Serenity Estates At Morris

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide dignity to a resident during provisions of care.This applies to 1 of 26 residents (R118) reviewed for dignity in the sample of 26.The findings include: R118's EMR (Electronic Medical Record) showed R118 was admitted to the facility on [DATE], with diagnoses that included intervertebral disc disorder with radiculopathy, lumbar region, acute respiratory failure with hypoxia, generalized muscle weakness, other chronic pain, dizziness, and giddiness. R118's MDS (Minimum Data Set), dated October 27, 2025, showed R118 was cognitively intact and was dependent on staff for showering.On December 16, 2025, at 9:04 AM, R118 said there was an incident, he thinks it was maybe two weeks ago, when the CNA (Certified Nurse Assistant), whose name he said he could not remember, took him to the shower room and turned on the water. The CNA told R118 she would be right back; she had to go to the other shower room for another resident. R118 said it was around 15…

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 services to prevent further contractures for a resident and failed to apply recommended devices to treat a resident's contractures.This applies to 2 of 3 residents (R14 and R15) reviewed for range of motions in the sample of 26. The findings include: 1.R14's face sheet included R14 was admitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypomagnesemia, dysphagia following cerebral infarction, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, and ataxia following cerebral infarction. R14's quarterly MDS (Minimum Data Set), dated October 31, 2025, showed R14 was moderately impaired in cognition. R14's functional limitation in range of motions showed impairment on one side. On December 15, 2025, at 12:29 PM, R14 was seated in dining room. R14's left arm appeared flaccid with his palm…

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 recommended fall preventive measures were put in place at all times for residents who were identified as high risk for falls. This applied to 2 of 3 residents (R2, R4) reviewed for falls in the sample of 5. The findings include: Findings Include: 1. R2's face sheet documents R2 is 82 years-old who has multiple medical diagnoses including repeated falls, unsteadiness on feet, lack of coordination, and Alzheimer's disease. R2's Minimum Data Set, dated [DATE], shows R2 is cognitively impaired. Facility's fall incident log, dated May 8 to August 12, 2025, shows R2 had multiple fall incidents on May 31, June 13, June 16, June 19, July 3, and July 13, 2025. R2's fall care plan with initiated date of May 30, 2025, shows: R2 is at risk for falls in relation to poor safety awareness, history of falls, and dementia. This same care plan shows multiple interventions which include wheelchair cushions with non-skid mat (Dycem) to chair. On…

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 medications were readily available to newly admitted residents. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 3. The findings include: 1. R1's Face Sheet showed he was admitted to the facility on [DATE]. R1's 4/24/25 Minimum Data Set (MDS) showed he is cognitively intact. R1's Face Sheet showed his diagnoses include COPD (chronic obstructive pulmonary disease) with acute exacerbation, depression, emphysema, chronic respiratory failure, asthma, sciatica, hyperlipidemia, and a rib fracture. On 4/29/25 at 12:50 PM, R1 stated he waited a long time to get all of his medications after he was admitted . On 4/28/25 at 5:35PM, V3, LPN (Licensed Practical Nurse), stated she worked on 4/19/2025, and worked a double shift. V3 stated she assisted with R1's admission, but she was not his assigned nurse. V3 stated the cut-off time for the pharmacy ordering is between 4:00-5:00 PM for medications to be filled, but 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.

Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift for 1 of 4 residents (R1) reviewed for falls in the sample of 4. The findings include: R1's Physician Order Sheet, printed on 1/17/25, shows R1 has diagnoses that include dementia, weakness, meniers disease, and hearing loss. R1's fall risk assessment, dated 1/8/25, shows R1 is high risk or falls. R1's careplan, dated 4/6/24, shows R1 is a risk for falls due to vision, hearing, weakness, gait balance problems with intervention to include transfer status, mechanical lift with 2 staff. On 1/17/25 at 10AM, R1 was lying in bed. Through communication board, he was able to say he was ok and was not in pain. V3 (License Practical Nurse-LPN) checked R1's head. A diffuse bruise, reddish black in color, was noted at the back of his head. R4 (R1's wife and roommate with a BIMS of 14-no cognitive impairment) said she was not in the room on 1/8/25 when the incident happened. She went to the dining room to get coffee. When she came back, R1 was noted lying on…

