted to the facility on 1/9 2023 with diagnoses including epileptic seizures, hypertension, major depressive disorder, anxiety disorder, and a history of traumatic brain injury. On 12/13/23 at 11:22am, V15 (Nurse) was observed placing 1 propanol 10mg (milligrams) tablet, 1 Propanol 20mg tablet, 1 acetaminophen 325mg tablet and 1 amoxicillin 500mg tablet into a plastic bag and giving it to R53. V15 said that she was told to give the medication to R53 because she was going on an outing to the mall. V15 then checked R53's electronic health record and said that R53 did not have an order to self-administer medications. On 12/13/23, R53's physician order sheet…

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 personal care assistance to 2 of 4 residents (R15 and R100) reviewed for ADL's (Activities of Daily Living) in a sample of 25 residents. The findings include: 1. On 12/12/23 at 11:54 AM, R15 was observed gowned and in bed. R15 stated she had not had a shower since being admitted to the facility. R15 stated she received bed baths, but they do not do a good job cleaning her. R15 stated she had requested staff assistance with cutting her nails, but it was not done. R15's nails were long with chipped nail polish. R15 was admitted to the facility on [DATE]. R15's care plan dated 11/6/23 states she has an ADL (Activities of Daily Living) self-care performance deficit. Needs and participation may vary related to weakness and diagnosis of failure to thrive. R15 is dependent on staff for care needs. R15 requires the assistance of 1-2 based on fatigue, weightbearing and weakness. Review of R15 EMR (Electronic Medical Record) did not show…

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 obtain blood samples from 2 of 2 diabetic residents (R79 and R204) that were reviewed for blood glucose monitoring in a sample of 25. Findings include: 1. R79 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes, end stage renal disease, & respiratory failure. On 12/12/23 at 10:54 AM, V15 (Nurse) was observed obtaining a blood glucose sample from R79. V15 wiped R79's finger with an alcohol wipe, pricked her finger, and then collected the blood sample. R79's blood sugar level was 512. V15 did not wait for the alcohol to dry on R79's finger before collecting the sample. 2. R204 is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including type 2 diabetes, hypertension, and hemiplegia and hemiparesis. On 12/12/23 at 11:06 AM, V16 (Nurse) was observed obtaining a blood glucose sample from R204' finger. V16 wiped R204's finger with an alcohol wipe, pricked his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify environmental hazards that poses risks for potential accidents. This applies to 3 of 3 residents (R15, R44 and R49) reviewed for accidents/hazards in the sample of 25. The findings include: 1. On 12/13/23 at 09:05 AM, R49 had a power strip on the floor next his bed. The power strip had the capacity for ten devices to be plugged into. Seven devices were plugged into the power strip. There were seven cords from the power strip that were not contained and spread over the floor next to the bed. Two cords extended from the side of the bed and plugged into the power strip. On 12/14/23 at 09:59 AM, the power strip continued to be on the floor next to the bed, with seven outlets being used. The cords from each outlet continued to be spread over the floor next to the bed. A fan next to the window, three feet away from the power strip, had a cord that was in the middle of the floor, plugged into the power strip. On 12/13/23 at 03:05 PM, V24…

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 conduct monthly medication reviews. This applies to 2 of 2 residents (R28 and R33) reviewed for monthly medication review by a pharmacist in a sample of 25 residents. The findings include: 1. R33's EMR (Electronic Medical Record) was reviewed. No MMRs (Monthly Medication Reviews) were observed for the prior twelve months. R33's Monthly Medication Reviews was requested from V3 (ADON/Assistant Director of Nursing) and V22 (Regional Nurse Consultant). On 12/14/23 at 12:31 PM, V3 stated they did not have the MMRs. On 12/14/23 at 12:35 PM, V22 stated they did not have the requested MMRs. On 12/14/23 at 3:08 PM, V37 (Pharmacist) stated he was located in the pharmacy headquarters. MMRs are completed by a specific pharmacist for the region. V37 stated he would forward the surveyor contact information to the consultant pharmacist. V37 stated he could not comment on the facilities MMRs or the significance of them not being completed. No return call from the consultant pharmacist was received. 2. R28's POS (Physician Order Sheet)…

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

Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 31 opportunities with 5 errors resulting in a 16.13% error rate. This applies to 2 of 6 residents (R2 & R6) observed in the medication pass in a sample of 25 Findings include: 1. R2 On 12/13/23 at 9:30 AM, V18 (Nurse) was observed putting the following medications in a cup to administer to R2: 1. Potassium Cl 20meq 1 tab 2. Hydroxychloroquine 200mg 1 tab 3. Vitamin B-6 1 tab 4. Hydrocodone - APAP 5-325 mg 1 tab V18 counted the medications and confirmed she had 4 medications in the cup and then gave R2 the medications. On 12/14/23 at 11:02 AM, a review of R2's physician orders showed: 1. Bupropion HCL 75mg QAM with a start date of 8/19/23 2. Furosemide 40mg 1 tab QAM with start date of 7/31/23 3. Polyethylene Glycol 17gm QAM with start date of 7/31/23 On 12/13/23 at 9:30 AM, R2 did not receive: Bupropion HCL 75mg, furosemide 40mg, & Polyethylene Glycol 17gm, as R2's physician ordered. 2. R6 On 12/13/23 at 8:51 AM, V18 (Nurse) was observed putting the following…

