Thrive Of Lake County

Based on observation, interview, and record review, the facility failed to ensure an insulin pen and an inhaler were dated upon opening, and failed to ensure medications were stored in a secure manner and not accessible to residents to 3 of 31 residents (R48, R56, R161) reviewed for medication storage in the sample of 31.The findings include: 1. On 6/10/26 at 9:08 AM, V9 (Registered Nurse-RN) checked the medication cart for 1000 unit. R48's insulin pen of Lispro (long-acting insulin) was opened but not dated. V9 (RN) said R48 has an order for 70 units of Lispro to be given at bedtime. (V9) said insulin pens should be dated when opened because insulins are only good for 28-30 days after open date. 2. R56's inhaler of Anoro Elipta for 1 puff daily for COPD was also opened but was not dated. V9 (RN) said inhalers were only good for 30-40 days after they were opened. V9 said there was a nurse that used to check the medication carts but was not sure if that was still being done. On 6/10/26 at 11:20 AM, V2 (Director of Nursing-DON) said all medications carts will be audited to ensure 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.

Based on observation, interview, and record review, the facility failed to ensure a resident was served the noon meal in the ordered form for 1 of 31 residents (R4) reviewed for diets in the sample of 31. The findings include:R4's Physician's Order Sheet shows she is on a pureed diet. R4's Meal Ticket showed she was on a pureed diet. The Diet Spreadsheet for the noon meal shows residents on a pureed diet should receive a pureed dinner roll.On 6/8/26 at 12:08 PM, the kitchen staff were plating the noon meal for delivery to the units. R4's tray was in the transportation cart and had a regular dinner roll on the tray. A plate or pureed food was placed on R4's tray. At 12:30 PM, V15 (Certified Nursing Assistant) served R4 her lunch tray with the regular dinner roll still on the tray. V15 stated to the resident, You have a roll here too and started unwrapping the roll. On 6/8/26 at 12:54 PM, V5 (Dietary Manager) said residents on a pureed diet should have received pureed roll for the noon meal and not a regular roll. V5 said the kitchen staff should serve the diet type that is listed 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 staff wore the correct Personal Protective Equipment (PPE) when caring for residents on Enhanced Barrier Precaution (EBP) isolation room, which applies to 1 of 31 residents reviewed for infection control in a sample of 31.The findings include:R14's Facility Assessment, dated 3/1/26, showed R14 uses a urinary catheter and has a diagnosis which included history of Escherichia Coli (E. Coli).On 6/9/26 at 8:45 AM, R14 had an EBP sign displayed on the room's door frame. A small 3-drawer cart was next to the doorframe with PPE in it. V14 (Certified Nursing Assistant) was in the hallway gathering washcloths and then entered R14's room without putting on a gown.On 6/9/26 at 12:10 AM, V14 stated she was changing R14's gown and cleaning her up after she spilled some of her breakfast. V14 stated she should have put on a gown to care for R14.On 6/9/26 at 12:30 PM, V13 (Licensed Practical Nurse-LPN) stated EBP is used when a resident has a device (central line, catheter, dialysis catheter) or chronic wounds. PPE…

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 resident care was safely provided to 1 of 3 residents (R1) reviewed for falls in the sample of 5.The findings include:R1's face sheet shows she has diagnoses including Alzheimer's Disease, Osteoarthritis, Osteoporosis, and abnormality of gait and mobility. R1's current care plan shows she has a cognitive deficit, is at high risk for falls, incontinent of bowel and bladder, and requires extensive assistance for bed mobility.R1's Fall Risk Evaluation completed on 12/9/25 shows she is at high risk for falls.A fall incident report completed by V3 (Licensed Practical Nurse/LPN) on 3/15/26 at 7:00 PM states, while nurse aide (V4) was changing resident, she slid off the side of the bed. Resident was transferred to a local hospital for further evaluation.R1's Electronic Medical Record shows R1 is still at a local community hospital. R1's X-ray report of her left foot, from a local community hospital, shows the following, Osteopenia and Chronic Arthritic changes present involving the interphalangeal joints of the digits.…