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 employ sufficient staff to carry out the functions of the Food and Nutrition Services, including meal preparation. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On Wednesday 10/8/24 at 11:45 AM, R205 said on the previous Monday they were supposed to have tuna salad on toast, but it was not served on toast, it was just white bread. On 10/10/24 at 11:27 AM, R205 said there had been multiple occasions when the meals served did not match the menu, and that made R205 feel like her ability to choose had been taken away from her. On 10/8/24 at 10:27 AM, V9 said the facility does not have sufficient Dietary staff. On 10/8/24…

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 their menus. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On Wednesday 10/8/24 at 11:45 AM, R205 said on the previous Monday they were supposed to have tuna salad on toast, but it was not served on toast, it was just white bread. On 10/10/24 at 11:27 AM, R205 said there had been multiple occasions when the meals served did not match the menu, and that made R205 feel like her ability to choose had been taken away from her. On 10/8/24 at 10:27 AM, V9 said the facility does not have sufficient dietary staff. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said she switched the meals this week on Monday…

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/store items, remove expired items, sanitize equipment, and wear hair restraints in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On 10/9/24 at 10:59 AM, V10 (Cook) was observed during lunch service. V10 checked the temperature of a tray of enchiladas and the placed the thermometer on the serving table, with the probe of the thermometer touching the table. The table was noted to have visible food debris/crumbs and dried liquid smudges on it. V10 then picked up the thermometer off the table, and without sanitizing the probe, stuck the thermometer in another tray 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 provide appropriate fall interventions and a hazard free environment to all residents. This applies to 4 residents (R207, R158, R360 and R261) reviewed for safe environment in a sample of 28. The findings include: 1. R207's Face Sheet shows he was admitted to facility on 8/15/23. R207's Face sheet shows a diagnosis of long term use of anticoagulants. R207's Morse Fall Scale Assessment performed on 9/19/24 shows he is high risk for falling. R207's Care Plan initiated on 10/7/24 shows resident has potential for and actual impairment to skin integrity of skin tear to right elbow related to history of falls. Care Plan initiated on 7/28/24 shows resident is at risk for falls. Interventions show resident needs a safe environment. The facility's Un-witnessed Fall Report, dated 10/7/24 at 8:00 AM, shows R207 was found lying on the floor next to his bed and reported to the nurse that he rolled out of bed and hit the floor and had pain on the right…

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 10. R63 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 10/08/24 at 10:35 AM, a half-full 60-gram Nystatin topical powder bottle (used to treat fungal or yeast skin infections) was observed at R63's bedside. 11. R64 is a [AGE] year-old female with cognition intact as per the MDS, dated [DATE]. On 10/08/24 at 10:38 AM, R64 was observed in her bed with a wound cleanser bottle (3/4th of a 16-ounce bottle, used to clean wounds), Hibiclens (3/4th of an 8-ounce bottle, used as an antimicrobial skin cleanser), and Betadine (half of an 8-ounce bottle, used to prevent infection and promote healing in skin wounds, pressure sores, or surgical incisions) at her bedside. On 10/09/24, at 9:45 AM, V2 (Director of Nursing / DON) stated the Nystatin, Hibiclens, Betadine, wound cleanser, etc., at the bedside should have been stored in the treatment cart. V2 added if the staff doesn't follow this guideline, the residents may likely ingest those. A review of 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 follow infection control practices for residents under TBP (Transmission Based Precautions) and during transportation of dirty linen. This applies to 4 of 4 residents (R357, R356, R156, and R158) reviewed for infection control in a sample of 28. The findings include: 1. R357 was admitted to the facility with diagnoses including enterocolitis due to clostridium difficile. R357's POS (Physician Order Sheet) showed an order for Contact Isolation for CDIFF starting October 7, 2024. On 10/9/24 at 11:45 AM, V18 (Family Member) was in R357's room without wearing any PPE. V18 said goodbye to R357 and walked out of the room without washing her hands with soap and water. At 11:48 AM, V18 said she was in the facility every other day, and she was aware she was on isolation for C. Diff. V18 said she was never instructed on what she needed to wear prior to going into the room. V18 also said she was not instructed she needed to wash her hands prior to leaving the room. On 10/10/24 at 1:53 PM, V19 (Occupational Therapist)…

