Norridge Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal care to dependent residents. This applies to 2 of 4 residents (R2, R3) reviewed for activities of daily living care in a sample of 4. Findings Include: 1. R2 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE] and dependent on staff for personal hygiene. On 5/30/24 at 10:10 AM, R2 was observed with V10 (LPN-Licensed Pratical Nurse) in her room. R2 was noted with a strong urine odor. V10 (Licensed Practical Nurse/LPN) checked on R2, and R2 was observed to be dirty and soaked incontinent brief with urine and discoloration (blackish). On 5/30/24 at 10:10 AM, V10 stated, The CNAs are supposed to change residents every two hours. I don't think R2 was changed today, and I will check with my CNA (Certified Nursing Assistant) to change R2. A review of R2's care plan documents that R2's care is planned for the risk of impaired skin integrity, with interventions including…

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 urinary catheter insertion was completed to prevent potential cross contamination. This applies to 1 of 3 residents reviewed for urinary tract infection in a sample of 4. Findings include: R1 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. R1 was admitted with an admitting diagnosis, including spina bifida, chronic idiopathic constipation, bladder dysfunction, and a history of urinary tract infection (UTI). A review of R1's physician order sheet (POS) indicates that R1 has an order to perform a straight urinary catheterization every four hours. V4 (Nurse) was observed on 5/30/2024 at 2:35PM with V5 (CNA-Certified Nursing Assistant) performing a straight catheterization procedure on R1. V4 did not to clean the left and right labia area of R1. V4 was also observed holding the catheter and directing the urine into the collection chamber without using sterile gloves.…

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 Activities of Daily Living assistance was provided for three of three residents (R1, R2, R3) reviewed for requiring extensive assistance with Activities of Daily Living on the sample list of eight. Findings include: 1. R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, heart failure, dermatitis, and malnutrition. R1's MDS (Minimum Data Set) dated February 19, 2024 shows R1 is not cognitively intact, is dependent on staff for toileting hygiene and personal hygiene. R1 is always incontinent of bowel and bladder. R1's Care Plan initiated December 20, 2021 shows R1 requires total assist with personal hygiene and dressing. R1 has bowel and bladder incontinence and to check resident every two hours and assist with toileting as needed. On April 8, 2024 at 9:59 AM, R1 was still laying in bed. There was a notable odor outside of R1's room. At 10:28 AM, V3 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 ensure comfortable temperatures for 3 of 8 residents (R1, R2, and R3), a comfortable bed mattress for 1 of 8 residents (R1), and odorless air for all 93 residents third-floor residents. Findings include: On 03/14/2024, during the investigation, the writer entered the third floor via elevator five different times from 11:00 AM to 3:00 PM. The third-floor entrance from the elevator, dining room, and 300 wing had a strong urine odor. Though the facility's third-floor flooring, residents' rooms, and bathrooms were clean, the mentioned areas had a strong odor of urine. 1. R1's face sheet showed R1 was admitted to the facility on [DATE] with diagnoses including catatonic disorder, schizophrenia, depression, encephalopathy, and urinary retention with acute kidney failure. At 11:28 PM, R1 was in bed, withdrawn, staring at the writer, and did not respond to the writer's interview. R1's bed was sagging in the center, urine odor was present by his…

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

Based on observation, interview and record review, the facility failed to provide incontinent care and provide Activities of Daily Living care to residents. This applies to 8 of 8 residents (R3-R10) reviewed for incontinent care and Activity of Daily Living Care on the sample list of 10. Findings include: 1. On 2/28/24 at 10:57 AM, R3 was sitting up in bed in hospital gown watching TV. R3 said she wears an incontinent brief and needed to be changed. R3 said the last time she was changed was at 5:30 AM (over 5 hours earlier) this morning and she does not know which CNA (Certified Nurse Assistant) was assigned to her. At 10:59 AM, R3 pushed her call light and V5 (Restorative Aide) answered the call light at 11:02 AM. V5 said she does not know who R3's CNA (Certified Nurse Aide) was, but will inform her that R3 needed to be changed. At 11:06 AM, V6 (Restorative Aide) came in to change R3. During R3's incontinent care, it was observed that R3's incontinent brief was soaked with urine to the point the incontinent pad that R3 was laying on was also wet. R3's buttocks were noted with…