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 was safely turned and positioned during incontinence care for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4.The findings include: R1's admission Record, dated 11/19/25, shows R1's diagnoses include, but are not limited to type 2 diabetes, morbid obesity, presence of a cardiac pacemaker, hypertension, polyneuropathy, restless and agitation, and a history of falling.R1's Minimum Data Set, dated [DATE], shows R1 has impairment to her functional range of motion on one side to her lower extremity (hip, knee, ankle, foot), has moderate cognitive impairment and is dependent (meaning the helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity.) on staff to provide toileting hygiene and to roll left and right (the ability to roll from lying on back to left and right side and return 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 administer medication as ordered by a physician for 1 resident (R1), failed to ensure medications were stored in their original packaging prior to administration for 5 residents (R7,R8,R9,R10,R11). These failures apply to 6 of 8 residents reviewed for medications in the sample of 11.The findings include: 1) R1's electronic face sheet dated 8/20/25 showed R1 has diagnoses including but not limited to Alzheimer's disease, hypothyroidism, asthma, and hypertension.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment.On 8/20/21 at 10:21AM, R1 was in her bed laying on her left side with a white patch dated 8/19 stuck to her bed linens. Surveyor reported findings to V4 (Registered Nurse). Surveyor and V4 entered R1's room and V4 stated, Oh, that's her lidocaine patch. She gets one on her left shoulder. I haven't put her new one on yet this morning, but it was supposed to be put on around 8:00AM, I think. This patch…

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 thoroughly investigate an injury of unknown origin to 1 of 3 residents reviewed for unknown origin in the sample of 4. The findings include: R1's electronic face sheet accessed last 7/9/25 documents, R1 96 y/o readmitted to the facility last 4/2/25 with diagnoses that include acute respiratory failure, kidney failure hypertension and diabetes. R1's progress notes dated 4/6/25 by V3 (RN) show [R1] refused to eat and drink, no urine output, family requested to send resident to the hospital. R1 was sent out to the ER. R1's Hospital Records dated 4/6/25 documents, 96 y/o presenting with decreased output, ordered hip X-ray. R1's radiology report dated 4/7/25 with final result -left femoral neck fracture. R1's hospital records dated 4/8/25, R1 underwent surgery -left hip hemiarthroplasty (left hip replacement) On 7/9/25 at 11:30 AM, V7 (R1's daughter) said she was told in the hospital that R1 had a new hip fracture to her left hip. V7 said that was the reason why R1 needed surgical repair because of this new left hip fracture. V7…

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 accurately bill and issue a refund for an overpayment to a resident in a timely manner for 1 of 3 residents (R1) reviewed for billing in the sample of 3. The findings include: R1's face sheet shows she was admitted to the facility on [DATE]. On 1/1/2023 R1's payer source changed to hospice medicaid which it remained until the time of her passing on 7/3/2024. On 4/3/25 at 10:20 AM, V3 (Senior [NAME] President of Business Office) said she became involved a few weeks in the issue with R1's bill. V3 said that its very time consuming and she will have to go back over every single payment that was made and everything billed for R1 since 2023 but the best she can tell is that R1 did have an overpayment and was due a refund back in 2023. She believes the reason was that R1's spouse {V10} had a financial change and as a result the amount medicaid paid and the amount he was liable for R1's bill had changed so a former business office employee identified as 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.

