Claridge Healthcare Center

Based on observation, interview and record review the facility failed to have a system in place for monitoring resident room temperatures during hot weather. This applies to 4 of 5 residents (R1-R4) reviewed for comfortable room temperatures in the sample of 5. The findings include: On 6/24/25 at 9:20 AM V2 (Director of Nursing) stated, I have a guy that comes everyday to check on the temperatures but with this heat it just can't keep up. He is here now. I have pictures. V2 then showed Surveyor a picture, with no date or time, of a thermometer on the wall at the nurse's station on the second floor. The picture shows the thermometer at 70 degrees Fahrenheit (F). On 6/24/25 at 9:40 AM V5 (Heating and Cooling Representative) stated, I come in every morning at 7 AM to check. There are 2 condensers and there seems to be an obstruction in one of them- one of the condensers is not as cold as it should be. I ordered the parts, but it will take 2-3 days to get them. Then it is a 2-day job to fix it. It is blowing cold air but not cold enough. One is 50 degrees (F) and the other is about 65…

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 protect a resident (R1) from physical abuse by another resident (R2). This applies to 2 of 5 residents (R1, R2) reviewed for physical abuse in the sample of 5. The findings include: R1's Facesheet shows that R1 has diagnoses that include, but are not limited to, dementia and insomnia. R2's Facesheet shows that R2 has diagnoses that include, but are not limited to, psychosis, major depressive disorder, and insomnia. R1's Minimum Data Set (MDS) Section C dated 11/17/24 shows R1 scored a five out of fifteen on his brief interview for mental status (BIMS), indicating severe cognitive impairment. On 12/31/24 at 9:10 AM, R1 was in R1's room, lying in bed half asleep and half watching the television. R1 stated he was not in pain and that he did not have bruising on his torso area. R1 was unable to recall the 12/23/24 incident but appeared pleasant and had his needs met. On 12/31/24 at 9:50 AM, R3 stated that R2 typically eats his breakfast 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 notify law enforcement when an allegation of physical abuse occurred which applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse notification in a sample of 7. The finding include: 1. The facility's Final Incident Report dated 8/4/24 showed R1 and another male (R2) had an altercation on 7/31/24. It is noted R1 and R2 have dementia and cognitive deficits. R1 approached R2 who was sitting in a chair. R1 attempted to get R2 to move from the chair. R2 stood up and struck R1 in the face. R1 then fell back onto the floor. This report showed the police were not contacted after both residents' families declined to contact them. R1's Hospital Records showed he was admitted on [DATE] with a right hip fracture after having an altercation with another resident. These records showed R1 needed to have hip surgery to repair the fracture. 2. The facility's Incident Report dated 7/10/24 showed R5 was found sitting on the floor outside another resident's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a qualified, full time activity director. This failure applies to all 84 residents residing in the facility. The findings include: The CMS-671 form dated June 2, 2024, shows, there was 84 residents residing in the facility. On June 2nd and 3rd, 2024, no activities were observed. On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities. They have to entertain themselves. R74's Minimum Data Set, dated [DATE], shows, he is cognitively intact. On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing stated, there is no activity director and one activity assistant. On June 5, 2024, at 9:14 AM, V2 Director of Nursing stated, she does not have a activity director. She has been gone since March 2024. There is only 1 activity assistant for the entire building. She does not have the qualifications of an activity director. The facility's job description and performance standards for…

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 sufficient nursing staff to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84. 1. R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling left to right in bed, and for all transfers. On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she had a difficult time asking for help from staff. On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM. During that time, R4 was making…

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 medically related social services to meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84. 1. R21's face sheet list diagnoses to include dementia. On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. At 11:15 AM, she was trying to leave the dining room. V22 Certified Nursing Assistant (CNA) brought her back into the dining room and put her at the table. At 12:03 PM, she was standing up and down in her wheelchair trying to take food off other resident's trays. She wheeled herself over to the lunch cart and was trying to take food off the cart. At 12:58 PM, she wandered out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one 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 observation, interview, and record review the facility failed to ensure a serving spoon was sanitized and air dried to prevent foodborne illness. This has the potential to affect all 82 residents in the facility receiving food from the kitchen. The findings include: The CMS 671 dated 6/2/24 shows there are 84 residents residing in the facility. On 6/2/24 at 11:53 AM, V12 (Cook) handed V10 (Dietary Aide) a serving spoon that became soiled during service. V10 took the serving spoon to the three-compartment sink, and quickly dipped the spoon through each individual sink. At the sanitizer sink, V10 dipped the spoon a few times, removed the spoon from the sink, and proceeded to dry the spoon with brown disposable paper towels. V10 returned the spoon to V12 and V12 continued to use the spoon for the remainder of service. On 6/2/24 at 10:01 AM, V4 stated that all dishes are currently being done using the three-compartment sink. The dish machine has been broken for a few years and is not currently in use. When using the three-compartment sink, dishes need to be fully submerged for…

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

Based on observation, interview and record review facility administration failed to manage the facility in manner to effectively meet the needs of the residents. This failure has the potential to affect all 84 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84. 1. On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65 were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television was the only thing on. On June 2, 2024, at 10:30 AM, R74 the resident council president stated, there isn't any activities. They have to entertain themselves. On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing (ADON) stated, there is no activity director and only 1 activity assistant. 2. On 6/3/24, during the resident meeting, R11, R55, and F74 each stated the facility did not have a full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in 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/employ a qualified, full-time social worker. This failure has the potential to affect all 84 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84. The facility's Facility Assessment Tool revised 7/31/23 showed the facility has a maximum bed capacity of 230 beds. On 6/3/24, during the resident meeting, R11, R55, and R74 each stated the facility did not have a full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's assistance to help her work with my insurance so I can find a dentist but there's no one to help do that either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes in but, I have no one to talk to…

