Bella Terra Lombard

Based on interview and record review the facility failed to treat a resident in a dignified manner. This applies to 1 of 29 residents (R9) reviewed for dignity in the sample of 29. The findings include: On 6/24/2024 at 9:53AM, R9 said on Sunday (6/23/2024) in the morning he put his call light on. R9 said his call light was on from approximately 6:20AM until 8:20AM. R9 said he had soiled himself with stool and urine, requiring staff assistance. R9 said he didn't receive help until after 8:20AM from the nursing staff. On 6/25/2024 at 1:50PM, V9 Registered Nurse (RN) said R9 is very alert and oriented. V9 said R9 is aware of when he needs to be cleaned up and lets staff know. V9 said residents should be checked every 2 hours or as needed. V9 said residents should be cleaned up right away when they are soiled. R9's Minimum Data Set section C dated 5/30/2024 shows a BIMs score of 14, cognitively intact. R9's Task B&B - Bowel charting does not show any documentation on 6/23/2024. R9's Care Plan dated 6/7/2024 states, [R9] is always incontinent of bladder and bowel related to multiple…

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 fall interventions were in place for residents with a history of falls for 2 of 29 residents (R108, R33) reviewed for safety in the sample of 29. The findings include: 1. On 6/24/24 at 9:56 AM, R108 was in bed with fall mats on each side of the bed. R108's bed was not in the lowest position. R108 said he fell and broke his hip and leg. On 6/25/24 at 9:46 AM, R108 was in bed (not in lowest position) with the call light on the floor near the head of the bed. On 6/25/24 at 1:55 PM, R108 was yelling out help me. R108's bed was not in the lowest position and his call light was wrapped around the bed rail and dangling down towards the ground, not within R108's reach. On 6/26/24 at 10:48 AM, V3 Restorative Nurse said after R108's fall he implemented the interventions of bed alarm, floor mats, and bed in lowest position. The facility's Post Fall Investigation dated 6/16/24 for R108 shows R108 got up from bed and fell. The same form shows interventions to address incident: Provided resident with bed alarm 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 resident nebulizer equipment was stored in a manner to prevent cross contamination for 3 of 6 residents (R3, R26, R69) reviewed for oxygen in the sample of 29. The findings include: 1. On 6/25/24 at 11:52 AM, R3's nebulizer mask/tubing was in an opened plastic bag on the nightstand next to the bed. The plastic bag was dated 4/22/24. R3's June 2024 Medication Administration Record (MAR) shows an order for Ipratropium-Albuterol Inhalation Solution nebulizer treatment was administered on 6/9/24. 2. On 6/24/24 at 10:08 AM, R26's nebulizer mask/tubing was in an open plastic bag on nightstand next to the bed. The plastic bag was dated 4/22/24. On 6/25/24 at 10:32 AM, R26's nebulizer mask/tubing was on the nightstand, still dated 4/22/24. R26 said she uses the nebulizer once in a while. R26's June 2024 MAR shows an order for Ipratropium-Albuterol Solution nebulizer treatment was administered on 6/9/24. 3. On 6/24/24 at 10:07 AM, R69 stated she was short of breath yesterday and received a nebulizer treatment.…

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 reorder a resident's medication. This applies to 1 of 29 residents (R340) in the sample of 29 reviewed for pharmacy services. The findings include: On 6/24/2024 at 9:42AM, R340 was observed lying in bed in his room. R340 said he was waiting on the facility to reorder his morphine. On 6/24/2024 at 12:18PM, V8 Registered Nurse said the prescription from the hospital had a requested quantity of 60 but the pharmacy only sent 6 of the morphine tablets. On 6/26/2024 at 10:36AM, V2 Director of Nursing (DON) said the hospital prescription was electronically signed, but the pharmacy requires an actual signature for the medication. V2 said this is why the pharmacy sent only 6 pills and didn't fill the entire script. On 6/24/2024 at 1:39PM, V7 Nurse Practitioner (NP) said the prescription could have been filled over the weekend by the covering provider. V7 said [R340] had oxycodone ordered as well for pain control. V7 said she did refill his prescription for the morphine on 6/24/2024. R340's Medication Administration…

