Serenity Estates of Lena

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform glove changes and hand hygiene during incontinence care for 1 of 8 residents (R5) reviewed for infection control in the sample of 26. The findings include: R5's electronic face sheet printed on 3/27/25 showed R5 has diagnoses including but not limited to chronic kidney disease stage 4, urinary tract infection, and anxiety disorder. R5's facility assessment dated [DATE] showed R5 has moderate cognitive impairment and is dependent on staff for personal hygiene. On 3/25/25 at 12:07PM, V5 and V14 (Certified Nursing Assistants) provided incontinence care to R5. V14 cleansed feces off R5's buttocks with toilet paper, handed the toilet paper to V14 to throw away. This occurred 4 times between V5 and V14 throughout R5's incontinence care. V5 and V14 then applied a clean incontinence brief, touched the mechanical lift remote, R5's bed controls, and R5's wheelchair without removing their soiled gloves. V14 stated gloves are not removed…

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 offer a resident the flu vaccine for the 2024/2025 flu season. This applies to 1 of 5 residents (R7) reviewed for vaccinations in the sample of 26. The findings include: R7's admission Record (Face Sheet) showed an original admission date of 2/8/24 with diagnoses to include dementia without behavioral disturbance, influenza, and covid-19. R7's Immunization History (as of 3/27/25) showed she did not receive the 2024/2025 flu vaccine. On 3/26/25 at 1:46 PM, V2 (Director of Nursing/DON) stated R7's Power of Attorney was in the Intensive Care Unit the end of October 2024, and he was not reachable. V2 said R7's (family) was not willing to make decisions for R7. V2 said R7 was not given the flu shot and R7 did have flu early in 2025. On 3/26/25 at 2:50 PM, V2 said if a resident has a diagnosis of dementia, they do not allow the resident to sign consents, only the power of attorney. On 3/26/25 at 3:17 PM, R7 was oriented to date, city, and her medical history. R7 said, Early this year I was sick with both flu and covid; I had 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 offer a resident the covid vaccine for the 2024/2025 covid season. This applies to 1 of 5 residents (R7) reviewed for vaccinations in the sample of 26. The findings include: R7's admission Record (Face Sheet) showed an original admission date of 2/8/24 with diagnoses to include dementia without behavioral disturbance, influenza, and covid-19. R7's Immunization History (as of 3/27/25) showed she did not receive the 2024/2025 covid booster. On 3/26/25 at 1:46 PM, V2 (Director of Nursing) stated R7's Power of Attorney was in the Intensive Care Unit the end of October 2024, and he was not reachable. V2 said R7's (family) was not willing to make decisions for R7. V2 said R7 was not given the covid booster and R7 did have covid early in 2025. On 3/26/25 at 2:50 PM, V2 said if a resident has a diagnosis of dementia, they do not allow the resident to sign consents, only the power of attorney. On 3/26/25 at 3:17 PM, R7 was oriented to date, city, and her medical history. R7 said, Early this year I was sick with both flu and covid; I…

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

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering residents' rooms that were on isolation for influenza. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for infection control in the sample of 3. The findings include: 1. R1's Face Sheet printed on 2/11/25 showed R1 was diagnosed with influenza on 2/3/25. R1's Order Summary Report printed on 2/11/25 showed an order for R1 to be on droplet isolation for influenza dated 2/5/25 with no end date. A second order for droplet isolation with a start date of 2/11/25. On 2/11/25 at 8:31 AM, on R1's door was a sign indicating R1 was on enhanced barrier precautions. There was no sign up indicating R1 was on droplet/contact isolation. V9 (Activity Aide) was in R1's room. V9 had on a surgical mask and no other PPE. V9 was within 6 feet of R1. On 2/11/25 at 8:50 AM, V3 (Certified Nursing Assistant - CNA) was outside of R1's room placing a droplet/contact isolation sign on R1's door. On 2/11/25 at 9:15 AM, V3 said there was some…