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

Based on observation, interview, and record review the facility failed to ensure food was prepared in a form to meet a residents needs which applies to 5 of 5 residents (R76, R84, R153, R213, R222) reviewed for puree diets in a sample of 35. Findings include: The facility's weekly dietary menu showed the noon meal to be a chicken soft taco, Spanish rice, seasoned corn, and fruit mix on 11/28/23. On 11/28/23 at 10:00 AM, V32 [NAME] stated puree foods should have a smooth consistency like pudding. During the puree prepping, V30 Dietary Manager stated the food processor they have does run at a slower speed so it does take a while to puree the foods. After the puree foods were prepared V32 and V28 Assistant [NAME] did not sample the food items prior to packaging it for serving. On 11/28/23 12:31 PM, A test tray was sampled for the pureed food. The puree chicken was gritty with particulates in it. The puree corn still had parts of the corn kernal shells in it. On 11/28/23 at 1:00 PM, V30 Dietary Manager tried the pureed food, and said the chicken needed to be blended more, and the corn…

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

Based on observation, interview, and record review the facility failed to ensure the food service areas were sanitized prior to serving food. This failure affects 5 of 5 residents (R84, R124, R153, R213, R380) reviewed for food service in a sample of 35. Findings include: On 11/28/23 at 11:50 AM, V29 Dietary Aide opened the 3rd floor kitchenette where the steam tables are kept for meal serving. There were seven dirty meal trays in the kitchenette. The trays had used, dirty plates, cups, silverware, and paper garbage on them. V29 stated they had no idea why the trays were there. V29 removed the trays from the kitchenette, set up the steam tables, and started serving the noon meal without sanitizing the food serving area. On 11/28/23 at 1:00 PM, V30 Dietary Manager stated the dirty trays should not be stored/left in the kitchenette. They are supposed to be put on the dirty tray carts and brought down stairs to the dishwasher area. The dirty trays could cause cross contamination. The food serving areas should be kept clean. The facilities Kitchen Sanitation Policy dated 12/2015 showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff donned and doffed Personal Protective Equipment PPE when entering and leaving rooms with residents who were on isolation due to testing positive for the COVID-19 virus. The facility also failed to ensure doors were kept closed for rooms with COVID-19 positive residents, failed to ensure a COVID-19 positive residents remained isolated in their rooms. The facility also failed to implement enhance barrier precautions. These failures affect 16 of 35 residents (R129, R48, R73, R89, R18, R5, R139, R62, R79, R173, R159, R58, R6, R43, R134 and R100) reviewed for infection control in the sample of 35. Findings include: 1. On 11/27/23 at 9:50 AM, R129, R48, R73's room had a sign on the doorway of droplet contact isolation precaution. V4 (Infection Control Nurse-IP) said the facility was in a COVID-19 outbreak and R129, R48 and R73 were all COVID-19 positive residents that were on isolation. V7 (License Practical Nurse-LPN) entered 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 residents who require extensive assist received assistance with incontinence care and toileting. This applies to 3 of 25 (R124, R41, R76) residents reviewed for activities of daily living in the sample of 35. Findings include: 1. On 11/27/23 at 9:49 AM, R124 was observed lying in bed, a strong foul smelling odor was present. V15 (Certified Nursing Assistant-CNA) provided incontinence care to R124. R124's disposable incontinence brief was heavily saturated with urine and stool. Large amounts of stool soaked through her incontinence pad. R124's buttocks were covered with stool and stool was down her right leg. V15 (CNA) said the facility is short staffed today. She did not have time to change R124 until now and R124 still needs to eat breakfast. It's hard to have this many residents. R124's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, requires extensive assist with toileting and frequently…