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

Based on interview and record review the facility failed to ensure nursing staff received dementia care training and education, annually, as required. This failure has the potential to affect all 84 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a resident census of 84. On 6/4/24 at 11:00 AM, the following employee files were reviewed: 1. V22 Certified Nursing Assistant's (CNA) file showed V22 had been employed by the facility since 4/6/2014. V22's file showed V22 had received no dementia education or training in 2023 or 2024. 2. V28's file showed V28 had been employed by the facility since 8/12/1991. V28's file showed V28 had received no dementia education or training in 2023 or 2024. 3. V26's file showed V26 had been employed by the facility since 8/7/2015. V26's file showed V26 had received no dementia education or training in 2023 or 2024. 4. V21's file showed V21 had been employed by the facility since 11/1/2017. V21's file showed V21 had received no dementia education or…

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 observation, interview, and record review the facility failed to ensure the residents were provided activities. This applies to 3 of 20 residents (R48, R65, R74) reviewed for activities in the sample of 20. The findings include: On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65 were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television was the only thing on. On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities. They have to entertain themselves. On June 3, 2024, at 10:03 AM, R48 and R65 were sitting in the dining room in their reclining wheelchairs. There were no activities going on. The television was the only thing on. At 10:21 AM, V22 Certified Nursing Assistant (CNA) started playing BINGO with the residents that could play (5 residents). R48 and R65 did not play bingo but remained in the dining room watching everyone else play. On June 4, 2024, at…

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

Based on observation, interview, and record review the facility failed to ensure opened, multi-dose bottles of medication, inhalers, and insulin pens were labeled with expiration dates for 4 of 4 residents (R64, R20, R45, R82) reviewed for medication storage in the sample of 20. The findings include: 1. R64's June 2024 (physician) Order Summary report showed R64 received Advair Diskus (powder) inhaler, 100-50 mcg (micrograms), one puff, twice a day. The order showed R64 received 30 units of Glargine insulin, subcutaneous (SQ), daily. R20's June 2024 (physician) Order Summary report showed R20 received Lispro insulin, as per sliding scale instructions, SQ (subcutaneous), four times a day. R45's June 2024 (physician) Order Summary report showed R45 received Lantus insulin, 25 units, SQ, daily. On 6/2/2024 at 10:50 AM, the third-floor medication (med) cart was reviewed by this surveyor and V16 Registered Nurse (RN). Upon inspection of the cart, the following medications were found opened and not dated with an opened or expiration date: a) A Lantus insulin pen and Advair Diskus inhaler…

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 a resident with a multi-drug resistant urinary infection was placed on contact isolation. The facility failed to initiate enhanced barrier precautions on residents with a catheter, tube feeding, and/or wounds. These failures apply to 5 of 20 residents (R51, R4, R84, R1, R24) reviewed for infection control in the sample of 20. The findings include: 1. R51's Order Summary Report shows R51 is receiving Meropenem-Sodium Chloride (intravenous antibiotic), two times a day for a UTI (urinary tract infection). This order was started on 5/29/24. On 6/3/24 at 8:39 AM, R51's door or room had no signs of contact isolation precautions in place. At 9:09 AM, R51 was lying in bed receiving her scheduled intravenous antibiotic. On 6/3/24 at 8:26 AM, V3 (Assistant Director of Nursing) stated that R51 had ESBL (extended spectrum beta-lactamase; a multi-drug resistant organism) in the urine and that R51 was not on contact isolation and there 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 observation, interview, and record review the facility failed to ensure a resident, dependent upon staff for cares, had a call light system in place to meet the needs of the resident. This applies to 1 of 20 residents (R4) reviewed for accommodation of needs in the sample of 20. The findings include: R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling left to right in bed, and for all transfers. On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she had a difficult time asking for help from staff. On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM. During that time, R4 was making intermittent audible verbal sounds at 12:07 PM, 12:10 PM, 12:13 PM,…

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

Based on observation, interview, and record review the facility failed to ensure a resident was provided privacy during wound dressing changes. This applies to 1 of 20 residents (R6) reviewed for privacy in the sample of 20. The findings include: On June 2, 2024, at 11:39 AM, R6 was sitting in his reclining wheelchair in the dining room. V15 Registered Nurse (RN) changed R6's right heel dressing while he was sitting in the dining room. There were approximately 20 residents in the dining room. They could see/watch V15 change his dressing. On June 2, 2024, at 12:48 PM, R6 was lying in bed. V15 RN was changing the dressing to R6's buttocks. The bedside curtain and door to his room was open. R6 is the first bed in the room. You could see R6 from the hallway. One June 5, 2024, at 12:36 PM, V3 Assistant Director of Nursing stated, staff should not be doing dressing changes in the dining room, and they need to provide privacy for the residents. The facility's residents right to personal privacy dated September 1, 2011, shows, Policy: Facility staff must examine and treat residents in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff-dependent residents were bathed, their nails were cut, and facial hair was groomed for 3 of 20 residents (R1, R24, R64) reviewed for activities of daily living (ADL's) in the sample of 20. The findings include: 1. On 6/2/24 at 11:39 AM, R24, who is nonverbal, was lying in bed. His nails, on both hands, were approximately 1/2-1 inch in length, with some curling back. R24's shower schedule shows he should receive showers/baths on Monday and Thursday. The facility shower sheets for R24 showed he had a bed bath on 5/6/24 and not again until 6/3/24. R24's active care plan shows he has diagnoses of dementia, communication deficit, and requires extensive to total staff assistance with his Activities of Daily Living. On 6/2/24 at 11:57 AM, V24 (Certified Nursing Assistant/CNA) stated residents should be given showers or baths 2 times a week, nails should be cut, and facial hair shaved during that time. On 6/3/24 at 10:10 AM V3…