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 treat a resident with respect and dignity. This applies to 1 of 6 residents (R1) reviewed for resident rights in the sample of 6. The findings include: R1's face sheet shows he is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cellulitis, COPD, weakness, and dehydration. On 9/30/24 at 10:55 AM, V7 (Certified Nursing Assistant-CNA) said on 9/19/24 she was receiving report from V5 (CNA). V5 told her rudely, she took away R1's call light last night because his call light was going off frequently. V5 reported R1 had soft touch call light that kept going off and she was not going to go in his room every 15 minutes. When she went to get R1 up from his bed. R1 said the girl last night (V5) took his call light away from him. He said what if I needed help and couldn't get it. R1's call light was under his bed on the floor. Staff should make sure a residents call light is within reach before leaving the room. On 9/30/24 at 12:00…

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 administer a Physician prescribed medication as ordered. This applies to one of three residents (R1) reviewed for medication administration in the sample of six. The findings include: The facility face sheet shows R1 was admitted to the facility with diagnoses to include Type 2 Diabetes Mellitus, congestive heart failure and hypertension. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires moderate assistance with his activities of daily living. On 8/27/24 at 9:30 AM, V2 (Director of Nursing) said she was the nurse working the floor on 8/18/24. V2 said she was having a very busy night with another resident having a change in condition. V2 said she was running behind in her bedtime medication pass and was also trying to give a shift to shift report to the oncoming nurse. V2 said she looked at the Medication Administration Record (MAR) and saw the order for R1's scheduled insulin and she prepared that and then drew up 40…

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 the Director of Nursing and Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This applies to all residents in the facility. The findings include: The CMS 671 dated 4/11/24 shows 56 residents residing in the facility. On 4/11/24 at 12:55PM, V1 (Administrator) said the facility has a formal QAPI meeting quarterly. V1 said the Medical Director, Administrator, a leader from nursing, and dietary are required to attend the quarterly meetings. V1 said there were a couple meetings the DON had to cover the floor and couldn't attend. V1 did not identify that the Director of Nursing and Infection Preventionist should attend all quarterly meetings. On 4/11/24 at 1:15PM, V2 (Assistant Director of Nursing) said she is the Infection Preventionist. V2 said she has attended the quarterly QAPI meetings, but it's been awhile. She would attend if they were scheduled on the days she was in the building, working. If I attended the meeting, I would sign the sheet. I was off for 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 prevent a resident from falling from a broken beauty shop chair and failed to implement interventions to prevent falls for 4 of 5 residents (R43, R3, R20, R50) reviewed for falls in the sample of 23. The findings include: 1. R43's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia with agitation, lack of coordination, need for assistance with personal care, muscle weakness, difficulty walking, depressive episodes, and history of falls. R43's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires partial to moderate assistance with most cares. R43's 3/19/24 initial fall note showed, Resident was in beauty shop chair and chair broke and resident fell backward and hit head on floor . Interventions: Make sure someone is in the room at all times with residents and fix the chair . R43's 3/22/24 Progress Note showed, Chair that was previously out of service due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician's orders for a resident on CPAP (Continuous Positive Airway Pressure) therapy for 1 resident (R410), failed to store nebulizer and CPAP masks in a sanitary manner for 4 residents (R6, R24, R50, R410). These failures apply to 4 of 8 residents reviewed for respiratory care in the sample of 23. The findings include: 1) R410's electronic face sheet printed on 4/11/24 showed R410 has diagnoses including but not limited to pneumonia, history of COVID-19, anxiety disorder, and gastroesophageal reflux disease. On 4/9/24 at 9:58AM, R410 had a CPAP machine on his bedside table with the CPAP mask laying out on top of the table, uncovered. R410 stated his machine came from home and the staff assist him to apply it every night before bed. R410 stated he is unsure of what the settings are supposed to be but thought staff at the facility knew what they were. R410's physician's orders showed no active orders for R410 to utilize a CPAP…