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 personal protective equipment (PPE) when providing direct resident care for residents on enhanced barrier precautions (EBP) for 2 of 29 residents (R28 and R97) reviewed for infection control in the sample of 29. The findings include: 1. R97's current Care Plan shows that R97 is on EBP related to having a gastrostomy tube. The Care Plan shows interventions of: Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting). On 6/24/24 at 11:14 AM, V15 (CNA) went into R97's room to provide incontinence care and reposition R97. V15 put gloves on but did not don a gown. V15 performed incontinence care and repositioned R97. R97 was observed to have a gastrostomy tube. 2. R28's current Care Plan shows that R28 is on EBP related to an indwelling foley catheter and a surgical wound. The Care Plan shows interventions of: Ensure that gown and gloves are used…

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 timely incontinent care to dependent residents. This applies to 4 of 5 residents (R1, R3, R4, and R5) reviewed for activities of daily (ADL) care in a sample of 9. The Findings Include: 1. R1 is a [AGE] year-old female admitted on [DATE] with severely impaired cognition as per the MDS dated [DATE]. MDS also indicates that R1 is dependent on toilet hygiene. On 4/9/24 at 9:22 AM, R1 was observed with V5 (Certified Nursing Assistant/CNA) and R1 was observed with an inner liner inside an incontinent brief soaked with urine and feces. V5 stated on 4/9/24 at 9:22AM, I started my shift at 6:00 AM, and I checked her around 6:20 AM, and R1 was dry then. We are supposed to check residents for incontinence every two hours. A review of R1's incontinent care plan documents R1's preference to check on her for incontinent episodes every two hours. R1 also prefers assistance to wash, rinse, and dry her perineum. 2. R3 is an [AGE] year-old female…

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 who is dependent on staff received assistance with incontinence care. This applies to 1 of 4 (R1) residents reviewed for activities of daily living in the sample of 4. The findings include: R1's face sheet shows he is [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, generalized anxiety, and major depression disorder. On 4/2/24 at 9:10 AM, R1 was observed lying in a bariatric bed. He said on 3/28/24 during third shift, V9 (Agency Certified Nursing Assistant/CNA) did not change him during her shift from 10 PM to 6 AM. R1 said he pressed his call light on a few times in the morning and someone answered and said they would come. V8 (CNA) the day shift CNA answered his call light after 6:00 AM to change him. R1 said he was soaked with urine and stool and had not been changed from the night before about 8:30 PM. On 4/2/24 at 9:41 AM, V5 (CNA)…

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 re-assess and allow a resident to return to the facility during an involuntary discharge appeal for 1 of 1 resident in a sample of 8. The findings include: R4's face sheet showed R4 was admitted to the facility on [DATE] without any psychiatric or behavioral diagnoses. R4's Behavioral Note dated 12/13/23 at 8:28 AM showed R4 being verbally and physically aggressive towards staff. R4 pushed a shower bed at the Certified Nursing Assistant (V13) and striking her body twice. On 2/20/24 at 11:20 AM, V1 Administrator stated the facility did not allow R4 to return after being sent to the hospital due to his aggressive behaviors to staff, and to not put the other residents at risk. R4's Hospital records showed R4 was sent to the hospital and admitted to the hospital's behavioral health unit on 12/13/23 with behavioral disturbance as the diagnosis. The Facility's Involuntary Discharge Form dated 12/13/23 showed the notice to resident was on 12/13/23. On 2/21/23…