Based on observation, interview, and record review the facility failed to ensure dry goods were stored in a manner to prevent cross-contamination, serve food in a manner to prevent cross-contamination, and failed to properly sanitize the food preparation surfaces. These failures affect all residents residing in the facility. The findings include: The CMS 671 Form dated 3/11/25 showed the facility census was 161 residents. 1. On 3/11/25 a kitchen tour was conducted with V16 (Dietary Manager). At 9:47 AM, in the rear of the kitchen (where the facility performs the puree process), on low shelf below the commercial blender there was an open pitcher with approximately 2 inches of a white powder substance. There was not a cover on the pitcher. The surveyor pointed down to the pitcher and asked V16 what was inside. V16 stated, Oh that's thickener. The surveyor asked him if the thickener should be covered. V16 replied, Yes, this is garbage. I'll throw it out. The kitchen tour continued into the dry storage room. There was a large box, with a clear plastic liner open with a white powder…

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 food at an appetizing temperature to the residents for 3 of 3 residents (R112, R80, R68) reviewed for appetizing food temperatures in the sample of 31 and 2 residents outside of the sample (R113, R79). The findings include: On 3/12/25 at 10:30 AM, during the Resident Group Meeting the residents said the meals are served late most of the days. They said last night dinner time was supposed to be 5 PM, but the food doesn't arrive until 6 PM. The residents asked the surveyor have you ever had to eat cold food all the time? It's definitely not satisfying and the food tastes different. There is very much a temperature issue with the food here and it's seems like it's been worse this year. The residents said the cold food had been an ongoing complaint of the Resident Council, but the Dietary Manager has yet to attend the meeting. The residents said food is a continuous concern at the facility and all five residents agreed with the concerns and contributed in the discussion. On 3/11/25 at 9:51 AM, V16 (Dietary…

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 contact isolation precautions were posted (R465), failed to ensure personal protective equipment was worn in enhanced barrier precaution rooms (R157, R16) and failed to change gloves during pericare (R80) to prevent cross contamination for 4 of 5 residents reviewed for infection control in the sample of 32. The findings include: 1. R465's face sheet showed an admission date of 3/7/25. Diagnoses included acute osteomyelitis of the right ankle (bone infection), MRSA infection (Methicillin resistant staphylococcus aureus), and aftercare following toe amputations. On 3/11/25 at 11:37 AM, R465 had an isolation sign and a PPE bin (personal protective equipment) outside of the door. The sign showed EBP (enhanced barrier precautions) were in place. Gowns and gloves were required only during high-contact resident cares. On 3/12/25 at 9:50 AM, R465 had a new isolation sign outside of the door. The sign showed contact precautions were 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 maintain a resident's dignity during personal care. This applies to one of one residents (R66) reviewed for dignity in the sample of 32. The findings include: The facility face sheet shows R66 was admitted to the facility with diagnoses to include dementia, hemiplegia (loss of motor skills on one side of the body) and chronic pain. The facility assessment dated [DATE] shows R66 to have severe cognitive impairment and is dependent on staff for toileting. On 3/11/2025 at 12:00 PM, R66 was heard telling staff she needed to use the bathroom. V11 CNA (Certified Nursing Assistant) and V12 Social services took R66 into her room and using the mechanical lift assisted her into bed. R66 said, When am I going to the toilet?. V11 said to R66, it's OK to just go in your brief and I promise I'll come clean you up. I'll leave so you can have some privacy. R66 was later heard yelling, Help me! Help me! On 3/12/25 at 1:49 PM, V11 CNA said she wasn't sure if…

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 transfer a resident in a safe manner. This applies to one of eight residents (R66) reviewed for safety in the sample of 32. The findings include: The facility face sheet shows R66 was admitted to the facility with diagnoses to include dementia, hemiplegia (loss of motor skills on one side of the body) and chronic pain. The facility assessment dated [DATE] shows R66 to have severe cognitive impairment and is dependent on staff for transfers. On 3/11/25 at 12:00 PM, R66 was asking to go to the bathroom. V11 CNA (Certified Nursing Assistant) and V12 Social Services took R66 to her room and brought in the mechanical lift. V11 attached the hoops of the sling to the lift and began lifting R66 up. V12 was behind V11 at the entrance to the room. V12 was not near R66 during the transfer of R66. V11 lifted R66 and pushed her away from the wheelchair over to her bed, V11 then asked V12 to help guide her legs. V12 then came close to the resident but…