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

Based on observation, interview, and record review the facility failed to ensure a resident with a skin rash was assessed and failed to ensure a skin treatment was applied according to standards of practice, for 1 of 20 residents (R17) reviewed for quality of care in the sample of 20. The findings include: On 6/2/24 at 11:06 AM, R17 stated she has a terrible rash, that has been there for over 2 weeks, on her back and in her groin. R17 proceeded to pull down her pants and show this surveyor the rash, that was bright red in color, between her legs and spreading down both thighs. R17 also pulled up her shirt and showed this surveyor a spotty pinpoint rash on her back with some scabbed areas from itching. In R17's shirt pocket was a bottle of Nystatin powder. R17 stated she has told the nurses about the rashes, but no doctor has seen her. The nurses gave her the powder and told her to put it on herself. R17 stated she told the nurse again today (V16 Registered Nurse) who stated she would come and take a look at it. On 6/3/24 at 12:32 PM, V16 RN stated she had not been in to see R17'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 ensure a sacral pressure injury was assessed, reported to the physician, and a treatment for the injury was in place. The facility also failed to follow physician orders for pressure injuries. This applies to 1 of 3 residents (R6) reviewed for pressure injuries in the sample of 20. The findings include: On June 2, 2024, at 11:39 AM, V15 Registered Nurse (RN) was changing R6's right heel dressing. R6 had an approximate 1-inch abrasion to his left knee. V15 RN stated, they are leaving it open to air and then put betadine on it. On June 2, 2024, at 12:48 PM, V15 RN was changing R6's sacral wound dressing. R6 had a large, ping pong ball size, purple/red open area on his right buttock. He (R6) had the same size/color wound on his left buttock that was connected to the right buttock. V15 RN stated, she first saw the wound on Wednesday of that week. She was waiting for the wound doctor to come in and evaluate the wound. He was supposed to come that day (June 2, 2024) but wasn't coming now. She (V15) stated, the wound…

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 restorative services to 2 of 5 residents (R24, R64) reviewed for restorative cares in the sample of 20. The findings include: 1.) On 6/2/24 at 11:37 AM, R24 who is nonverbal, was lying in bed with contractures noted to both hands. R24's active care plan shows he has diagnoses including dementia and right sided weakness due to a cerebral vascular accident with contractures to his upper body. R24's Restorative Care Plan shows he requires extensive staff assistance with his Activities of Daily Living and should receive PROM (passive range of motion) to his affected extremities for 15 minutes a day. R24's restorative documentation for the last 30 days showed he was provided range of motion for 15 minutes on 8 out of 30 days 5/9/24, 5/10/24, 5/11/24, 5/16/24, 5/20/24, 5/24/24, 5/29/24 and 6/1/24. On 6/3/24 at 1:42 PM V3 (Assistant Director of Nursing) stated they have a restorative CNA (Certified Nursing Assistant) who should be doing range of motion, and working with residents but he gets pulled to work the floor a lot…

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 residents at risk for falls were supervised and interventions were in place to prevent falls. The facility also failed to ensure residents were transferred in a safe manner. These failures apply to 2 of 20 residents (R21, R65) reviewed for safety/supervision in the sample of 20. The findings include: 1. On June 2, 2024, at 10:08 AM, R21 was sitting in her wheelchair in the dining room. Her (R21) left eye was yellow/green with sutures to her eyebrow. R21's incident/occurrence report dated May 26, 2024, shows, Resident fell forward in the bed after night CNA (certified nursing assistant) put her back to bed after falling. Noted bleeding on her left forehead d/t (due to) laceration. R21's hospital records dated May 26, 2024, shows, she had a fall with a cut on her face. Chin and left eyebrow laceration, stitches or tape. The same records continue to show, Pt (patient) arrives via EMS (emergency medical services) with c/o (complained of) mechanical fall and facial lacerations. Pt resides at the facility…

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 oxygen tubing was dated and failed to change humidifier containers on the oxygen concentrator for 2 of 4 residents (R23, R61) reviewed for oxygen administration in the sample of 20. The findings include: On 6/2/24 at 10:42 AM, R23 was in bed with a portable oxygen concentrator next to the bed. R23 stated I am not using it right now because they don't change the filter on the back of the machine or the water container. R23's nasal cannula tubing was not dated, and the humidifier container was dated 4/18/24. On 6/2/24 at 11:10 AM, R61 was in her room with her portable oxygen concentrator running. The nasal cannula tubing was also not dated, and the humidifier container was dated 4/18/24. Both R23 and R61's May 2024 Treatment Administration Record (TAR) shows their oxygen tubing and humidifier container are to be changed every week on Sundays. R23 and R61's TAR is initialed as the oxygen tubing and humidifiers being changed however the date on the humidifier for both residents was 4/18/24, and the tubing…

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

Based on observation, interview, and record review the facility failed to monitor behaviors and provide stimulation for residents with a diagnosis of dementia. This applies to 3 of 3 residents (R21, R53, R138) reviewed for dementia in the sample of 20. The findings include: 1. R21's face sheet list diagnoses to include dementia. On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. There were no activities going on and she was just sitting there. At 11:15 AM, she was trying to leave the dining room. V22 Certified Nursing Assistant (CNA) brought her back into the dining room and put her at the table. At 12:03 PM, she was standing up and down in her wheelchair trying to take food off other resident's trays. She wheeled herself over to the lunch cart and was trying to take food off the cart. At 12:58 PM, she wandered out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one was watching her. On June 3, 2024, at 9:17…