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 dressings and pressure relieving interventions were in place for residents with pressure injuries and at risk for pressure injuries. This applies to 3 of 8 (R3, R213, R84) reviewed for pressure in the sample of 35. Findings include: 1. On 11/27/2023 at 9:59 AM, R3 said she did not have a dressing in place on her right side. R3 said she hasn't had a dressing in place for a couple of days. On 11/27/2023 at 10:30 AM, V5 Wound Nurse and V31 Wound Nurse were observed providing wound care to R3. No dressing was observed on R3's pressure injury on her right gluteal fold when R3 was checked by V5 and V31. V31 measured the area and stated it was 8cm (centimeters) x 6cm. V5 said a dressing should be in place. V5 said the order for dressing changes was every 3 days and as needed when soiled or loose. R3's 11/27/2023 Progress Note shows R3 had a deep tissue pressure injury to the right gluteal fold with no signs and symptoms of infection. R3's Order Summary Report Dated 11/28/2023 shows an order for 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 Based on observation, interview and record review the facility failed to safely transfer residents. The facility also failed to supervise a resident who is at a high risk for falls and has history of falls for 3 of 35 residents (R76, R68, R41) reviewed for safety and supervision in the sample of 35. Findings include: 1. R76's electronic medical record accessed on 11/28/23 show R3 has diagnosis of dementia and in need of 2 plus staff for transfer. On 11/27/23 at 12:25 PM, V5 (Wound Nurse) and V6(Certified Nursing Assistant-CNA) were transferring R76 from his wheelchair to bed. V5 (Wound Nurse) applied a gait belt to R76 while V6 (CNA) held onto R76 who was unable to sit up in his wheelchair. R76 was leaning back. During the transfer, R76 was unable to bear weight. R76 was lifted under his arms and transferred to bed. When R76 was being transferred back to his wheelchair, R76 was unable to hold himself up and again kept leaning back. V5 held R76's back for R76 to sit upright. A gait belt was again applied. V5 and…

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

Based on observation, interview, and record review the facility failed to ensure a residents urinary catheter tubing and drainage bag was below the level of the bladder for 1 of 8 residents (R380) reviewed for urinary catheter care in the sample of 35. Findings include: R380's Face sheet shows R380 has diagnoses of hyrdonephrosis with ureteropelvic junction obstruction and retention of urine. R380's Care Plan shows R380 has a history of urinary tract infections requiring antibiotic treatment. On 11/27/23 at 10:16 AM, R380 was in bed leaning on her left side. R380's urinary catheter tubing was coming from R380's urethra and draped over R380's upper right leg close to her hip. There was yellow urine in the tubing that was unable to drain into the drainage bag. R380 said she had just returned from the hospital and had problems with the shunt in her kidneys and they put the urinary catheter in. On 11/28/23 at 9:12 AM., R380 was in bed with the urinary catheter drainage bag hanging on bed rail even with mattress. There was yellow urine in tubing all the way to R380's urethra. The tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility to ensure a resident with a diagnosis of dementia that is exhibiting behaviors,, was provided necessary care and services. This applies to 1 of 10 residents (R68) reviewed for dementia care in the sample of 35. Findings include: 1. R68's face sheet shows she is a [AGE] year old female with diagnoses including unspecified dementia with other behavioral disturbance, frontal lobe and executive function deficit following cerebral infarct, bipolar disorder and repeated falls. R68's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, has little interest or pleasure in doing things, trouble concentrating on things, being so fidgety or restless that have been moving around a lot more than usual, being short tempered, easily annoyed, has behaviors of hallucinations, delusion, physical, verbal and other behavioral symptoms not directed towards others, and wandering behaviors daily. On 11/27/23 at 10:51 AM, R68 was observed in the…

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

Based on observation, interview, and record review the facility failed to ensure a resident's narcotic controlled substance record for was in place for 1 of 1 residents (R213) reviewed for controlled substance medications in the sample of 35. Findings include: On 11/28/23 at 09:31 AM, V11 Registered Nurse was reviewing controlled substance medications in the medication cart with this surveyor. R213 had an opened bottle of liquid morphine (narcotic pain reliever) with approximately 25 ml (milliliters) left. There was no controlled substance proof of sheet/form for R213's morphine. V11 stated there is no sheet for this. There should be a sheet to sign off when the medication is given. R213 had a dose once and he did not like it so we don't give it to him. V11 said she did not reconcile/count R213's morphine with the night nurse at shift change. On 11/29/23 at 9:59 AM, V10 RN stated liquid morphine should have a medication reconciliation sheet to sign off when a dose is given and to verify that what's left in bottle matches the amount given. All narcotics are checked shift to shift…