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 dressing change and measurement of an IV PICC (a peripherally inserted central catheter) line's external catheter was completed for 1 of 1 resident (R15) reviewed for PICC lines in the sample of 32. The findings include: R15's admission Record, provided by the facility on 3/13/25 showed she had diagnoses including, but not limited to, severe protein-calorie malnutrition, Guillain-Barre Syndrome, anxiety disorder, depression, chronic kidney disease, a personal history of transient ischemic attack (TIA-stroke), cerebral infarction without residual deficits, and heart failure. R15's Order Summary Report, provided by the facility on 3/13/25, showed the following orders were received on 2/7/25: IV PICC line (a thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart for long-term intravenous infusions of medications, fluids, or nutrition) change dressing every 7 days-with a start date 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.

Based on observation, interview, and record review the facility to ensure medications were administered as prescribed. There were 31 opportunities with 2 errors, resulting in a 6% error rate. This applies to 1 of 2 residents (R264) observed in the medication pass. The findings include: On 3/12/25 at 9:10 AM, V7 (LPN - Licensed Practical Nurse) administered R264's 9 AM medications including amiloride 5 mg, celecoxib 200 mg, ezetimibe 10 mg, folic acid 1.5 mg, zinc 220 mg (V7 administered 225 mg dose), multivitamin, a liquid protein supplement, pregablin, vitamin C, and Norco 10/325 mg. V7 did not prepare or administered R264's Thiamine 100 mg tablet. V7 looked through the medication cart for R264's Zinc 220 mg capsules. V7 was unable to locate the medication. V7 held up a Zinc 50 mg tablet and stated, This is all I have, so I'll give 4 tablets to equal 200 mg and I'll cut a fifth tablet in half to make 25 mg. It's the best I can do. I know it's not exactly 220 mg. V7 administered 225 mg of Zinc tablets as he described. V7 did not check the medication room for Zinc 220 mg capsules and…

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

Based on interview and record review the facility failed to ensure treatments were completed as prescribed for a resident with an unstageable sacral pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 6. The findings include: R1's Wound Physician Progress note dated 1/25/23 documents right sacral (prominent bone)-reopned unstageable pressure ulcer measuring 5 cm (centimeters) x 3.8 cm x 0.3 cm. 100 % necrotic eschar tissue. The treatment orders changed on 1/25/23 to cleanse with normal saline, apply Iodosorb/Calcium alginate and foam dressing three times a week and as needed. R1's Treatment Administration Record (T.A.R.) for January 2023 showed orders including sacral pressure injury cleanse with normal saline apply medihoney, adpatic, cover with calcium alginate and foam dressing daily (discontinued dated 1/26/23). New orders dated 1/26/23 show pressure injury cleanse with normal saline apply Iodosorb, adpatic, cover with calcium alginate and foam dressing three times a week and as needed. R1's T.A.R. showed 2 out of 11 treatments…

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 immediately notify a power of attorney about the initiation of treatment for a pressure injury for 1 of 3 residents (R1) reviewed for notifications in the sample of 3. The findings include: R1's Face Sheet printed on 12/30/24 showed R1 admitted to the facility on [DATE]. On 12/30/24 at 11:50 AM, V5 (R1's Power of Attorney) said she was not made aware of R1's pressure injury or that the pressure injury required a dressing until R1 was in the emergancy room on 12/25/24. R1's Progress Note dated 12/19/24 showed the facility was obtaining consent from V5 regarding R1's treatments. R1's Wound Assessment Details Report dated 12/20/24 showed R1 had a pressure injury to her coccyx that measured 0.50 centimeters (cm) x 1 cm x 0.1 cm. The report showed the pressure injury was present on admission. R1's hospital paperwork and hospital medication administration record (prior to being admitted to the facility on [DATE]) did not indicate R1 had a pressure injury or a…