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 maintain temperature logs, label food items, and discard outdated food items. This applies to 3 of 3 residents (R6, R20 and R49) reviewed for personal food storage in a sample of 25 residents. The Findings include: 1. On 12/12/23 at 11:14 AM, R20's refrigerator was inspected. No temperature log was observed. A 4 oz (Ounce) cup of orange sherbet was noted incased in frost. An ice cream bar was stuck to the refrigerator and could not be lifted. No date observed. A grocery store prepared bowl of strawberries with a sell by date of 12/3/23 appeared mushy and discolored. A grocery store prepared bowl of watermelon with a sell by date of 12/4/23 appeared mushy. Seven manufacture containers of cheese and crackers did not have an observable expiration date. A large caramel colored spill was at the bottom of the refrigerator. R20 stated he ate some of the fruit in the refrigerator on 12/11/23. On 12/13/23 at 4:30 PM, V3 (ADON/Assistant Director 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that floor mats were provided while a resident was in bed to enhance resident safety and per plan of care. This applies to 1 of 3 (R1) residents reviewed for fall interventions in the sample of 3. The findings include: R1 had multiple diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary malignant neoplasm of brain, secondary malignant neoplasm of bone, secondary and unspecified malignant neoplasm of lymph node, secondary malignant neoplasm of other specified sites, nontraumatic intracerebral hemorrhage, aphasia, and history of falling, based on the face sheet. R1 was admitted to the facility under hospice care. R1's hospice physician visit notes dated October 23, 2023, showed that the resident had terminal illness of metastatic lung cancer to brain, bone, pancreas and lymph nodes. R1's BIMS (Brief Interview for Mental Status) dated October 26, 2023, showed that the resident was…

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 effectively resolve and manage resident grievances for staff call light response. This applies to 5 of 10 residents (R1, R10-R12, R16) reviewed for call light response in a sample of 17. Findings include: Resident Council Meeting Minutes dated 7/31/2023 documents a voiced resident concern of staff not answering call lights in a timely manner. The 8/10/2023 Resident Council Concern Follow-up Documents Nursing Assistants are being reminded not to turn off lights when they cannot address the residents need at the time. Resident Council Meeting Minutes dated 8/28/2023 documents voiced resident concern of staff are not answering call lights in a timely manner. The 8/28/2023 Resident Council Concern Follow-ups do not document a resolution or action taken to address the residents call light concerns. 1. On 10/25/2023 at 1:15 PM R1 stated when he signals staff he needs to be changed he has to wait an hour or more because staff come in and turn off the call light and do not return. A Grievance Form dated 9/15/2023 documents R1'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.

Based on observation, interview and record review the facility failed to provide showers/bathing to residents dependent on staff for ADL (Activity of Daily Living) care. This applies to 5 of 7 residents (R1, R3, R5, R6, R9) reviewed for ADL assistance in a sample of 17. Findings include: On 10/26/2023 at 11:42 AM V2 (Director of Nursing) stated residents are to be showered/bathed twice a week which includes washing hair. 1. On 10/25/2023 at 10:15 AM R1 stated, I am not getting my showers regularly. R1's POC Response History dated 10/27/2023 documents in the prior 30 day time period he was not bathed twice weekly. R1's Care Plan for ADL assistance dated 4/27/2023 documents R1 as requiring extensive staff assistance to bathe. R1's 7/13/2023 Brief Interview of Mental Status documents R1 as cognitively intact. 2. On 10/25/2023 at 9:55 AM R5 sat in a wheelchair in the activity room with greasy and unkempt hair. On 10/26/2023 at 9:45 AM R5 sat in her room in a wheelchair with greasy and unkempt hair. R5's POC Response History dated 10/27/2023 documents in the prior 30 day time period 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.

Based on interview and record review, the facility failed to ensure a resident was free from a physical restraint that was imposed for staff convenience. This applies to 1 of 3 residents (R1) reviewed for restraints in a sample of 8. Findings include: R1's Face Sheet dated 8/10/2023 documents R1's diagnoses include dementia with behavioral disturbances, anxiety, unsteadiness on feet and, psychosis. R1's 8/24/23 Minimum Data Set showed he is severely cognitively impaired and had wandering behaviors for 1-3 days during the lookback period. The facility's 10/6/2023 Final Incident Report Investigation documents on 10/2/2023 at 9:22 PM, V13 CNA (Certified Nurse's Aide) observed R1 sitting a chair in the hallway with a green towel wrapped around his waist. When V13 asked why R1 had a blanket wrapped around his waist, V12 (CNA) stated she placed the blanket around his waist so she could get her work done. The Investigation showed V10 LPN (Licensed Practical Nurse) .came over and unwrapped the blanket around the resident so he would be able to get up if he wanted to. V12's interview during…