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 reassess for preferences and nutritional needs after a resident was readmitted with a diet change for 1 of 1 resident (R22) reviewed for dietary services. The findings include: R22's face sheet showed he was admitted to the facility on [DATE] (65 days ago) with diagnoses to include dementia without behavioral disturbance, candidal esophagitis, gastro-esophageal reflux disease, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's April 2024 Physician Order Sheet showed, . 4/2/24 Regular diet, Full Liquid texture, thin consistency . Dietary Supplements: House Supplement three times a day, 237 mililiters (1 carton) three times a day . R22's care plan initiated 2/9/24 showed, The resident is on a regular diet . Administer medications as ordered. Monitor/Document for side effects and effectiveness. Provide and serve diet as ordered. No changes were made to R22's care plan after his diet change to a liquid diet. R22'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 a resident was assessed by a physician within the first 30 days after admission for 2 of 2 residents (R22, R9) reviewed for physician visits outside of the sample. The findings include: R22's face sheet showed he was admitted to the facility on [DATE] (65 days ago) with diagnoses to include dementia without behavioral disturbance, atherosclerosis, and a non-pressure chronic ulcer of part of the foot. R22's record showed he was seen by a Nurse Practitioner on 2/15/24, 3/18/24, and 4/1/24. On 4/10/24 at 1:13 PM, R9 and R22 were in the group with the surveyor. R22 said he was upset that the facility does not have a doctor that comes in and sees the residents. R22 said he and R9 have only been seen by a nurse practitioner. R22 said the facility staff told him a nurse practitioner is a doctor. On 4/11/24 at 11:46 AM, V10 RN said the facility has nurse practitioners that come in every week. V10 said R9 and R22's physician does come into…

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 scheduled medication was available for administration for 1 of 1 resident (R10) reviewed for medications in the sample of 23. The findings include: R10's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance, pain in right leg, muscle wasting and atrophy, lack of coordination, anxiety disorder, need for assistance with personal care, hypertension, chronic kidney disease, and osteoarthritis. R10's facility assessment dated [DATE] showed she has severe cognitive impairment and is requires moderate to substantial assistance from staff for all cares. R10's care plan initiated 5/23/23 showed, I use anti-anxiety medications related to anxiety disorder . Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. R10's August 2023 Physician Order Sheet showed and order dated 5/22/23 for Alprazolam 0.25…

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.

Based on observation, interview and record review the facility failed to ensure vegetables were not overcooked, leaving them with a soft mushy texture and a bland flavor. This applies to 2 of 2 residents (R1, and R13) reviewed for food preparation in a sample of 23. The findings include: On 04/11/24 at 11:48 AM, This surveyor sampled the mixed vegetables from the kitchen as V6 (Cook) was serving them to the residents. This surveyor found the vegetables too soft and was able to masticate (smash up) using my tongue and the roof of my mouth. The vegetables had a bland taste. On 04/11/24 at 12:44 PM, trays throughout the dining area had most of the vegetable uneaten after the residents left the table. 04/10/24 at 01:04 PM, V6 said, he cooks the mixed vegetables by boiling them for 45 minutes in water, then he removes them from the water a puts them in the oven at 275 degrees Fahrenheit to keep them warm. On 4/11/24 at 1:30 PM, V5 (Dietary Manager) said, we don't put salt in like the recipe says to because a lot of residents are on a low sodium diet. On 4/10/24 at 2:00 PM, R13 said, 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 observation, interview, and record review the facility failed to ensure the correct personal protective equipment (PPE) was worn while providing care for resident in contact isolation with a multi drug resistant organism (MDRO). This applies to 1 of 8 (R54) residents reviewed for infection control in the sample of 23. The findings include: R54's admission Record showed an original admission date of 3/28/24 with diagnoses to include a MRSA (an MDRO) (onset date 4/6/24), an abscess, and diabetes. R54's 4/10/24 Infection/Viral Charting showed she was ordered two antibiotics for her MRSA infection. R54's Care Plan showed Contact precautions maintained. Date initiated: 4/6/24. On 4/10/24 at 1:06 PM, V15 Registered Nurse performed wound care for R54's abscess to her upper/middle back. The dressing had bloody and yellow discharge on the dressing. The wound had a 2 inch incision from the 7 O'clock to 1 O'clock position. The wound appeared as if it had been a large abscess that had been surgically drained. The skin surrounding the incision was dark maroon/purple in color and was the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a copy of a resident's (R1) advanced directive was present in the medical record, and failed to ensure a residents care plan was updated with current code status. This applies to 1 of 3 residents reviewed for advanced directives in the sample of 9. The findings include: R1's electronic face sheet printed on [DATE] showed R1 had diagnoses including but not limited to urinarty tract infection, hemiplegia and hemiparesis following cerebral infarction affecting right side, dementia without behaviors, hyperglycemia, and major depressive disorder with psychotic symptoms. R1's nursing care plan dated [DATE] showed, Education on advanced directives, end of life care options, and establishing a health care representative was provided. Pursuant to resident rights, (R1) has selected the advanced directive of Full Code .As indicated, my advanced directives code status will be documented on my physician order sheet in the electronic medical system and be…