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 medications were dispensed according to standards of practice for 1 of 20 residents (R26) reviewed for pharmacy services in the sample of 20. The findings include: On 6/2/24 at 11:52 AM, on R26's bedside table was a pill cup containing 1 blue pill. R26 stated sometimes when he is in the bathroom, they just leave his medication for him to take. R26 was not able to indicate what pill was in the cup or what time it was left for him. R26 took the pill while this surveyor was in the room. On 6/2/24 at 12:22 PM, V16 (Registered Nurse/RN) stated residents should be supervised taking their medication and R26 does not have an order that he can self-administer his own medication. V16 also stated if the pill was blue, she believes it was probably his Levothyroxine. On 6/3/24 at 8:30 AM, V3 (Assistant Director of Nursing/ADON) stated medications should not just be left for residents to take they should be supervised. R26's Physician Order Summary (POS) shows an order for Levothyroxine to be given one time a day 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 ensure a resident admitted for therapy services received therapy services. This applies to 1 of 4 residents (R84) reviewed for therapy services in the sample of 20. The findings include: R84's Face sheet shows that R84 was admitted to the facility on [DATE] with a primary admitting diagnosis of a right femur fracture. R84's Care Plan shows the resident has a right hip fracture related to a fall from a car accident. On 6/2/24 at 2:12 PM, R84 stated he was admitted to the facility following surgery after a car accident. He did not believe he was receiving therapy services. He said that V30 (Physical Therapist) was working with him to exercise his leg before V30 went on vacation. R84 stated that V32 (Restorative Certified Nursing Assistant (CNA)) currently works with him on transfers but does not help him walk. On 6/5/24 at 11:08 AM, R84 stated his goal with therapy is to be able to stand and walk again and discharge back home. On 6/2/24 at 2:40 PM, V32…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were screened for and received all recommended doses of the pneumococcal (pneumonia) vaccine for 2 of 5 residents (R388, R38) reviewed for the vaccine in the sample of 20. The findings include: 1. R388's immunization record (undated) showed R388 was admitted to the facility on [DATE]. The record showed R388 last received a pneumococcal vaccination on 12/26/2000 which showed R388 was currently eligible for an additional pneumococcal vaccine. R388's medical record was reviewed and showed no documentation R388 was screened for or offered a pneumococcal vaccine upon admission to the facility or at any time during his stay in the facility. 2. R38's immunization record (undated) showed R38 was admitted to the facility on [DATE]. R38's Authorization and Release for Pneumococcal Vaccine form dated 8/25/2023 showed R38 was screened for the vaccine and consented to receive the vaccination. R38's medical records dated 8/25/2023-6/2/2024 were…

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 an allegation of sexual abuse was immediately reported to the Administrator for 1 of 1 resident (R1) reviewed for abuse reporting in the sample of 7. The findings include: On 5/14/24 at 10:20 AM, R1 stated that she was in the dining room sleeping on 2/2/24. R1 stated that as she woke up, a Chinese man had his hand under her gown touching her breast. R1 stated that she did not report the incident to anyone right away but did report it a few days later to V6 (Registered Nurse), V2 (Director of Nursing) and V8 (Social Services). R1 stated that an investigation was not done immediately. R1 stated that she had notified the ombudsman about the incident recently and that is when the facility started to investigate what had happened and called the police. On 5/14/24 at 12:00 PM, V6 (Registered Nurse) stated that in February, R1 came to him and told him that she was sleeping in the dining room and when she woke up a Chinese man was touching her breast. V6 stated that R1 had voiced to him that she had already notified social…

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 residents were not verbally abused by R2 for 3 of 4 residents (R1, R3, R4) reviewed for abuse in the sample of 4. The findings include: The Final Incident Investigation Report dated 3/27/24 for R2 showed the resident that was verbally abused was R1 and the resident accused of abuse was R2. The original allegation showed R2 was in an area of the dining room, repeatedly in an agitated manor calling R1 a black n* multiple times and this was witnessed by other African American residents. The facts that were determined in the investigation showed R2 was in the dining room and was using derogatory statements towards the African American Resident population. On 4/2/24 at 9:33 AM, V3 ADON (Assistant Director of Nursing) stated R2 was calling R1 a n*. R1 was upset and said we need to get R2 out of there. V3 stated she told R2 to leave the dining room. V3 stated R2 is alert and oriented but has a lot of psychiatric problems. V3 stated R2 was moved to the third floor. On 4/2/24 at 10:05 AM, R1 stated R2 was calling him…

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 thorough investigation of an abuse allegation was conducted for 1 of 3 abuse investigations reviewed involving 2 of 4 residents (R1, R2) in the sample of 4. The findings include: The Final Incident Investigation Report dated 3/27/24 for R2 showed the resident abused was R1 and the resident accused of abuse was R2. The original allegation showed R2 was in an area of the dining room, repeatedly in an agitated manor calling R1 a black n* multiple times and this was witnessed by other African American residents. The facts that were determined in the investigation showed R2 was in the dining room and was using derogatory statements towards the African American Resident population. The investigation did not have any interviews conducted with R1, R2, or any other residents present (R3). The investigation did not have any interviews of other employees and residents that have contact with R2. On 4/2/24 at 9:33 AM, V3 ADON (Assistant Director of Nursing) stated R2 was calling R1 a n*. R1 was upset and said we need to…

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

Based on observation, interview, and record review the facility failed to ensure the dishes were sanitized after washing in the 3-compartment sink. This has the potential to affect all 88 residents in the facility. The findings include: The CMS 672: Resident Census and Conditions Report dated 7/11/23 shows the current facility census as 88 residents. On 7/10/23 at 9:50 AM during the initial kitchen tour the sanitizer in the 3-compartment sink was checked as staff were observed washing dishes. The strip registered as 0- minimal sanitizer present. At 9:55 AM, V8 (Dietary Manager) drained the water from the sink and new water with sanitizer was added to the sink. The water was tested again, and the strip measured 150ppm (Parts per million). V8 stated that he just got that sanitizer this morning because they were out, and it is a different sanitizer than they are used to, and they did not use enough in the 20 gallon sink. V8 also stated that the dishwasher has not been working (broken for the last year) so all dishes are being done by hand. V8 stated that the dishes are washed, rinsed,…

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 facility wide assessment was reviewed and updated at least every year. This failure has the potential to affect all 88 residents residing in the facility. The findings include: The facility's Resident Census and Conditions of Residents (CMS-672) form dated 7/10/23 shows the facility census is 88. On 7/12/23 at 12:08 PM, V1, Administrator, said he is responsible for the facility assessment. V1 said the facility assessment has not been updated since 3/19/21. V1 said he knows it needs to be updated and it just has not been done. The Facility Assessment provided by the facility shows the most recent date it was reviewed was 3/11/21. An Addendum to the Facility Assessment Tool shows a revision date of 3/19/21.