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 medication regimen reviews (MRRs) were being completed and documented on a monthly basis. The facility also failed to ensure those recommendations were being followed up on by a physician. This applies to 2 of 5 (R3, R50) reviewed for MRRs in the sample of 35. Findings include: On 11/29/2023 MRRs for the last 6 months was requested for R3 and R50 from V1 Administrator. 1. On 11/29/2023 at 1:15PM, V2 Director of Nursing (DON) attempted to pull up MRR records for R3 for the last 6 months in the computer charting under progress notes and was unsuccessful. V2 said the pharmacist was going to send the records for [R3]. The facility failed to provide copies of monthly medication reviews from individual months for R3. On 11/29/2023 at 12:22PM, V25 Pharmacist said the MRRs are completed monthly and should be visible in the computer charting system under progress notes under pharmacy. V25 said he is unsure why they wouldn't be showing up in the computer charting system. R3's MRRs provided were all dated 11/29/2023. 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 failed to implement a pharmacy recommendation of a gradual dose reduction (GDR) for a resident who is receiving a antipsychotic medication. This applies to 1 of 5 residents (R185) reviewed for unnecessary medications in the sample of 35. Findings include: 1. R185's Physician Order Sheets (POS) shows he has diagnoses including unspecified psychosis, unspecified dementia, unspecified severity with other behavioral disturbance and generalized anxiety. The POS shows orders dated 8/3/2023 for Olanzapine (anti-psychotic) 15 mg (milligram) at bedtime for psychotic behavior. The Pharmacy Medication Report dated 11/21/23 shows R185 is due for a GDR and recommends to decrease Olanzapine 15 mg at bed time to Olanzapine 12.5 mg at bedtime. The form is not completed or signed by the physician regarding the recommendation. On 11/29/23 at 1:26 PM, V13 (ADON) said pharmacy sends the recommendation and we fax the form to the physician to review and sign. V13 confirmed R185's GDR was not sent over to the physician until today (11/29/23.) The facility did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure insulin administration pens were labeled with an opened date and failed to dispose of expired insulin for 2 of 8 residents (R160, R181) reviewed for medication storage in the sample of 35. Findings include: On [DATE] at 09:31 AM, the 3rd floor medication cart 2 contained R160's lantus insulin pen that was opened and not labeled with an open date or an expiration date. The same cart contained R160's insulin aspart solution bottle that was dated as opened on [DATE], which expired [DATE] and R181's levemir insulin solution bottle with an open date of [DATE] and an expired date of [DATE]. V11 Registered Nurse (RN) said R181's levemir and R160's insulin aspart are expired and should have been thrown out. V11 said R160's lantus insulin solution pen should be dated with the date is was opened. V11 said insulin is good for 28 days once opened. R160's Medication Administration Record (MAR) for [DATE] shows an order for lantus 30 units…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have adequate staff to provide assistant with activities of daily living in a timely manner. This failure has the potential to affect all 248 residents residing in the facility. The Findings include: The facility census sheet dated 10/17/2023 documents 248 residents reside in the facility. On 10/17/23 at 11:25 AM, V14 (Registered Nurse / RN) stated, We have four nurses and six CNAs working on the floor for a census of 101 residents on the fourth floor. Most of the time, we are short of staff. On 10/18/23 at 3:10 PM, V14 added, You come to the weekend to see the accurate staffing picture. We are really short on weekends. On 10/19/23 at 10:20 AM, V12 (Staffing Coordinator) stated, We have low staffing on weekends due to many call-offs and agency staff didn't show up. We tried to replace the call-off staff with restorative aides, but we are short sometimes on weekends. Last Tuesday (10/17/23), I had four CNAs on the third floor, six on 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 follow the menu items as planned. This failure has the potential to affect all 235 residents consuming food from the kitchen. The Findings include: On 10/19/23 at 1:00 PM, V3 (Director of Nursing) stated, We have 235 residents eating from the Kitchen. Record review on lunch menu dated 10/19/23 document Shepherd's Pie for resident lunch. On 10/19/23 at 11:55 AM, the kitchen tray line contained baked ham that was being served to the residents instead of shepherd's pie as per the menu. On 10/19/23 at 12:00 PM, V16 (Cook) stated, We didn't receive the shipment for [NAME] Pie to serve for resident today (Thursday). We are serving baked ham and au gratin potatoes today instead of [NAME] Pie. On 10/19/23 at 12:15 PM, V17 (Dietary Manager) stated, We are planning menus four weeks ahead and should be followed. The order for ground beef to make Shepherd's Pie was placed for Monday (10/16/23) delivery, and somehow, we didn't receive that. If we put…