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 food in the refrigerator was dated, failed to ensure expired food was discarded, and failed to ensure a freezer was monitored. This applies to all 67 residents residing in the facility. The facility Census and Condition of Residents form #672 dated 5/23/23 documents there are 67 residents residing in the facility. On 5/23/23 at 9:15 AM, there was a tub of cottage cheese with an expiration date of 5/2/23 in the refrigerator and a plastic container labeled pork gravy which was undated. During the kitchen tour there was a storage area which had a chest freezer containing cookie dough. The freezer had a significant amount of ice visible. There was no log of temperature monitoring for the freezer. On 5/23/23 at 9:15 AM, V4 said, That is the activity department's freezer. I don't do anything with it. I don't have a log and I'm sure she doesn't either. It needs defrosted. On 5/24/23 at 11:45 AM, V4 said, There was no log for the activities freezer so I gave her one to start filling out. I told her she needs 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 provide residents with palatable food for 3 of 3 residents (R40, R47, R59) reviewed for food in the sample of 20 and 3 residents outside the sample (R6, R19, R27). The findings include: On 5/23/23 at 10:03 AM, R47 was lying in his bed. R47 stated, The food sucks here! The meat is so tough, most of the time I can't eat it and I try. If I can't cut it with my knife, then I won't be able to chew it with my teeth. And they won't give me a butcher knife. I still have my own teeth. Last night they served pork and it was so tough I couldn't eat it and I wasn't the only one. I eat in the dining room with other people. Most of the guys at my table couldn't eat it. On 5/23/23 at 12:30 PM, R59 said the food isn't great here. R59 open the lid to her lunch tray. There were two chicken legs with the skin still on them that appeared gray and dry; cheesy potatoes; a vegetable medley; and a slice of cake. R59 stated, This actually looks better than usual. R59 picked up a chicken leg, but this is hard to eat. R59 was unable to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure dignity was provided for 1 of 2 residents (R1) reviewed for dignity in the sample of 20 and 1 resident (R28) outside of the sample. The findings include: 1. On 5/23/23 at 9:18 AM, R1 was sitting in a recliner in her room. R1 stated she came to the facility for therapy after a broken leg. R1 stated she is tired of being in a nursing home. R1 stated being in a nursing home has changed a lot and she doesn't like it. R1 stated it will take staff a half an hour to answer a call light. R1 stated she can't wait a half an hour to go to the bathroom. R1 stated she has had accidents while waiting for someone to toilet her and it makes her feel bad. On 05/24/23 at 12:25 PM, V2 DON (Director of Nursing) stated call lights were to be answered as soon as possible. V2 stated there wasn't a policy with a set time for answering call lights V2 stated it was not okay for a resident to wait 30 minutes for their call light to be answered and be…

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 nail care and facial care to 1 of 2 residents (R10) reviewed for activities of daily living (ADL) care in the sample of 20. The findings include: R10's electronic face sheet printed on 5/25/23 showed R10 has diagnoses including but not limited to Dementia without behaviors, unsteadiness on feet, restlessness & agitation, hypertension, generalized anxiety disorder, and depression. R10's facility assessment dated [DATE] showed R10 has moderate cognitive impairment and requires 2 staff assist with personal hygiene. R10's care plan dated 1/26/22 showed, I have an ADL self-care performance deficit related to dementia .personal hygiene assist x 1. R10's shower sheets dated 4/30/23-5/21/23 showed R10 did not receive nail care. On 5/24/23 at 8:45AM, R10's fingernails had black and orange matter stuck underneath them and were long past his fingertips. R10 stated he only likes to keep 1 of his thumbnails long so that he can pick up papers…