Based on interview and record review the facility failed to have a written QAPI plan and failed to show evidence of an ongoing QAPI Program. This has the potential to affect all 88 residents in the facility. The findings include: On 7/12/23 at 10:00 AM V1 (Administrator) stated, We use to have meetings every Thursday and that kind of fell by the wayside. I know it is important and I am not going to lie to you, but it has just kind of fallen by the wayside. We have QA (quality assurance) meeting every quarter. For example, we know that falls is a big thing. When we are out on the floor, we are all looking at that. When we have a meeting, I get the minutes from the last meeting, and I try to remind everyone what we talked about at the last meeting. I am a numbers guy. V3 (Assistant Director of Nursing) is the solution person. I can look at something and see that it has gone up 20%- they need to be able to tell me why. Or if something has gone down then they need to say if something is working or not and why. We put a lot of faith in V3 and sometimes she just says, I don't know. I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and maintain an Enhanced Barrier Precautions Policy and Procedure, failed to develop, and maintain a Water Management Plan to detect and prevent water borne pathogens, and failed to have a system in place for tracking and trending any infections in the facility. The facility also failed to ensure that staff change their gloves and wash their hands while providing care to residents to prevent cross contamination. This has the potential to affect all 88 residents in the facility. The findings include: 1. On 7/11/23 at 10:30 AM V3 (Assistant Director of Nursing) stated, I just learned about that- enhanced Barrier Precautions so I am not too familiar with it, I don't really know too much about that. When the County came in just recently, they mentioned that to me. That was the first time I really heard about it. V3 stated for certain procedures for certain residents you need to wear personal protective equipment (PPE) for them, like…

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

Based on observation, interview, and record review the facility failed to ensure oxygen was administered in a manner to prevent infection for 4 of 4 residents (R58, R26, R1, R338) reviewed for oxygen in the sample of 20. The finding include: 1. On 07/10/23 at 10:09 AM, R58 was in bed sleeping. R58 had a nasal cannula on, delivering oxygen. The oxygen tubing was not labeled, and the humidifier bottle was dated 6/5. R58's Physician Orders for July 2023 shows Oxygen titrated up to 4 Liters/minute per nasal cannula continuously. 2. On 07/10/23 at 12:30 PM, R26 was sitting up in her wheelchair eating lunch. R26 had a nasal cannula on delivering oxygen. There was no date on the oxygen tubing or the humidifier bottle. R26's Physician Orders for July 2023 shows Oxygen at 2-4 Liters/minute via nasal cannula continuous. Change humidifier weekly on Sunday, Change nasal cannula weekly on Sunday. 3. On 07/10/23 at 12:27 PM, R1 was in bed and had a nasal cannula on delivering oxygen. There was no date on the oxygen tubing or the humidifier bottle. R1's Physician Orders for July 2023 shows Change…

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 at the ordered time and ordered dosages. There were 28 opportunities with three errors resulting in a 10.71% error rate. This applies to 2 of 3 residents (R41 and R43) observed in the medication pass. The findings include: 1. R41's July Physician's Order Sheet (POS) shows orders for: Ferosul 325 milligrams (mg)-Take 1 tablet by mouth once daily with breakfast and Senna 8.6 mg-Take 2 (17.2 mg) by mouth twice daily for small bowel obstruction/increase bowel regimen. On 7/11/23 at 9:24 AM, V7, Registered Nurse (RN) gave R41 her 9:00 AM medications. V7 administered Senna 8.6 mg-one tablet and omitted Ferrous Sulfate 325 mg. 2. R43's July POS shows an order for: Fish Oil 1000 mg-Take 1 capsule by mouth once daily. On 7/11/23 at 9:28 AM, V12 (RN) administered R43's Fish Oil 1200 mg. On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that a nurse should compare the medication administration record to the medication being provided. V3 said that the nurse should verify that they are…

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 treat a resident in a dignified manner for two of 20 residents (R48, R51) reviewed for dignity in the sample of 20. The findings include: 1. R48's admission Record shows she was admitted to the facility on [DATE] with diagnoses including alzheimer's disease, altered mental status, anxiety disorder, and major depressive disorder. On 7/10/23 at 12:10 PM, V4 CNA (Certified Nursing Assistant) was feeding R48 a pureed diet during the lunch meal while she was standing over R48. R48's Physician Orders dated 7/1/23-7/31/23 shows an order for pureed diet. On 7/11/23 at 1:38 PM, V6 CNA said residents should be fed sitting down. 2. R51's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, and toxic encephalopathy. R51's Physician Orders dated 7/1/23-7/31/23 shows an order for pureed diet with nectar thick liquids. On 7/11/23 at 10:51 AM, R51 was sitting next to her spouse that resides at the same…

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 implement their abuse policy by not investigating and reporting an injury of unknown origin and verbal abuse allegation for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20. The findings include: 1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee. R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x-ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware. R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x-ray and will notify doctor. The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin and an allegation of verbal abuse to the abuse coordinator for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20. The findings include: 1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee. R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware. R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x ray and will notify doctor. The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with a fracture to the index…