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 serve hot food to residents at a palatable temperature. This failure has the potential to affect all 235 residents consuming food from the kitchen. The Findings include: On 10/19/23 at 1:00 PM, V3 (Director of Nursing) stated, We have 235 residents eating from the Kitchen. On 10/19/23 at 11:50 AM, the lunch meal tray line was observed, and a test tray was requested. The test tray was the last tray loaded into the food cart to the last serving unit (Third floor). On 10/19/23 at 12:59 PM, V16 (Cook) checked the food temperature from the test tray (on the Third floor) using the facility thermometer. The temperatures were as follows: Au gratin potatoes - 136.2 F Steamed broccoli - 108 F Baked ham - 95F On 10/19/23 at 12:59 PM, V16 stated, The serving temperature for hot food should be a minimum of 135F. We may have to use ceramic food warmer instead of plastic to maintain the food temperature during delivery. R2 is a [AGE] year-old female…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal care to residents requiring assistance with ADL (Activities of Daily Living) needs. This applies to 6 of 9 residents (R4-R9) reviewed for activities of daily living (ADL) from a sample of 9. The Findings include: 1. R4 is an [AGE] year-old female with mild cognitive impairment as per MDS (Minimum Data Set) dated 7/24/23. The MDS also document two-person total dependance with toilet use. On 10/17/23 at 11:00 AM, R4 was in her bed with a urine odor. R4 stated, They haven't changed me yet, and I think I am wet. They changed me last night, and nobody changed me after that. On 10/17/23 at 11:07 AM, V5 (Certified Nursing Assistant / CNA) and V6 (Licensed Practical Nurse / LPN) checked R4 for incontinence. R4 was observed with a double incontinent brief with an inner one with blackish discoloration. Record review on R4's care plan documented that R4 was care planned to prevent UTI with interventions including Checking at least…

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 adequate staffing in order to: answer call lights timely, provide incontinent care, and provide showers/bed baths. This failure has the potential to affect all 245 residents who reside in the facility. The findings include: On 9/30/23 at 10:31 AM, V2 (DON-Director of Nursing) stated, We are okay with staffing. Some days we are short. We are using 2 agencies. We are especially short on the weekends. We ask staff to stay over. We do have call offs and no show no calls. On the 2nd floor, in the morning shift (7am to 3pm), there should be 3 nurses in the morning and 3 nurses in the evening (3pm to 11pm). In the overnight shift (11pm to 7am), there should be 2 nurses. In the morning, there should be 4 CNA's (Certified Nursing Assistants) in the morning and evening. In the night shift, there should be 3 CNA's. On the 3rd floor, there should be 4 nurses in the morning and 4 nurses in the evening. In the night shift, there should be 2 nurses. In the morning and evening, there should be 6 to 7 CNA's. On 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 assist residents identified as needing assistance with incontinence care and toileting, and showers/bed baths. These failures affect 4 of 6 residents (R1, R2, R5, R8) reviewed for Activities of Daily Living in the sample of 8. The findings include: 1. On 9/30/23 at 9:37 AM, V3 and V8 (LPN-Licensed Practical Nurse) went to R2's room. R2 was sleeping in bed. She was wearing a gown and her hair was greasy and not combed. Both V3 and V8 checked (R2)'s brief and she was wet. R2 stated, I think the last time they changed me was at 4 AM. It was still dark outside. Since then, they didn't check me. I fell asleep. They don't check on me every 2 hours. It's like this all the time, I'm always soaked, and they never check on me. Even when I press my call light, I have to wait 8 or 9 hours to be changed. There's not enough staff here, especially on the weekends. It's like there's only one nurse and one CNA for 50 residents, especially on the evening…