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

Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: The facility's Incident Investigation Report dated 3/18/24 shows R1 and R2 were in their room sleeping. Staff was alerted to the room to find R2 standing at the bedside of R1. R1 was observed to have a gait belt around his neck. On 3/26/24 at 10:03 AM, R1 was dressed and sitting at a table in the activity room with other residents in the memory unit. R1 was alert but was not participating in the activity and appeared to be just staring off into the distance. On 3/26/24 at 10:15 AM, V2 Assistant Director of Nursing in charge of the memory unit said on 3/18/24, V7 Certified Nursing Assistant (CNA) heard noises from R1 and R2's room and went to the room where she found R2 standing over the bedside of R1 and R1 had a gait belt around his neck. V2 said the staff separated R2 and removed the gait belt from R1's neck. V2 said R1 did not have any marks or injuries on his neck. V2 said…

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 safe environment for 2 of 5 residents (R1 and R2)reviewed for safety in the sample of 5. The findings include: The facility's Incident Investigation Report dated 3/18/24 shows R1 and R2 were in their room sleeping. Staff was alerted to the room to find R2 standing at the bedside of R1. R1 was observed to have a gait belt around his neck. On 3/26/24 at 10:03 AM, R1 was dressed and sitting at a table in the activity room with other residents in the memory unit. R1 was alert but was not participating in the activity and appeared to be just staring off into the distance. On 3/26/24 at 10:08 AM, V4 Registered Nurse (RN) said R1 is Arabic and there is a bit of a language barrier. V4 said R1 can understand some words and communicates with hand gestures. V4 said R1 is confused and has behaviors of trying to stand up by himself but is usually very quiet. On 3/26/24 at 10:14 AM, V5 RN said R2 was alert with confusion, ambulatory, and had behaviors of exit seeking and asking for alcohol and cigarettes. V5 said…

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 have a process in place to discard medications, failed to ensure controlled substances were reconciled according to standards of practice, failed to ensure residents (R26, R139) were supervised during medication administration, and failed to ensure medications were re ordered from pharmacy as indicated for a resident (R11). These failures have the potential to effect all 163 residents residing in the facility. The findings include: The facility completed form CMS-671 dated 1/22/24 shows there are 163 residents residing in the facility. 1.) On 1/22/24 at 10:20 AM, The medication room of the 4000 and 5000 hallway had piles of resident medications inside. There was a large black plastic bin on the counter that was full of punch cards with resident medications inside them in addition to inhalers, insulin pens, eye drops, and ointments. Beside the black bin was another pile of hundreds of resident medications. There was also 2 large plastic bags of resident medications, a box full of medication and numerous stacks…

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 fully submerge a pitcher, hotel pan, and food service container with a lid to ensure the items were sanitized to prevent foodborne illness. This has the potential to affect all residents residing in the facility. The findings include: The CMS 671 dated 1/22/24 shows there are 163 residents in the facility. On 1/22/24 at 9:33 AM, V19 (Dietary Aide) was washing dishes at the three-compartment sink. V19 first washed and rinsed the lid of the food service container and dipped it into the third sink with sanitizer for two seconds and removed it. V19 then placed it on a rack to dry. V19 followed the same process for the food service container and the hotel pan; both items were dipped in the third sink with sanitizer for two seconds and removed. None of the items were fully submerged for at least 60 seconds. On 1/22/24 at 9:42 AM, V27 (Food Service Director) said the three-compartment sink process includes using the first sink filled with water and dish detergent to wash the items, the second sink is filled with warm…