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 investigate injuries of unknown origin and allegation of verbal abuse for two of 20 residents (R82, R46) reviewed for abuse in the sample of 20. The findings include: 1. R82's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, benign neoplasm of connective and other soft tissue, sebaceous cyst, and osteoarthritis in left knee. R82's Nurses Notes dated 5/14/23 shows, Resident came back with his son and checked left hand x-ray for swelling. 7:00 PM, writer informed that [R82] had a fracture of index finger, left hand. Doctor made aware. R82's Nurses notes dated 5/29/23 8:45 PM, shows, Resident placed in bed around 8:00 PM. CNA (Certified Nursing Assistant) noticed right hand was swollen .will order x-ray and will notify doctor. The facility's Monitoring Flow Sheet for Incident shows on 5/13/23, R82 had swelling to his left hand with a fracture to the index finger. This same flow…

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 staff failed to ensure residents who require extensive assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 20 residents (R41 and R16) reviewed for ADLs in the sample of 20. The findings include: 1. R41's Minimum Data Set assessment dated [DATE] shows that she needs extensive assistance with personal hygiene and is always incontinent of urine and stool. On 7/10/23 at 10:30 AM, R41 was laying in bed. There was a strong urine odor present in the room. R41 said that she asked V6, Certified Nursing Assistant (CNA) to be changed around 7:00 AM but she had not returned yet. R41 said that she was last changed around 12:00 AM. On 7/10/23 at 11:30 AM, R41 was provided incontinence care by V5 (CNA). At 11:58 AM, V5 said that R41's incontinence brief was saturated with urine and stool. V5 said that her incontinence bed pad and sheets were saturated as well and needed to be changed. V5 said that R41 is not on 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 observation, interview and record review the facility failed to ensure necessary care and treatment was performed for a resident with leg ulcers and failed to ensure compression stockings were applied for a resident with edema. This applies to 2 of 20 residents (R4, R16) reviewed for quality of care in the sample of 20. The findings include: 1. R4's face sheet shows she is an [AGE] year-old female with diagnosis including hemiplegia and hemiparesis following intracerebral hemorrhage affecting right dominant side, dysphasia, aphasia following cerebral infarct, vascular dementia, gastrostomy status and non-pressure chronic ulcer of left lower leg. On 7/11/23 at 9:39 AM, R4 was observed laying in bed. A soiled gauze dressing dated 7/9/23 was observed to her left lower leg and foot. V2 (Director of Nursing) was in the room and said R4's dressing should be changed daily. R4's Wound Progress note dated 6/26/23 documents she has a chronic ulcer to the left calf with fat layer exposed measuring 15 cm…

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 arrange for a resident to see the eye doctor upon resident complaints of being unable to see. This applies to 1 of 20 resident (R62) reviewed for vision and hearing in a sample of 20. The findings include: On 7/11/23 at 1:45 PM R62 stated, I was told I need to see the eye doctor- I didn't know there was an eye doctor that came here. I love to read my books and I can't see and it kind of irritates me. My niece sent me some new books, but I can't see. I told the nurse, and she said I should see the eye doctor and get new glasses. I haven't heard anything more about it. On 7/11/23 at 2:06 PM V3 (Assistant Director of Nursing) stated, The eye doctor came today because I called him yesterday. I didn't know anything about (R62). He makes his own schedule- if there is an issue then we call him and let him know and he will come in. The nurses will call him- more often than not it will get carried over from day to day to day (on the 24 hours report sheet) until the doctor comes in and then someone may tell him about it. Honestly 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 observation, interview, and record review the facility failed to ensure pressure ulcer treatment orders were followed and in place for a resident with pressure injuries for 1 of 3 residents (R26) in the sample of 20. The findings include: On 07/10/23 at 9:56 AM, R26 was sitting up in the wheelchair in her room. R26 had compression stockings on her legs and feet and her feet were resting on a folded sheet, flat on the floor. On 07/10/23 at 12:30 PM, V14 Certified Nursing Assistant (CNA) removed R26's compression hose and there was no dressing on R26's right heel. V14 said R26 doesn't usually have a dressing on her heel. On 7/10/23 at 1:21 PM, R26 was transferred to bed. V14 CNA removed R26's brief and R26 had a dressing on her sacral area and a red peri-area. V12 Registered Nurse (RN) removed the dressing and cleaned R26's sacral area. R26 had a red, open area on her sacral area. V12 applied honey to the sacral wound and then a pink foam dressing. V12 applied zinc cream over R26's peri-area. V12 said the wound doctor made rounds the day before and the floor nurses are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have fall prevention interventions in place and failed to safely transfer residents for two of 20 residents (R73, R76) reviewed for safety in the sample of 20. The findings include: 1. F76's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, major depressive disorder, unsteadiness on feet, cognitive communication deficit, and restlessness and agitation. R76's MDS (Minimum Data Set) dated 4/22/23 shows R76 is not cognitively intact, requires extensive assistance with one person in transferring and toilet use, and is not steady and only able to stabilize with staff assistance. R76's Fall Risk Evaluation dated 5/7/23 shows R76 is a high risk for falls. R76's Care Plan dated 4/22/23 shows R76 is at risk for falls. R76 has an unsteady gait, lower extremity weakness, and cognitive impairment. On 7/10/23 at 11:23 AM, V5 CNA Certified Nursing Assistant transferred R76 from his wheelchair…

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 notify the physician of a significant weight loss, failed to ensure residents with a significant weight loss were assessed by a dietitian, and weight loss prevention interventions were implemented for 2 of 9 residents (R3 and R4) reviewed for weight loss in the sample of 20. The findings include: On 7/10/23 at 12:00 PM, R3 was in her room eating lunch. R3 ate 50% of her noon meal. R3 appeared very thin. R3's Monthly Weight/Vital Flow Sheet shows that in January and June 2023, R3 was 89 pounds. R3 was 84 pounds in July (5.62% weight loss in 1 month). R3's Medication Administration Record shows that Two Cal HN (nutritional supplement)-1 can twice daily was discontinued on 6/28/23. R3's Clinical Record shows that the last time she was seen by a dietitian was 6/6/22 and R3's weight was 92 pounds. R3's clinical records do not document that the physician or dietitian was notified of R3's significant weight loss in July. R3's clinical records do not…