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 sufficient nursing staff to provide care and services for all residents in the facility. The findings include: The CMS 672 Resident census and conditions of residents report dated 1/25/23 shows the facility has 239 residents. The report shows 191 residents are occasionally or frequently incontinent of bladder and 150 are incontinent of bowel. The report also shows the facility has 19 facility acquired pressure injuries. The CMS staffing data report for the 3rd quarter of 2022 documents the facility triggered for excessively low weekend staffing. On 1/26/23 at 8:07 AM, V38 (Ward Clerk/Scheduler) said normally there are 4 aides on 2nd floor, and 6 for both the 3rd and 4th floors, that is minimal staffing. V38 said on the weekends she tries to over staff, but there are call offs. The 2nd floor has less residents, so an aide is moved to cover another floor with more residents. Currently the facility uses only one agency to fill the shortage of staff. V38 said there are a lot of call offs on the weekends, which…

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 an Infection Preventionist who completed the specialized training in Infection Prevention and Control. This has the potential to affect all of the residents in the facility. The findings include: The Resident Census and Conditions of Residents form (form CMS-672) dated 1/25/23, showed 239 residents resided in the facility. On 1/24/23 at 9:56 AM, V2 (Assistant Administrator) identified V4 as the facility's Infection Preventionist. V2 said V4 was on vacation and would return on 1/25/23 or 1/26/23. On 1/25/23 the document titled Resident Vaccination Status as of 1/18/23 was reviewed. The document had 74 residents that had no record of having a COVID-19 vaccine. On 1/26/23 at 9:45 AM, V4 (Infection Preventionist) said she just started working for the facility 2 months ago. V4 said she received no training for the job, adding I have had no guidance or direction on what I am supposed to do. V4 said Today is my last day at the facility. I gave them at least a 2 week notice, and they do not have anyone hired yet…

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 obtain vaccination status for residents. This has the potential to affect all of the residents in the facility. The findings include: The Resident Census and Conditions of Residents form (form CMS-672) dated 1/25/23, showed 239 residents resided in the facility. On 1/24/23, the facility provided a list titled Resident Vaccination Status (as of 1/18/23). The list showed 74 residents that had no record of vaccination status in their medical record. The list showed 7 residents showing only dose one in their medical record and 41 residents with no information regarding boosters in their medical record. The NHSN (National Health Safety Network) website data for the facility, for the week ending 1/8/23, showed the residents with their primary vaccination was 84%. On 1/26/23 at 9:45 AM, V4 (Infection Preventionist) said on 1/17/23 she swept all of the residents' charts for vaccination status. V4 said all of the residents that show no record on the list that was provided do not have any information regarding their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents, who are dependent on staff, received assistance with basic ADLs (Activities of Daily Living), such as feeding, toileting, oral hygiene and changing of adult garments in a timely manner. This applies to 5 of 8 resident (R345, R343, R45, R85 and R220) in the sample of 35. The finding include: 1. R345's Face Sheet shows his admission date was on 1/18/23, and his diagnoses include cerebral palsy, pressure ulcer (admitted with), Parkinson's disease, and a need for assistance with personal care. On 01/25/23 at 1:02 PM, R345's breakfast tray was placed on a dresser beyond R345's ability to reach (R345's lunch tray had not yet arrived). R345's breakfast tray was untouched, including his liquids. R345 was alert and made eye contact with this surveyor and gestured to his tray, then to his mouth. When this surveyor pointed to his tray, R345 nodded his head 'yes.' R345 indicated he did not speak English. On 1/25/23 at 1:30 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, failed to ensure residents' air mattresses were inflated according to their weight; failed to ensure residents' pressure relieving interventions were implemented; and failed to identify a resident at risk for pressure injury for 6 of 15 residents (R124, R220, R224, R45, R26, R68) in the sample of 35. The findings include: 1. R124's face sheet showed a [AGE] year-old male with diagnoses including sepsis, malignant neoplasm of anus and rectum, severe protein calorie malnutrition, gastrostomy, colostomy and human immunodeficiency virus (HIV). On 01/24/23 at 01:29 PM, R124 said, The state lady said I should have an air mattress on my bed. I wish I did. I can't lay on my back because it's too painful. I've had buttock wound for about two years from the cancer. On 01/26/23 at 09:26 AM, V3 (Director of Nursing/DON) said, Residents should be checked and changed every hour. We do rounds to check on them. It's important to do this to ensure they're clean, dry, reposition…