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 order a residents chosen Advanced Directives status of DNR (Do Not Resuscitate). This applies to 1 of 1 resident (R268) reviewed for Advanced Directives in a sample of 28. Findings include: R268 admitted to the facility on [DATE], with diagnoses that includes encephalopathy, frontotemporal neurocognitive disorder, convulsions, type 2 diabetes, hypertension, anxiety, and dementia. On 10/10/24 at 3:16 PM, V25 (Family Member) stated R268 code status is DNR. V25 stated the code status was a part of the POA (Power of Attorney) paperwork that was provided to the facility. V25 stated R268 made the determination of her DNR status before she had cognition changes. V26 (Family Member) confirmed R268 made the decision for a DNR status some years prior to admission to the facility. On 10/09/24 at 3:49 PM, V2, DON (Director of Nursing), stated, All residents should have a code status on admission so the facility can adhere to the residents wishes of extending life…

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 ADL (ADL/Activities of Daily Living) care to dependent residents. This applies to 2 of 2 residents (R307 and R356) reviewed for ADL care in the sample of 28. The findings include: 1. R307 was admitted to the facility on [DATE], with diagnoses of displaced transverse fracture of shaft of humerus, anxiety, muscle weakness, abnormalities of gait and mobility, polyneuropathy, depression, and arthritis. R307's MDS (MDS/Minimum Data Set), dated 09/06/24, showed R307 had moderate cognitive impairment. MDS task Section GG showed R307 required substantial/maximal assist to dependency with personal hygiene. R307's ADL Self-Care Performance Deficit care plan, initiated 04/21/24, showed R307 usually requires substantial- dependence for personal hygiene. Level of assistance may vary depending on resident's status. On 10/08/24 at 11:14 AM, R307 was in bed. R307's right eye had a crusted substance on the upper lid and the inner corner. On…

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 anti-contracture devices and Controlled Ankle Movement (CAM) Boot were applied as ordered. This applies to 2 of 2 residents (R160 and R354) reviewed for assistive devices in a sample of 28. The findings include: 1. R160's Face Sheet shows diagnoses of Parkinsonism, weakness, and dementia. R160's Minimum Data Set of 10/17/24 shows R160's cognition is severely impaired. R160's Physician Order (POS) shows R160 has an order for hand rolls placed to reduce/risk of contractures every shift. R160's care plan, initiated 5/14/24, shows R160 has an Activities of Daily Living (ADL) self-care mobility performance deficit related to weakness, decreased mobility, with intervention to place handrolls in hands to reduce risk of contractures. On 10/8/24 at 11:52 AM, R160 was observed sitting in high back wheelchair in the dining room. R160's right hand was in fist form, arm folded on her abdomen. On 10/9/24 at 11:10 AM, R160 was sitting in her high back wheelchair in dining, with other resident; right hand still noted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to keep the indwelling catheter bag below the bladder level to prevent potential urinary tract infection (UTI). This applies to 1 of 2 residents (R57) reviewed for catheter care and treatment in a sample of 28. The Findings Includes: R57 is a [AGE] year-old male with severe cognitive impairment, as per the Minimum Data Set (MDS) dated [DATE]. R57 was admitted with an admitting diagnosis including urinary retention. On 10/8/24 at 11:00 AM, R57 was observed in his wheelchair with an indwelling catheter bag hanging behind his wheelchair and above his bladder level, with urine pooling in the catheter tubing. On 10/8/24 at 11:05 AM, V5 (Registered Nurse/RN) stated the therapist might be the one who left the indwelling catheter bag above bladder level. V5 also stated if the catheter bag is kept above bladder level, it can cause UTI. On 10/9/24 at 9:45 AM, V2 (Director of Nursing) stated the indwelling catheter bag should be below the bladder…