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

Based on observation, interview, and record review, the facility failed to properly label, date, seal and store food items and practice proper sanitation in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS-Centers for Medicare and Medicaid Services-672) dated 7/18/23 documents that the total census was 129 residents. On 7/18/23 at 3:39 PM, V2 (DON/Director of Nursing) said 3 residents are NPO (Nothing By Mouth) and do not eat from the facility kitchen. On 7/18/23 starting at 10:02 AM, the facility kitchen was toured in the presence of V3 (Director of Food and Nutrition Services). On 7/18/23 at 10:11 AM in cooler #1, one large tray of breakfast sausage patties and two large trays of bacon strips were found uncovered, unlabeled, and undated. Also in cooler #1, a medium sized bin was found with sliced turkey with expiration date of 7/17/23. On 7/18/23 at 10:15 AM in cooler #2, an opened 5 pound bag of shredded part skim mozzarella cheese was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment. This applies to 6 of 6 residents (R9, R10, R14, R82, R110, R178) reviewed for environment in a sample of 33. The findings include: 1. On 7/18/23 at 10:34 AM, R14 was lying in bed. Behind R14's bed, the baseboard that was in the middle of the wall was broken in half with a jagged and sharp edge. The wall was damaged in several areas with multiple areas where there were indentations and paint peeling off. On 7/18/23 at 10:35 AM, R14 stated she was unaware of the damage because she couldn't see behind her. R14 stated, I hope they could fix it because if they move my bed to a flat position when they clean and change me, I don't want that baseboard falling and injuring me. The nurse or CNA (Certified Nursing Assistant) never told me it was broken. R14's face sheet documents an admission date of 6/14/23. R14's MDS (Minimum Data Set) dated 7/20/23 documents a BIMS (Brief Interview 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 secure a metal oxygen tank in a holder in the resident's room and failed to safely position residents in proper sitting positions while eating meals in bed. This applies to 7 of 33 residents (R29, R38, R39, R54, R57, R68, and R115) reviewed for accidents and supervision in a sample of 33. The findings include: 1. On 7/18/2023 at 10:09 AM, R54 was in bed with an unsecured metal oxygen tank stored at the bedside without a holder to prevent the tank from tipping over. R54's oxygen tank was full. R54 shared the room with R115. R54's room was in close proximity to R57, R68, and R29's rooms. On 7/20/2023 at 11:57 AM, V2 (DON/Director of Nursing) said oxygen tanks should be stored properly in an oxygen base holder to keep it from falling, which can cause it to blow up or a fire. This can affect the residents in the room as well as everyone. The facility's Oxygen Storage policy reviewed 7/28/2022 showed Restrain or secure oxygen tanks at all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to don appropriate personal protective equipment (PPE) for residents under Enhanced Barrier Precautions (EBP) while providing high contact patient care. This affects 4 of 4 residents (R25, R71, R96, and R111) reviewed for infection control in a sample of 33. The findings include: 1. On 07/19/2023 at 09:36 AM, V8 (RN/Registered Nurse) went to R96's room to administer R96's medications, formula feed, and water flush through her G-tube (Gastrostomy). R96's room had the Enhanced Barrier Precaution signage posted at the doorway without a PPE (Personal Protective Equipment) supply bin. V8 donned gloves and entered R96's room. V8 did not wear a gown, mask, or face shield. V8 lifted R96's gown and began administering the medication, formula feed, and flush through R96's G-tube. The EMR (Electronic Medical Record) shows R96 was admitted to the facility with diagnoses including anoxic brain damage, psychotic disordered, dementia, gastrostomy status,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess residents for self-administering medications and obtain physician orders to have meds stored in resident rooms. This applies to 2 of 6 residents (R23, R179) reviewed for medications in the sample of 33. The findings include: 1. On [DATE] at 10:50 AM, R179 had a tube of Clotrimazole Betamethasone on top of his shelf in his room. R179 stated, It's always kept in my room. The nurses don't take it back. No one taught me how to use it. I know how to put it on by myself. The nurses don't watch me put it on. It's for my crotch. R179's POS (Physician Order Sheet) documents the following order: Lotrisone Cream 1-0.05% (Clotrimazole-Betamethasone): Apply to redness, abdominal folds topically two times a day for treatment. (Apply Lotrisone Cream thinly on the affected area). The order does not indicate that R179 may have the medication at the bedside. R179's electronic medical record was reviewed. There was no self-administration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times or in ordered dosage). There were 27 opportunities with 4 errors resulting in a 14.81% error rate. This applies to 2 of 4 residents (R88, R99) observed in the medication pass. The findings include: 1. On [DATE] at 08:01 AM, V14 (RN/Registered Nurse) was preparing R88's morning medications. V14 prepared Aspirin 81 mg (Milligram) ER (Extended Release) and Potassium Chloride 10 mEq (Milliequivalents) ER, along with other oral medications. At 08:24 AM, V14 said she usually crushed R88's pills because R88 had swallowing difficulties. V14 