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 received their range of motion programs for 1 of 1 resident (R43) reviewed for range of motion in the sample of 35, and for 3 residents (R59, R55 and R90) outside of the sample. The findings include: 1. R43's admission Record, printed by the facility on 1/26/23, showed he had diagnoses including cerebral palsy and age-related osteoporosis. R43's facility assessment dated [DATE] showed he was cognitively intact. The assessment showed he was dependent on staff for transfers and bathing. The assessment showed R43 required extensive assist of staff for dressing, toileting and personal hygiene. R43's care plan titled Restorative: AROM (Active Range of Motion) Program showed he requires AROM to all of his extremities daily related to decreased mobility, decreased muscle strength and endurance. R43's restorative program documents, provided by V22 (Restorative Nurse) on 1/26/23, showed he was at risk for impaired range of motion…

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 bedtime snacks were distributed to 4 of 4 residents (R220, R343, R350, and R228) reviewed for bedtime snacks in a sample of 35. The findings include: The facility's Resident Census and Conditions of Residents (Form CMS-672), dated 1/25/23, documents there are 239 residents residing in the facility. 1. On 1/25/23 at 2:20 PM, R220 was alert and oriented to person and place. R220 said she has never been offered a snack in the evening. R220's Face Sheet shows her diagnoses to include fracture of the right pelvis, femur, and sacrum. 2. On 1/25/23 at 2:25 PM, R343 was alert and oriented to person, place and time. R343 said he has never been offered a snack in the evening. On 1/26/23 at 9:03 AM, R343 said he was not offered a nighttime snack last night. R343's shows, his diagnoses to include Type 2 diabetes mellitus. 3. On 1/26/23 9:01 AM, R350 was alert and oriented to person, and time. R350 said she has never been offered a nighttime snack. R350 said she asked for a milk the evening of 1/25/23 and was told…

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 incontinence care in a dignified manner for 2 of 2 residents (R139, R65) reviewed for dignity in the sample of 35. The findings include: 1. On 1/25/23 at 10:40 AM, V21 (Agency Certified Nursing Assistant/CNA) was providing incontinence care to R139. R139 was on her back with her vaginal and rectal areas exposed. R71 (R139's roommate) was sitting in her wheelchair at the foot of the bed watching R139's care. V21 did not intervene. R71 watched the remainder of the incontinence care from the foot of R139's bed. R139's Face Sheet printed 1/25/23 showed diagnoses to include, but not limited to: chronic non-pressure ulcer to the right foot, diabetes, contractures of bilateral lower extremities, COPD (Chronic Obstructive Pulmonary Disease), Stage 3 CKD (Chronic Kidney Disease), dementia, depression, and personal history of strokes. On 1/26/23 at 9:31 AM, V3 (Director of Nursing/DON) stated, Residents are supposed to be provided privacy…