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 residents who require extensive assist with activities of daily living received assistance with incontinence care and during meals/feeding. This applies to 9 of 32 residents (R118, R72, R124, R113, R89, R94, R107, R93, R3) reviewed for activities of daily living in the sample of 32. The findings include: 1. R118's face sheet shows she is a [AGE] year old female with diagnoses including weakness, irritable bowel syndrome, age-related osteoporosis, cellulitis of right lower limb and unsteadiness on feet. On 1/22/24 at 12:35 PM, V25 (Certified Nursing Assistant-CNA) delivered R118's noon meal. R118 was sitting up in her in her bed. A strong permeating smell of urine was present. At 12:41 PM this surveyor asked V25 if she smelled anything when she delivered the room tray. V25 said R118 smells like urine. The CNA assigned to this floor is busy with another resident. I'll let V31 (CNA) know she needs to be changed. At 1:06 AM, V31 (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 observation, interview, and record review the facility failed to provide activities and monitor behaviors for residents with a diagnosis of dementia. This applies to 6 of 8 residents (R15, R16, R48, R89, R90 & R135) reviewed for dementia care in the sample of 32. The findings include: 1. R90's face sheet shows she is a [AGE] year old woman with diagnoses to include: Alzheimer's disease, dementia and anxiety disorder. She is residing on a locked memory care unit within the facility. On January 22, 2024 at 10:13 AM, R90 was sitting in the dining room in a regular chair. R48 was sitting next to her in his wheelchair. They were talking to each other and she was fixing his shirt. At 1:16 PM, R90 was walking around the unit going in and out of other residents rooms. At 1:22 PM, she was still walking around the unit going into other residents rooms. V37 Registered Nurse (RN) and V39 Certified Nursing Assistant (CNA) were on the unit working with other residents and not paying attention to what R90 was doing.…

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 controlled substances were secured and reconciled, failed to ensure expired medications were disposed of, failed to ensure the medication refrigerator was in proper working condition with a thermometer inside, and failed to ensure the medication rooms were free from excessive discharged /discontinued resident medications. This failure has the potential to effect all 43 residents residing in the Transitional Care Units (TCU) of the facility. The findings include: The facility provided roster shows there was 43 residents on the TCU on 1/22/24. On 1/22/24 at 10:08 AM, the medication cart of the 4000 and 5000 wing of the TCU was checked with V43 (Licensed Practical Nurse). The cart contained the following medications that were expired Famotidine which expired in 10/23, Docusate Sodium which contained 1,000 tablets and was approximately ¾ full expired 9/23 and Sodium Bicarbonate which was also still ¾ full and expired 9/23. On 1/22/24 at 10:20 AM, The medication room of the 4000 and 5000 hallway had piles 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.

Based on observation, interview, and record review the facility failed to serve a single #6 scoop of pureed baked mostaccioli to residents receiving a pureed diet. This applies to 13 of 13 (R38, R60, R49, R101, R15, R66, R104, R138, R67, R92, R89, R23, and R61) residents reviewed for pureed diets in the sample of 32. The findings include: Facility provided sheet of residents on Pureed Diets shows R38, R60, R49, R101, R15, R66, R104, R138, R67, R92, R89, R23, and R61 receive a pureed diet. On 1/22/24 at 11:45 AM, V28 (Cook) started to plate the lunch meal which consisted of baked mostaccioli, Italian blend vegetables, and garlic bread. V28 placed a #8 scoop into the pureed baked mostaccioli, which provides 4 ounces (oz) in volume, in the puree entrée for service. This scoop was used from 11:45 AM until lunch was finished being served at 12:57 AM. Facility provided Diet Spreadsheet for Pureed diets shows the portion size to be used for the pureed baked mostaccioli is a #6 scoop, which provides 5.33 oz in volume. On 1/24/24 at 9:28 AM, V27 (Food Service Director) said if the correct…