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

Based on observation, interview, and record review the facility failed to ensure diet orders were followed for a resident on a tube feeding for 1 of 2 residents (R1) reviewed for tube feeding in the sample of 20. The findings include: On 07/10/23 at 10:13 AM, R1 was in bed with his gastric tube feed connected and running at 40 cc/hr. R1 stated I want to eat a sandwich, I don't like pureed food. On 07/10/23 at 11:48 AM, V10 Dietician said she is going to increase R1's tube feeding rate since he is not eating much of his pureed diet. V10 said R1 told me he doesn't like pureed food and wants a sandwich. On 07/10/23 at 11:48 AM, R1's lunch tray contained pureed food. R1's dietary card was marked pureed, nectar thick liquids. On 07/10/23 at 12:35 PM, V14 Certified Nursing Assistant said R1 doesn't like pureed food, and R1 tells her that he wished to take a bite of a sandwich. On 07/11/23 at 1:35 PM, V12 Registered Nurse said R1 is on a puree diet. V12 stated R1 hasn't been eating because he doesn't like puree, he wants a sandwich. The doctor is following him. I have not seen any issues…

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 controlled drugs were reconciled and failed to ensure medications were administered for 2 of 2 residents (R11, R41) reviewed for medication administration in the sample of 20. The findings include: 1. On 07/12/23 at 09:43 AM, V12 Registered Nurse reviewed the 3 south medication cart narcotic lock box with this surveyor. R11's Lorazepam 0.5 mg medication card, dispensed on 6/24/23, showed take 1 tablet by mouth three times daily, and contained 14 tabs. R11's Controlled Drug Receipt/Record/Disposition Form dated 6/24/23 showed 15 tabs remaining. V12 said she didn't count the narcotics this am, she had got called in late to work. On 07/12/23 at 11:00 AM, V3 Assistant Director of Nursing stated I can figure it out why the narcotic count is off. The dose for today was not given this am yet. The nurses should have done a narcotic count at change of shift, the narcotic sheet and medication card should match. I will have to look into this…

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

Based on observation, interview and record review the facility failed to ensure a resident's liquid Morphine (Schedule II Controlled Substance) was stored in a separately locked, permanently affixed compartment for storage of controlled drugs for 1 of 1 resident (R5) reviewed for medication storage in the sample of 20. The findings include: On 7/11/23 at 10:00 AM, R5's liquid Morphine was located sitting on a shelf in an unlocked refrigerator in the second-floor medication room. On 7/12/23 at 12:11 PM, V3 (Assistant Director of Nursing) said that if a controlled substance needs to be refrigerated, it should be kept inside a locked refrigerator in the locked medication room. V3 said that all controlled substances should always be double locked. V3 said that the refrigerators used to have locks on them. V3 said that when they switched to a different pharmacy last year sometime, the refrigerators all got replaced and a lock was never added to them. The facility's Storage of Medications Policy revised on 5/1/18 shows, Controlled substances that require refrigeration are stored within a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist a resident who is having mouth pain in making a dental appointment for 1 of 20 residents (R41) reviewed for dental services in the sample of 20. The findings include: R41's Minimum Data Set Assessment (MDS) dated [DATE] shows that she was admitted to the facility on [DATE]. R41's MDS dated [DATE] shows that she has moderate cognitive impairment, uses a wheelchair for mobility, has obvious or likely cavities or broken natural teeth and has mouth or facial pain, discomfort, and difficulty with chewing. On 7/10/23 at 10:30 AM, R41 had reddened gums and chipped teeth. R41 said that she has had discolored gums and mouth pain for months. R41 said that she has told multiple nurses about the pain, but no one has helped with setting her up with a dental appointment. R41 said that she has not seen the dentist since admission. On 7/11/23 at 10:18 AM, V7 (Registered Nurse) said that R41 has been complaining of mouth pain for more than a few…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents received all recommended doses of the Pneumonia Vaccine. This applies to 2 of 5 residents (R13, R66) reviewed for vaccinations in the sample of 20. The findings include: R13's medical record shows that she was admitted to the facility on [DATE]. R13's medical record shows that she gave consent to receive the Prevnar 13 vaccine on 4/9/2021. R13's Immunization Record shows that she received the Pneumovax 23 vaccine on 4/12/21 but there is no documentation of R13 ever receiving the Prevnar 13 vaccine. R66's medical record shows he gave consent for the Prevnar 13 on 4/9/2021. R66's Immunization Record shows that he received the Pneumovax 23 on 4/13/21. There is no documentation showing that R66 ever received the Prevnar 13 vaccine. On 7/11/23 at 10:24 AM V3 (Assistant Director of Nursing) stated, for Pneumonia they do a consent on admission. I am not as familiar with that as I am influenza, it is probably not tracked very well. I know I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff removed PPE (personal protective equipment) when exiting the COVID-19 unit, failed to ensure a COVID-19 positive resident remained isolated, failed to ensure staff wore a N95 mask when cleaning a COVID-19 positive room, and failed to prevent cross contamination by cleaning a COVID-19 positive room then a COVID-19 negative room. This has the potential to effect all 84 residents at the facility. The findings include: 1. The federal form 672 that was filled out by the facility on 5/11/22 show the facility's census to be 84. On 05/10/22 at 12:46 PM, V7 (Certified Nursing Assistant- CNA) was in the COVID-19 unit (where COVID-19 positive residents were being taking care of). V7 had on the following personal protective equipment: N95 mask, gloves, eye protection, and a yellow disposable isolation gown. V7 was going in and out of COVID-19 positive resident rooms picking up meal trays. V7 exited the COVID-19 unit. V7 did not remove 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 observation, interview, and record review the facility failed to prevent a resident from eloping off of a locked memory unit, failed to supervise a resident at risk for aspiration while eating, and failed to transfer a resident in a safe manner after a fall. This applies to 4 of 22 residents (R10, R62, R38, R48) reviewed for safety in a sample of 22. The findings include: 1. R10's Facility assessment dated [DATE] showed R10 to be an [AGE] year old, cognitively impaired female admitted on [DATE] with diagnoses which include: dementia, schizophrenia, and Alzheimer's disease. The facility's Resident Roster printed on 5/9/22 showed R10 is a resident on the second floor locked memory unit. On 5/9/22 at 9:30 AM, R10 was repeatedly walking with a walker up and down the hall. At 9:55 AM R10 was waiting next to the nurses station by the elevators. V18 Kitchen aide came to the elevator with the dirty meal tray cart and drink cart. V18 used his security access card reader to activate the elevator buttons. V18 got…