put all the medications from the medication cup together and crushed them. V14 mixed the medication in applesauce and administered it to R88. V14 also took R88's expired Anoro Ellipta inhaler, which was opened on [DATE] with a manufacturer label sticker which showed to throw away after six weeks of opening and administered the inhaler to R88. The EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light system was in good working condition for a dependent resident. This applies to 1 of 1 resident (R28) reviewed for call lights system. The findings include: R28's face sheet (7/20/23) showed that R28 had the following diagnoses vascular dementia, generalized anxiety disorder and encounter with palliative care. R28's Minimum Data Set (MDS) dated [DATE] showed that R28's cognition is severely impaired and needs extensive assistance with two or more person physical assist with bed mobility, total dependence with one person physical assist with toilet use and personal hygiene. R28's current ADL (Activities of Daily Living) and fall care plan shows that R28 has self-performance deficit and impaired mobility, and R28 is at high risk for falls related to palliative care, generalized anxiety and vascular dementia. The care plan encourages R28 to use call light for assistance. On 7/19/23 at 9:54 AM, R28 could be heard 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 observation, interview and record review the facility failed to ensure that residents medications were administered after it was prepared to prevent medication error and the facility failed to ensure that controlled pain medication was not borrowed from another resident. This applies to 13 of 13 residents (R5, R8, R16, R17, R19, R21, R31, R40, R48, R62, R69, R73, R107) observed during medication cart observation in the sample of 24. The findings include: 1. On April 27, 2022, at 10:35 AM with V15 (Nurse/Psychotropic Nurse), V21 (agency Nurse) was observed in front of the third floor south medication cart. According to V21 she is passing the resident's medications. On top of the said medication cart were multiple plastic medication cups, all with multiple unidentified (out of original packaging) medications. The following were observed on top of the medication cart: - two medication cups stacked on top of each other, both with multiple unidentified medications. Only one of the said medication cups (on the bottom/outside) was labeled with room, bed number and only the first…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and incontinence care. This applies to 5 of 5 residents (R13, R31, R32, R33 and R62) reviewed for ADL (activities of daily living) in the sample of 24. The findings include: 1. R13 has multiple diagnoses which include anoxic brain damage, seizures, encephalopathy and type 2 diabetes mellitus, based on the face sheet. R13's quarterly MDS (minimum data set) dated January 25, 2022, shows that the resident is severely impaired with cognitive skills for daily decision making. The same MDS shows that R13 would require extensive assistance from the staff with regards to toilet use (how the resident cleanses self after elimination, changes pad and adjusts clothes) and total assistance from the staff with regards to personal hygiene. On April 25, 2022, at 12:32 PM, R13 was in bed, alert but non-verbal. R13 had an accumulation of long, curling chin hair and her fingernails 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 observation, interview, and record review, the facility failed to provide bladder and urinary indwelling catheter care in a manner that would prevent urinary tract infection. This applies to 4 of 8 residents (R13, R33, R60, R61) reviewed for bladder and urinary catheter care in the sample of 24. The findings include: 1. On 4/26/22 at 1:52 PM, V13 (Certified Nursing Assistant/CNA) rendered incontinence care to R33 who was heavily saturated with urine and had a large bowel movement. The stool was somewhat dry and pasty. Using wet wipes, V13 cleaned R33's pubic region, bilateral groins and the anterior part of R33's flaccid penis in a downward stroke multiple times using same wipes. However, V13 did not wipe/clean the tip of the penis and the posterior part of the shaft of R33's penis. Care Plan showed: R33 is always incontinent of both bladder and bowel movement related to Benign Prostatic Hypertrophy (BPH), Atrial-Fibrillation, Hypertension, and abnormal gait and balance. R33's care plan has multiple interventions which include R33 need assistance to wash, rinse and dry his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow pharmacy instructions/recommendation of how to store medications. The facility also failed to ensure that an expired medication is removed from the refrigerator where it was mixed with other medications. This applies to 4 of 4 residents (R66, R82, R99, R111) reviewed for medication storage and labeling in the sample of 24. The findings include: On [DATE] at 10:56 AM, medication storage and labeling observations were conducted on the second floor north med cart with V28 (Nurse), and the following medications were observed: 1. R111 has a Latanoprost 0.005% ophthalmic solution that was sealed and has not been used yet. The medication box label has instructions which indicates to refrigerate if the package is still unopened. 2. R82 has a sealed/unopened Lantus 100 unit/ml with instruction to refrigerate while unopened. 3. R99 has a sealed/unopened Levemir Insulin 100 units/ml with instruction to refrigerate while unopened. 4. On [DATE]…