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 who is positive for COVID-19 was isolated on droplet/contact precautions, failed to ensure staff wore the required PPE (Personal Protective Equipment) when entering a positive COVID-19 room, and failed to ensure staff changed their gloves during incontinence care in a manner to prevent cross contamination. This applies to 4 of 32 residents (R67, R142, R96, R9) reviewed for infection control in the sample of 32. The findings include: 1. R67's Physician Order Sheets (P.O.S.) dated January 2024 shows diagnoses including wernicke's encephalopathy, unspecified mental disorder, anxiety and COVID-19. The P.O.S. shows orders dated 1/16/24 strict one room droplet isolation with all serviced provided in room alone every shift for 10 days end date of 1/26/24. The nurses' note dated 1/16/24 documents (R67) tested positive for COVID-19. On 1/22/24 at 12:35 PM, R67 was observed out of his room without a mask, self propelling 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.

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 diet orders were followed and supervised as prescribed by the physician. This failure resulted in R106's diet orders not being followed by receiving bread and needing the Heimlich maneuver for choking on bread pudding. The facility also failed to ensure residents were supervised during meals who require close supervision. This applies to 2 of 32 residents (R106 & R17) reviewed for safety/supervision in the sample of 32. The findings include: 1.R106's face sheet shows she is a [AGE] year old female with diagnoses to include: Parkinson's disease, dementia and dysphagia (difficultly swallowing). R106's speech therapy evaluation and plan of treatment dated August 22, 2023 shows, Current referral: Reason for referral/current illness: Patient referred to speech therapy for clinical bedside swallow evaluation due to a choking incident at her daughter's home resulting in need for administration of Heimlich {SIC} maneuver 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 maintain a residents urinary drainage bag below the level of her bladder for one of four residents (R96) reviewed for catheters in the sample of 32. The findings include: R96's Order Summary Report dated January 22, 2024 shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, morbid obesity, contracture left ankle, left knee contracture, neuromuscular dysfunction of bladder, Parkinson's, and bipolar disorder. R96's Care Plan initiated 10/16/2020 shows, Resident is at risk for complications related to indwelling catheter due to urinary retention. Daily indwelling catheter care: Assure catheter and drainage bag are at below the level of the bladder. On 1/22/2024 at 10:01 AM, V3 CNA (Certified Nursing Assistant) prepared to provide incontinence care to R96. R96's urinary drainage bag was full of amber urine with sediment. There was dark amber urine with sediment in the tubing. V3 picked R96's urinary…

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 psychotropic medications ordered as needed (PRN) had a duration/end date. This applies to one of six residents (R11) reviewed for unnecessary medication in the sample of 32. The findings include: R11's Order Summary Report dated 1/22/2024 shows she was admitted to the facility on [DATE] with diagnoses including: anxiety disorder, morbid obesity, major depressive disorder, history of falling, and cognitive communication deficit. The Order Summary Report shows an order for lorazepam oral tablet 0.5 mg give one tablet by mouth every four hours as needed for anxiety. There is no stop date. On 1/24, 2024 at 10:03 AM, V8 RN (Registered Nurse) said psychotropic medications ordered as needed should have a stop date. The facility's Psychotropic Medications policy revised May 2023 shows, To ensure all state and federal regulations are followed regarding the administration and monitoring of psychotropic medications.

Based on observation, interview and record review the facility failed to ensure food was served at an appetizing temperature for 5 of 5 residents (R2-R4, R6 and R10) reviewed for cold food in the sample of 10. The findings include: On 12/23/23 at 9:30 AM, V6 (Certified Nursing Assistant/CNA) was picking up breakfast trays and putting them into a cart. There were no insulated covers seen in or on the cart or trays. V6 said that the breakfast trays that morning did not come with insulated covers on them. V6 said that it is hit or miss on the food trays being covered when they are delivered. V6 said that he does get a lot of cold food complaints. On 12/23/23 at 9:20 AM, V7 (CNA) said that the food sometimes has the insulated covers on them and sometimes does not. V7 said that she does have quite a few residents that complain about cold food. On 12/23/23, R2, R3, R4, R6 and R10 all said that the food is sometimes cold when it is served to them. On 12/23/23 at 1:36 PM, V17 (Dietary Aide) said that she does not have a reason why the breakfast trays were served without the insulated covers…