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 their policy on maintaining a Peripherally Inserted Central Catheter (PICC) line. This applies to 1 of 1 resident (R62) reviewed for central line catheter care in a sample of 28. The Findings Includes: R62 is a [AGE] year-old male with cognition intact, as per the Minimum Data Set (MDS) dated [DATE]. R62 was admitted with a diagnosis of Sepsis, Right Lower Limb Cellulitis, and Osteolysis. On 10/08/24 at 10:42 AM, R62 was sitting on his chair with a left upper arm double lumen PICC line, with a dirty reinforced dressing, with no date or label, and was peeling off from the insertion site: On 10/08/24 at 10:42 AM, R62 stated he was not sure the facility had ever changed his PICC line dressing. Reviewing R62's Physician Order Sheet (POS) on 10/8/24 indicates no order to change R62's PICC line. On 10/08/24 at 11:20 AM, V5 (Registered Nurse/RN) stated there should have been an order to change the PICC line dressing. If the order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain consents for psychotropic/antidepressant medications, and failed to follow pharmacy recommendations. This applies to 2 of 4 residents (R156 and R308) reviewed for unnecessary medications in a sample of 28. The findings include: 1. R308 was admitted to the facility on [DATE]. R308 had multiple diagnoses which included myalgic encephalomyelitis/chronic fatigue syndrome, major depressive disorder, anxiety, sleepwalking, and abnormalities of gait and mobility. R308's MDS (MDS/Minimum Data Set), dated 08/05/24, showed R308 had moderate cognitive impairment. The same MDS Section N showed R308 was taking an antianxiety and an antidepressant. R308's Psychotropic medication use for depression and anxiety showed R308 was taking Clonazepam and Mirtazapine. R308's active Order Summary Report, dated 10/10/24, showed R308 had current and active orders for: Clonazepam 0.5 mg two times per day for anxiety, started 07/18/24; and Mirtazapine 45 mg at bedtime 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 safely transfer a resident from her bed to her reclining wheelchair using a mechanical lift, resulting in a fall and skin tear. This applies to 1 of 3 residents (R1) reviewed for mechanical lift use. Findings Include: R1's 12/21/23 nursing note from 7:57 AM showed, Called to resident room by CNA [Certified Nursing Assistant]. Observed resident lying on her right side next to the wall by the foot of her bed, [mechanical lift] sheet partially underneath her. Blood noted by her right lower leg area .resident unable to say what transpired .CNA stated that during transfer [mechanical lift] started to tip over and as she (CNA) reached for the resident to prevent the fall the [mechanical lift] tipped anyway but she was able to break the fall so the resident did not hit the floor with her full body weight . The note showed 911 was called and R1 was transferred to the local Emergency Room. R1's nursing note from 11:30 AM showed she was returning…

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 sanitary practices during dish washing, meal prep, and meal service. This has potential to affect all 80 residents that received foods in the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS 672), dated September 24, 2023, showed the facility census was 80. Facility gave additional information there were no residents that were on nothing by mouth status. On September 25, 2023, at 9:49 AM, the initial tour of kitchen was conducted in the presence of V14 (Cook). In the reach in cooler, there was a container (1 gallon/container) of 2% milk, dated use by date September 24, 2023, which appeared less than half full. In the walk-in cooler, there were several unopened containers (1 gallon/container) showing use by dates as follows: 1 whole milk container September 3, 2023, 7 whole milk containers September 17, 2023, 4 whole milk containers September 24, 2023. V15 (Dietary Aide) stated that she served 2% milk for breakfast which was poured into jugs 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, the facility failed follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care, and by not donning of personal protective equipment (PPE) when entering an isolation room. In addition, the facility also failed to ensure they have a process to measure or monitor the growth of Legionella and other opportunistic waterborne pathogens in building's water system. This applies to all the 80 residents in the facility. The findings include: Facility Resident Census and Conditions of Residents form (CMS 672), dated September 24, 2023, showed the facility census was 80. 1. On September 25, 2023, at 11:29 AM, R7 was sitting on the bedside commode having a bowel movement; there were droppings of loose fecal matter on the floor. When R7 finished using the commode, V10 (Certified Nursing Assistant/CNA) assisted R7 to get up from wheelchair, and proceeded to clean R7's back perineum, pulled the incontinence brief and pants back in place, assisted R7 to transfer back to the motorized…