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

Based on observation, interview and record review, the facility failed to provide double portions of entrée and milk for residents with a diet order or preference for the same. This applies to 4 of 4 residents (R8, R34, R81,R100) reviewed for dining in the sample of 24. The findings include: On 04/25/22 starting a 12:00 PM, the lunch meal service and dining were observed on 3rd floor with V6 (Dietary Aide) serving from the steam table. On 04/25/22 at 12:41 PM, R34 received one #8 scoop (4 oz) of pureed meat along with one #8 scoop each of mashed potatoes and pureed vegetables. R34's meal ticket showed 2 times entrée. When this was brought to the attention of V7 (Certified Nursing Assistant) who had requested for pureed meal tray at the steam table, V7 remarked I thought it was 2 portions as they normally don't serve this much. On 04/25/22 at 01:07 PM, R8 was served a room tray and received one carton of 8 oz whole milk. R8's meal ticket showed Offer 2 whole milks. R8 remarked I like extra milk. If I can get two of these (pointing to the milk carton) that would be best. This 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 serve mechanical soft roast beef portions for the lunch meal. This applies to 4 of 4 residents (R8, R22, R36, R48) reviewed for mechanical soft diets in the sample of 24. The findings include: On 04/25/22 at 12:36 PM, the meal was observed in the 3rd floor dining room with V6 (Dietary Aide) platting food from the steam table. V6 used a green colored scoop to serve the mechanical soft roast beef and R8, R22, R36 and R48 received the same. V6 stated that she is serving 3 oz/ounce portion and that she uses serving utensils based on color to serve the food and that the green scoop is a 3 oz portion scoop. A scoop size guidance by color and capacity was posted on the wall behind the serving area which showed that #12 green scoop with capacity of 2 and 2/3rd oz or 1/3rd cup. The same scoop size guidance sheet showed that #10 beige scoop with a capacity of 3 oz. The same scoop guidance sheet showed that #8 gray scoop with capacity of 4 oz. Facility Menu Spreadsheet for lunch (Cycle 2, 2nd week) included 4 fluid oz…

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's urinary catheter bag was covered. This applies to 3 of 6 residents (R61, R72, R368) reviewed for urinary catheter in the sample of 24. The findings include: 1. R61's EHR (Electronic Health Record) showed diagnoses including stage 4 pressure ulcer to sacral region, major depressive disorder and dementia with [NAME] bodies. R61's MDS (Minimum Data Set) dated March 10, 2022, showed R61 had severe cognitive impairment. R61 required one staff extensive assistance for bed mobility, transfers, dressing, and personal hygiene. R61 was dependent on one staff for toilet use. R61 had an indwelling urinary catheter and was frequently incontinent of bowel. R61's care plan dated December 1, 2021, showed R61 has indwelling catheter related to an unstageable sacral wound. Interventions included . positioning the tubing below the bladder and away from the entrance room door . On April 25, 2022, at 2:51 PM, R61 was lying in bed. R61's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident received foot care and treatment for overgrown, thick toenails. This applies to 1 of 1 resident (R13) reviewed for foot care and services in the sample of 24. The findings include: R13 was admitted to the facility on [DATE]. R13 has multiple diagnoses which included anoxic brain damage, seizures, encephalopathy and type 2 diabetes mellitus, based on the face sheet. R13's quarterly MDS (minimum data set) dated January 25, 2022, shows that the resident is severely impaired with cognitive skills for daily decision making and would require extensive to total assistance from the staff with her ADLs (activities of daily living). On April 26, 2022, at 1:31 PM, R13 was in bed, alert but non-verbal. R13's toenails were long, jagged, thick and discolored. V8 (Nurse) was present during the observation and stated that R13 needs to be seen by the podiatrist. R13's electronic medical records from admission through April 26, 2022,…