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 puree bread for 4 of 4 residents (R21, R285, R42, and R84) reviewed for following the menu in the sample of 22. The findings include: On 5/9/22 at 11:20 AM, pureed bread was not noted when the noon meal was being plated. On 5/9/22 at 11:39 AM, V15, Kitchen Supervisor, said they forgot to puree the bread; they are shorthanded. The facility's menu for 5/9/22 shows Lunch includes Wheat Bread. The facility's list of residents requiring a pureed diet (dated 5/9/22) includes R21, R285, R42, and R84.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure nail care and personal hygiene were completed for 1 of 22 residents (R72) reviewed for Activities of Daily Living (ADL's) in the sample of 22. The findings include: R72's face sheet shows she has diagnoses including: hemiplegia and hemiparesis following cerebral infarction, osteoarthritis, and vascular dementia. R72's 4/17/22 facility assessment shows she has a cognitive deficit and requires extensive staff assistance with personal hygiene On 5/9/2022 at 10:17 AM, R72 was sitting up in her room in bed. She had dried food on her chin and around her mouth. Her fingernails were extremely long and had a black substance and what appeared to be food, heavily coating under [NAME] them. R72 yelled to the surveyor that staff do not help her and she was uncomfortable. The surveyor pulled R72's call light and V9 (Certified Nursing Assistant/CNA) and V6 (Registered Nurse/ RN) came into R72's room and re-positioned R72. V6 and V9 both left the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure ulcer. This apples to 1 of 5 residents reviewed for pressure injuries in a sample of 22. The findings include: R42's Face Sheet dated 1/27/22 showed R42 is a [AGE] year old female admitted to the facility on [DATE] with diagnoses which include: dementia and type 2 diabetes. R42's Facility assessment dated [DATE] showed R42 having severe cognitive impairment, at risk for pressure injuries, and needing extensive two person assistance with bed mobility and transfers. R42's Braden assessment dated [DATE] showed R42 being at moderate risk for developing pressure injuries. R42's Physician Wound Notes dated 5/1/22 showed R42 having a deep tissue pressure injury to the right posterior heel with measurements of 3 X 3 X 0 centimeters (cm). Treatment plan preventative measures which include: off load heels with heel protectors or pillow. On 5/9/22 at 9:50 AM, 11:25…

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 restorative care was being completed, and failed to ensure assistive devices were implemented for a resident with contractures, for 1of 8 residents (R52) reviewed for restorative services in the sample of 22. The findings include: R52's face sheet shows she has diagnoses including: hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting right dominant side, aphasia, and dysphagia. R52's facility assessment dated [DATE] shows she has a cognitive deficit, and an impairment of her range of motion (ROM) to both her upper and lower extremities. R52's active restorative care plan shows she is supposed to receive passive range of motion (PROM) to her upper and lower extremities for 15 minutes a day. The same care plan shows she is supposed to have a hand roll in her right hand. R52's May 2022 Restorative Program Minutes Tracking Sheet shows she did not receive any restorative (PROM) on 5/1/22, 5/6/22, 5/7/22,…

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 a resident was offered and assisted with eating to maintain weight and adequate nutritional intake. This applies to 1 of 4 residents (R48) reviewed for weight loss in a sample of 22. The findings include: R48's Facility admission Record shows that R48 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Fall, and Hypertension. R48's Monthly Weight/Vital Flow Sheet shows that R48 weighed 120 pounds in March, 113 pounds in April, and 100 pounds in May. R48's Nutritional Notes dated 4/9/22 state, Resident with 5.8% weight loss after admit. Weight 4/113#, 3/120#. Resident is refusing meal intake and drinking Glucerna 1.2 . Accepting 5 cans at this time to provide 1420 calories, 45 grams of protein and 960 ml. Resident nutritional needs 1530-1785 calories, 51-66 grams of protein and 1530-1785 ml of fluid. Recommend increase Glucerna 1.2 to 6 cans/day and oral fluids 4-5 cups of water or fluid…

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

Based on observation, interview, and record review the facility failed to ensure a medication ordered for a particular resident was not administered to another resident for 2 of 2 residents (R61 and R285) reviewed for pharmacy services in the sample of 22. The findings include: On 05/09/22 at 09:56 AM, in R61's room was a intravenous (IV) pole. Hanging on the pole was a empty antibiotic bag connected to IV tubing. The antibiotic was ceftriaxone 1 gram (gm). The resident's name on the bag was R285. R285 and R61 resided in different rooms. On 05/09/22 at 10:20 AM, V4 (Licensed Practical Nurse- LPN) confirmed the resident's name on the antibiotic was not R61's name but was R285's name. V4 said the nurse that administered the medication, Accidentally swapped R61's and R285's antibiotics. V4 said R61 and R285 were on the same antibiotic with the same dose. R61's Medication Administration Record (MAR) showed R61 had an order for ceftriaxone 1 gm to be given at 06:00 AM and 06:00 PM. R285's MAR showed R285 had an order for ceftriaxone 1 gm to be given at 09:00 AM. On 05/09/22 at 12:58 PM,…

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.