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 personal protective equipment (PPE) was properly worn to prevent the spread of COVID-19 for 1 of 4 residents (R8) reviewed for infection control in the sample of 10. The findings include: The facility provided list shows that R8 is on isolation due to being positive for COVID-19. R8's Physician's Order Sheet printed on 12/23/23 shows that he is on strict one room droplet isolation until 12/26/23. On 12/23/23 at 9:43 AM, V8 (Registered Nurse) went into R8's room to administer medications. V8 did not have eye protection on when she entered the room. V8 did not remove her N95 mask before exiting the room. At 9:56 AM, with the same N95 mask on, V8 entered R9's room (not on isolation) to administer medications. On 12/23/23 at 9:35 AM, V6 (Certified Nursing Assistant) entered R8's room to provide care. V6 placed an N95 mask over his surgical mask before entering the room. On 12/23/23 at 9:36 AM, V11 (Laboratory Technician) entered R8's room to perform a blood draw. V11 applied a surgical mask over his surgical…

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 staff donned (Personal Protective Equipment) PPE when entering a COVID positive resident's room, failed to ensure doors were kept closed and signage were posted on the type of isolation on COVID 19 positive residents room to 21 residents (R8-R28) reviewed for infection control in the sample of 28. The findings include: 1. R8's COVID 19 results dated 11/16/23 show R8 was COVID 19 positive with an order for droplet precautions. On 11/20/23 at 9:13 AM, this surveyor and V3 (Assistant Director Of Nursing-ADON ) were in wing 6000. V3 identified R8 who was in room [ROOM NUMBER] as a COVID 19 positive resident. V4 (Registered Nurse) entered R8's room wearing only a surgical mask. When V4 exited R8's room, V4 confirmed that R8 was COVID 19 positive. V4 said she should have donned N95 mask, face shield, gown and gloves. V3 ADON instructed V4 to wear N95 Mask, gown, gloves and faceshield and a when entering a COVID 19 positive resident who…

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's prescribed medications were administered as ordered. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 28. The findings include: R1's face sheet shows she is [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's, unsteadiness of feet, weakness and hyperlipidemia. R1's Minimum Data Set assessment dated [DATE] shows she's cognitively intact. On 11/20/23 at 11:20 AM, R1 said she received a bill for a medicated vaginal cream and did not receive the medication. R1 said there were other medications she did not receive as well. R1 said she was a nurse for over 30 years and knows what medications she received. R1's Medication Administration Record (MAR) or September 2023 shows orders for vaginal cream insert 1 gm (gram) at bedtime every Tuesday and Friday for hormone replacement. The Pharmacy Medication Packing Slip form dated 9/5/23 showed the vaginal cream…

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 that facility failed to ensure a resident with pain received pain medication in a timely manner for 1 of 3 residents (R1) reviewed for pain management in the sample of 3. The findings include: R1's Nursing Notes dated 9/26/23 at 4:42 PM shows, Resident was re-admitted for rehab (PT/OT) after a hospital stay .Abdominal wall fistula, diabetes and failure to thrive .Resident is alert and oriented to person and place, agitated, complaining of generalized pain, has norco 10-325 no script sent, waiting on signature . R1's Discharge Medication List from the local hospital shows to give norco (pain medication) 10-325 milligrams (mg) every 6 hours as needed for pain and the last time that she received it was at 1:22 PM. There was no order for Tylenol documented. R1's Tylenol order shows that it was ordered on 9/27/23 at 1:52 AM. R1's Medication Administration Record (MAR) shows an order for Norco 10-325 mg every 6 hours as needed for pain dated 9/26/23 at 3:58 PM. No doses were signed off as given on 9/26/23 or 9/27/23. R1's MAR shows that Tylenol 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.