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 mobility. This applies to 5 of 5 residents (R10, R13, R29, R63 and R75) reviewed for ADLs (activities of daily living) in the sample of 19. The findings include: 1. R13 had multiple diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, weakness and type 2 diabetes mellitus, based on the face sheet. R13's quarterly MDS (Minimum Data Set), dated July 31, 2023, showed the resident was cognitively intact and required extensive assistance with personal hygiene. R13's active care plan showed the resident had impaired physical mobility requiring assistance with mobility related to CVA (cerebrovascular accident) with left hemiparesis and hemiplegia. The same care plan showed multiple interventions including, Ensure that all hygiene needs have been met, e.g. (for example) skin care, oral care, hair,…

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 incontinence care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of the 4 residents (R4, R7, R9, R44) reviewed for incontinence care in the sample of 19. The findings include: 1. R7 is 82 years-old who has multiple medical diagnoses which include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, and urinary tract infection (UTI). On September 25, 2023, at 11:29 AM, R7 was sitting on the bedside commode having bowel movement. There were some drops of loose stool or fecal matter on the floor. After R7 used the commode, V10 (Certified Nursing Assistant, CNA) assisted R7 to get up and proceeded to clean R7 from mid-perineum to the back peri-area. V10 wiped R7 multiple times using same wet wipes. V10 took another set of wipes and gave R7 one final sweep from the mid-perineum to the back peri-area. V10 proceeded to pull the incontinence brief and pant back in place. V10 did not clean the frontal area such as the pubic,…

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 resident's choice of Advanced Directive was correctly reflected on Physician Order Sheet (POS) to inform patient's wishes in case of emergency. This applies to 1 of 1 resident (R53) reviewed for advance directives in the sample of 19. The findings include: R53's EMR (Electronic Medical Records) included diagnoses of chronic systolic (congestive) heart failure, diverticulosis of large intestine without perforation or abscess without bleeding, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, personal history of other venous thrombosis and embolism, need for assistance with personal care. On [DATE] at 2:11 PM, R53's EMR dashboard showed Full Code. No information for Advanced Directive was on POS (Physician Order Sheet). R53's POLST (Practitioner Order for Life-Sustaining Treatment) form uploaded in Documents section showed DNR (Do not Resuscitate) which was signed by Physician, POA (Power of Attorney), 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 observation, interview, and record review, the facility failed to ensure that residents identified with heart disease and renal disease were weighed daily as ordered by the physician. This applies to 2 of 19 residents (R18 and R284) reviewed for physician orders in sample of 19. Findings include: 1. Review of R18's face sheet documents an [AGE] year old male readmitted to the facility on [DATE], with diagnoses that include End Stage Renal Disease, Chronic Obstructive Pulmonary Disease with Exacerbation, Type 2 Diabetes Mellitus with diabetic Neuropathy, and Hypertensive Heart Disease with Heart Failure. R18's Physician orders document the following order by V23 (Physician), dated August 15, 2023: Daily weight every day shift for Chronic Kidney Disease. R18's care plan for congestive heart failure documents the following: Monitor/document/report as needed any signs and symptoms of congestive heart failure: dependent edema of legs and feet, and weight gain unrelated to intake. R18's care plan for renal…

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

Based on observation, interview, and record review, the facility failed to assess and provide supportive device/splint to a resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 3 residents (R13) reviewed for range of motion in the sample of 19. The findings include: R13 had multiple diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, weakness, and type 2 diabetes mellitus, based on the face sheet. R13's quarterly MDS (Minimum Data Set), dated July 31, 2023, showed the resident was cognitively intact and required extensive assistance from the staff with most of her ADLs (activities of daily living). The same MDS showed R13 had functional limitation in range of motion on one side of both upper and lower extremities. On September 25, 2023 at 11:27 AM, R13 was in bed, alert, oriented, and verbally responsive. R13 had weakness to her left arm and hand. R13 was not able to open her left hand to extend her fingers. R13 stated she does not use any splint or device on her left arm…