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 obtain and monitor weights for a resident with Congestive Heart Failure (CHF) for 1 of 2 residents (R16) reviewed for quality of care in the sample of 20. The findings include: R16's electronic face sheet printed on 5/25/23 showed R16 has diagnoses including but not limited to acute combined systolic & diastolic congestive heart failure, chronic kidney disease, edema, atrial fibrillation, and hypertension. R16's facility assessment dated [DATE] showed R16 has mild cognitive impairment. R16's care plan dated 4/10/23 showed, I am on diuretic therapy related to edema. R16's physician's order dated 4/17/23 showed, check weights weekly. R16's weight log showed, 5/1/23 195.4lbs, 5/5/23 154.3lbs (41lb weight loss in 1 week with no reweigh completed) 5/18/23 186.5lbs. (No weight had been obtained for 13 days and no reweigh had been completed for a 22lb weight gain) R16's progress notes dated 5/11/23 showed, Resident has unusual weights and needs to be…

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 received their prescribed pureed diet instead of a regular textured diet for 1 of 2 residents (R15) reviewed for diets in the sample of 20. The findings include: On 5/23/23 at 12:14 PM staff were passing trays in the dining room and gave R15 her lunch tray. R15 was given a regular tray that had chicken on the bone, au gratin potatoes and mixed vegetables. At 12:19 PM V5 CNA (Certified Nursing Assistant) looked at R15's meal tray that was in front of her and looked upset. At 12:22 PM, R15 was eating the meat off a chicken leg. V2 DON (Director of Nursing) came over to R15 and told her she needed to swap out her lunch tray. There was a menu card next to the resident on the table that stated she was to have a pureed, low concentrated sweets diet with thin liquids. V2 confirmed that the ticket was R15's and she should have had a pureed diet. V2 took the food tray away but left the chicken leg on the bone with R15 who continued to eat it after her tray was taken away. On 5/23/23 at 12:27 PM, V5…

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 meat was pureed per resident's needs for 3 of 3 residents (R15, R43, R373) reviewed for pureed diets. The findings include: R15's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia, need for assistance with personal care, dysphagia, and diverticulosis of the intestine. R15's current Physician Order Sheet showed an order dated 2/14/22 for, Diet: Low Concentrated Sweets, Pureed Texture, Thin Consistency. R43's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, need for assistance with personal care, and altered mental status. R43's current Physician order sheet showed an order dated 3/16/23 for Diet: Pureed texture, Thin Consistency . R373's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, hemiplegia, hyperlipidemia, and hypertension. R373's Physician Order Sheet showed an…

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 prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care for 1 of 4 residents (R11) reviewed for infection control in the sample of 20. The findings include: On 5/23/23 at 9:36 AM, R11 was sitting in a wheelchair in her room and her pants were soaked and there was a strong odor of urine in the room. V11 CNA (Certified Nursing Assistant) had gloves on, took R11 and transferred her to the toilet. V11 removed R11's wet incontinence brief and wet pants. V11 put a clean pair of black pants on R11's lower legs while she was sitting on the toilet. V12 CNA came into R11's room and V11 stated she was going to need help with peri care and R11's transfer. V12 put a clean incontinence brief on R11's lower legs and above her pants. V11 washed R11's vaginal area and buttocks. V11 did not remove or change her gloves. V11 pulled R11's brief and pants up. V11 pulled R11's wheelchair into the bathroom. V11 held onto R11's arm and shirt while sitting her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer pneumococcal vaccinations for 3 of 5 residents (R31,R47,R55) reviewed for immunizations in the sample of 20. The findings include: 1) R31's electronic face sheet printed on 5/24/23 showed R31 was admitted to the facility on [DATE]. R31's electronic immunization record showed R31 had not refused or received the pneumococcal vaccination. R31's immunization history report dated 3/15/23 showed, Shots overdue: pneumococcal vaccine. On 5/24/23 at 2:33PM, V2 (Director of Nursing) stated, We just offered the pneumonia vaccine to R31 today. I don't know why it wasn't offered on admission but we need to make sure we are doing that to prevent residents from getting pneumonia and infecting other residents. The facility's policy titled, Infection Control Immunization for Residents Influenza and Pneumococcal dated 3/1/2020 showed, .The facility will offer residents a Pneumococcal immunization unless immunization is medically contraindicated or the resident has…

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.