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 there were no discrepancies with resident advanced directives for 3 of 3 residents (R193, R439, R177) reviewed for Advanced Directives in the sample of 35. The findings include: 1. R193's face sheet showed a [AGE] year-old female with admitted to the facility on [DATE]. R193's diagnoses included hemiplegia and hemiparesis following cerebral infarction, gastrostomy, and seizures. On [DATE] at 9:50 AM, R193 was in her room and in bed. R193 was alert and oriented to person, place, time, and situation. On [DATE] at 09:26 AM, V3 (Director of Nursing/DON) said, There shouldn't be a discrepancy between a resident's POLST (Physician Order for Life Sustaining Treatment) and other information in the medical record. The POLST is a legal document, and we need to honor the resident's wishes. There shouldn't be any discrepancies. The correct information should be readily available in the resident's record. R193's medical record showed a [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to supervise residents with swallow precautions while eating for 2 of 6 residents (R3, R95) reviewed for safety in the sample of 35. The findings include: 1. R3's face sheet dated 1/25/23 showed diagnoses including but not limited to schizophrenia, depression, anxiety, and dementia. R3's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance of one person for eating. R3's physician orders showed an order start dated 7/17/22 for Mechanical soft texture diet. On 1/24/23 at 11:00 AM, R3 was in bed and her breakfast tray was still in front of her on the bedside table. R3 stated she eats her meals alone in her room. R3's diet ticket showed Aspiration Precautions/Mechanical Soft. The ticket listed interventions of tray set up, cut up solids, fully upright, slow rate, and small bites/sips. On 1/26/23 at 9:50 AM, V27 (Speech Therapist) stated she (R3) needs a mechanical soft texture diet to prevent aspiration. V27…

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 midline intravenous dressing was changed for 1 of 3 residents (R177) reviewed for intravenous fluids and dressings in the sample of 35. The findings include: On 1/24/23 at 10:15 AM, R177 was observed lying in bed wearing a hospital gown. She had IV (Intravenous) access to the right antecubital area. The IV site had a small circular pad at the entry point of the catheter, and a clear dressing over the site. The clear dressing was coming off at the edges and rolled up at the corners. The dressing was only covering half of the IV site, and the dressing was not dated. On 1/24/23 at 10:18 AM, R177 said she has had antibiotics through the IV but not for a while. She said the nurses have not done anything with it, such as change the dressing or flush the line. R177's progress notes show on 12/14/22 a midline single catheter was placed to the right brachial vein. The December 2022 nursing progress notes show R177 was receiving IV antibiotics for an upper respiratory infection. R177's December 2022 and January…

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

Based on observation, interview, and record review the facility failed to ensure medications were administered in a manner to meet professional standards for 1 of 5 residents (R112) reviewed during medication administration. The findings include: On 1/25/23 at 8:54 AM, V10 (Licensed Practical Nurse/LPN) began preparing R112's medications at the medication cart in the hallway. V10 had 10 pills in a medication up and one liquid medication prepared. V10 stated, I need to check his vital signs before I give the metoprolol (heart medication). V10 turned her back to the medication cart (leaving the pills and liquid medication) and walking into R112's room. R112 was located in the bed farthest from the door and his privacy curtain was pulled. V10 positioned herself near R112's bed so her back was to the privacy curtain and doorway. R112's medications were not under direct visualization while she checked R112's vital signs. R112's Face Sheet dated 1/25/23 showed diagnoses to include, but not limited to pneumonia, thrombocytosis, acute posthemorrhagic anemia, gastrointestinal bleed, CHF…

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 have a system in place to offer, track, monitor, record and re-offer immunizations for influenza and pneumonia for 3 (R220, R22, R99) of 5 residents reviewed for immunizations in the sample of 35. The findings include: 1. R220's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included COVID-19, malignant neoplasm of the left breast, need for assistance with personal care, malignant neoplasm of the bone, erosive osteoarthritis, fracture of the sacrum, pathological fractures of the right femur and pelvis. On 1/26/23 at 12:07 PM, V4 (facility identified Infection Preventionist) said R220 was not offered the pneumonia vaccine that she was aware of. V4 said there were no immunization refusals documented and she does not know if R220 was offered the influenza vaccine this season. V4 said there was no pneumonia vaccine history documented for R220 and it was not offered that she knew of. V4 said, If residents aren't…

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.