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 fall precautions were implemented for a resident with a history of multiple falls. This applies to 1 of 2 residents (R61) reviewed for falls in a total sample of 24 residents. The findings include: R61's EHR (Electronic Health Record) showed R61 has diagnoses including dementia with Lewy bodies, major depressive disorder, and stage four pressure ulcer of the sacral region. R61's MDS (Minimum Data Set) dated March 10, 2022, showed R61 had severe cognitive impairment, and required extensive assistance for bed mobility and transfer between surfaces. R61's care plan for falls initiated January 27, 2022, shows multiple interventions including: Bed alarm to alert staff when resident attempts to get out of bed unassisted, so staff can assist resident and prevent falls. Initiated December 1, 2021. Provide floor mats/floor pads at bedside. Initiated January 24, 2021. On April 25, 2022, at 2:56 PM, R61 was lying in bed. No floor mats or bed alarm were in place. On April 26, 2022, at 3:27 PM, R61 was lying in…

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 monitor resident behaviors who were receiving psychotropic medications.This applies to 2 of 5 residents (R24 and R61) reviewed for psychotropic medications in a total sample of 24 residents. The findings include: 1. R24's EHR (Electronic Health Record) showed R24 has diagnoses including dementia with behavioral disturbance and major depressive disorder. R24's MDS (Minimum Data Set) dated April 13, 2022, showed R24 has moderate cognitive impairment. R24's order summary report showed R24 was receiving the following medications since November 9, 2021: escitalopram oxalate tablet 10 mg (milligram), give one table by mouth one time a day for depression, and aripiprazole tablet 2 mg, give one tablet by mouth two times a day for psychosis. R24's care plan for psychotropic drug therapy initiated August 16, 2021, for aripiprazole (antipsychotic), and escitalopram (antidepressant) initiated August 12, 2021, showed the following intervention dated…

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

Based on observation, interview, and record review, the facility failed to follow standard infection control process with regards to hand hygiene and changing of gloves during provisions of care. The facility also failed to ensure that a catheter tubing and bag is not directly touching the floor. This applies to 3 of the 8 residents (R13, R33, R60) reviewed for infection control in the sample of 24. The findings include: 1. On 4/26/22 at 1:52 PM, V13 (Certified Nursing Assistant/CNA) rendered incontinence care to R33 who was heavily saturated with urine and had a large bowel movement. V13 initially changed gloves after wiping the frontal peri-area but did not perform hand hygiene prior to donning new gloves. V13 continue to clean from front to back. After completely cleaning the rectal and buttocks area, V13 proceeded to apply new incontinence brief and put pants R33's pants back on while wearing same soiled gloves. 2. On 4/26/22 at around 2:45 PM, V13 (CNA) cleaned R60's rectal and buttocks area after R60 used the toilet. V13 proceeded to pull R60 pants back in place and…

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

Based on observation, interview, and record review, the facility failed to ensure all staff were fully vaccinated for COVID-19. This has the potential to affect all 120 residents residing in the facility. The findings include: The Resident Census and Conditions of Residents form dated April 26, 2022, showed the facility census as 120 residents. According to the undated COVID-19 Staff Vaccination Status for Providers list provided by V3 (Infection Preventionist) on April 25, 2021, the facility had a total number of 279 staff members. Of the 279 staff members, two staff members were partially vaccinated. The Staff Formulas calculations showed the facility has a 99.3 percent staff vaccination rate. The COVID-19 Staff Vaccination Status for Providers list showed V23 (CNA-Certified Nursing Assistant) and V24 (CNA) received one vaccination of a multi-dose vaccination series for COVID-19. On April 25, 2022, at 4:05 PM, V23 was working on the second floor, caring for residents. V23 said she received her first vaccination in February 2022 but has not received her second dose. On April 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.