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 identified as needing assistance with oral and personal hygiene. This applies to 8 of 8 residents (R9, R13, R36, R45, R51, R58, R61 and R192) reviewed for ADL (activities of daily living) in the sample of 21. The findings include: 1. R61 has multiple diagnoses which includes hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dementia without behavioral disturbance and generalized muscle weakness, based on the face sheet. R61's quarterly MDS (minimum data set) dated November 25, 2022 showed that the resident is severely impaired with cognition. The same MDS showed that R61 required extensive assistance from the staff with regards to personal hygiene. On February 6, 2023 at 10:47 AM, R61 was observed sitting in her high back wheelchair inside the dining area. R61 was alert and verbally responsive. R61 observed with accumulation of long and curling chin hair, her right eye lashes had…

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

Based on observation, interview and record review, the facility failed to follow menu spreadsheet to serve the portions as shown for all consistency diets. This applies 12 of 12 residents (R5, R9, R11, R26, R27, R30, R41, R49, R51, R53, R63, R69) observed for meal service in the sample of 21. The findings include: The Week at a Glance main menu for the lunch meal included Herbed Pork Loin with [NAME] Gravy, Candied Sweet Potato, and Braised Cabbage. On February 06, 2023 at 09:54 AM, V9 (Cook) was seen slicing very thin slices of already prepared and frozen pork loin. When V9 asked if the slices were too thin, V9 was told to follow the serving portion of the reheated version of the same. On February 06, 2023 at 12:30 PM, the lunch meal service was observed in the facility kitchen. V10 (Dietary Aide) and V11(Dietary Aide) were platting the food from the steam table. A spread sheet with portion serving size for the meal was not seen in the area. For the residents on pureed consistency diets, the pureed pork and pureed cabbage was served with a blue color #16 scoop (2 oz/ounce…

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 diet order for nutritional interventions as ordered by the Physician. This applies to 4 of 4 residents (R11, R41, R63, R289) reviewed for dining in the sample of 21. The findings include: On February 06, 2023 starting at 12:30 PM and on February 07, 2023 starting at 12:20 PM, the following lunch tray line meal service observations were made: 1. R11's diet order on POS (Physician Order Sheet) included Regular diet, pureed texture, add double protein for all meals (revised date 11/29/2022). On February 06, 2023, R11 received only one portion of pureed Pork Loin served with a #16 scoop (2 oz portion/scoop) when spread sheet showed to use #10 (3 oz portion/scoop) of the same. On February 07, 2023, R63 received one portion of pureed consistency chicken (4 oz). R11's diet card did not show double portions protein at lunch on both days. 2. R41's diet order on POS included Regular texture, double protein portions for all meals (revised 1/31/2023). On February 06, 2023, R41 received only one portion of Pork Loin…

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 document any information when a resident was transferred to a higher level of care facility. This applies to 1 of 1 residents (R88) reviewed for hospitalization in the sample of 21. The findings include: R88's EMR (Electronic Medical Record) showed R88 was admitted to the facility with diagnoses that included weakness, congestive heart failure, atrial fibrillation, major depression, morbid obesity, moderate persistent asthma, and hypertension. The EMR census showed R88 was admitted to the facility on [DATE], payment to facility was stopped on January 16, 2023, and payment was restarted on R88's readmission to the facility on January 21, 2023. R88's MDS (Minimum Data Set) dated January 27, 2023 showed R88 was cognitively intact. On February 8, 2023 at 9:32 AM, V25 (Director of Clinical Services) was asked to provide documentation from R88's admission on [DATE] to R88's readmission on [DATE]. V25 provided the discharge summary from the local hospital…

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 assess and provide adaptive equipment and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 3 residents (R26 and R61) reviewed for mobility and range of motion in the sample of 21. The findings include: 1. R26 has multiple diagnoses which includes hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side and spinal stenosis, based on the face sheet. R26's annual MDS (minimum data set) dated December 9, 2023 showed that the resident is moderately impaired with cognition. The MDS showed that R26 required total assistance from the staff with most of her ADL (activities of daily living). The same MDS showed that R26 had functional limitation in range of motion on one side of both her upper and lower extremities. On February 6, 2023 at 10:43 AM, R26 was observed sitting in her wheelchair inside the unit dining area. R26 was alert 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 interview and record review, the facility failed to accurately tract and document the facility staff's Covid-19 vaccines. The facility failed to ensure 100% of the eligible staff were vaccinated with both Covid-19 primary series vaccines. This applies to 64 staff members reviewed for Covid-19 vaccination status and 1 of 64 staff members (V10) reviewed for completed vaccine series. 1. On February 7, 2023 the facility provided the staff Covid-19 vaccination matrix as part of the entrance conference. The list provided showed a total of 94 staff members, 5 staff had religious exemptions, and 55 had no Covid-19 vaccination dates documented. On February 7, 2023 at 1:51 PM, V3 (ADON/Assistant Director of Nursing) stated in order to work in the facility, all staff must have been vaccinated for Covid-19 unless they have a religious or medical exemption. New staff members must show proof of their vaccination status. If they have not started the Covid-19 vaccine series, they must get the first vaccine before they start and get the second vaccine when they are eligible to get 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.