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 pureed consistency Teriyaki beef tips and rice for the lunch meal. This applies to 2 of 2 residents (R37, R44) reviewed for pureed diets in the sample of 19. The findings include: On September 26, 2023, at 10:57 AM, the pureed meal prep by V19 (Dietary Aide) was observed in facility kitchen. V19 pureed three 4 oz/ounce portions each of cooked teriyaki beef and rice in a blender. V19 then opened the blender and stated it was ready for service, and was going to transfer the contents to a container. The pureed mixture appeared granular with shreds of intact beef and small grains of rice on the sides of blender. When taste tested, pureed item had grains of rice and small shreds of beef. V19 and V16 (Dietary Manager) were notified the mixture was not safe to serve. V16 stated the sides should have been scraped down and pureed again. V16 also added the item should be smooth like baby food. On September 26, 2023 at 01:26 PM, V18 (Dietitian) stated the final product of the pureed meat and rice mixture should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the wheelchair breaks were maintained in working condition. This applies to 3 of 3 residents (R1, R32, R50) reviewed for falls in the sample of 19. The findings include: 1. R1's face sheet included diagnoses of history of falling, unsteadiness on feet, need for assistance with personal care, spinal stenosis, site unspecified, muscle weakness (generalized), other abnormalities of gait and mobility, spinal stenosis, site unspecified. R1's quarterly MDS (Minimum Data Set), dated August 24, 2023, showed R1 was cognitively intact. On September 25, 2023, at 10:48 AM and on September 26, 2023, at 10:16 AM, R1 stated, I fell 3 weeks ago. I was trying to get into or out of bed. The CNA (Certified Nursing Assistant) was helping me. It was something with the wheelchair. The brakes went out and went backwards as I was standing up from it. I sat down on floor. I did not hurt myself. It happened about a week and a half ago at around…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to make timely notifications of status changes to family and a physician. This applies to 1 of 4 residents (R1) reviewed for condition changes in a sample of 12. Findings include: On [DATE] at 12:28 PM, V1 (Administrator) stated due to R1's cognitive impairments, V12 (R1's Husband) was making R1's decisions until he passed away in [DATE]. V1 stated at that point, V11 (R1's Daughter) became R1's emergency contact and decision maker, until V10 (R1's Daughter) obtained guardianship in [DATE]. R1's Progress Notes, dated [DATE], documents V12 expired on [DATE]. A Court Order Appointing Successor Guardianship for a Disabled Adult, dated [DATE], documents V10 (R1's Daughter) as R1's decision maker. 1. On [DATE] at 5:32 PM, V21 (Nursing Assistant) stated on [DATE], she was pushing R1 down the hall in her wheelchair after dinner, and as she was navigating R1 around another resident in the hallway, R1's arm accidentally scraped the hand rail causing a skin tear 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 complete a comprehensive nursing assessment for a new pressure injury, failed to ensure routine monitoring of a pressure ulcer, and failed to provide treatments as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for pressure injuries in a sample of 12. Findings include: The admission Record, printed 8/4/2023, documents R1 with diagnoses to include Dementia with Agitation, Diabetes, Hypertension and Arthritis. This record shows R1 discharged from the facility on 7/28/2023. R1's Skin Incident Form, dated 3/3/2023, documents R1 with a small pressure ulcer to the coccyx area which measured 1 X 2 X 0.1 centimeters (cm). R1's March 2023 TAR documents treatment orders during the period between 3/7 to 3/31/2023 for R1's coccyx pressure ulcer to include apply skin prep and a hydrocolloid dressing every four days. This TAR documents R1's treatment was not completed on 3/23/2023 and 3/31/2023 as ordered. R1's April 2023 TAR documents treatment orders during the period between 4/13 to 4/30/2023 for R1's coccyx…

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.