Bria Of Westmont

Based on observation, interview and record review, the facility failed to serve palatable coffee during meals. This applies to 9 of 9 residents (R2, R4, R6, R10, R13, and R28) reviewed for coffee in a sample of 29. The findings include: On 12/3/25 at 2:20 PM, R4 and R28 both stated the coffee served at the facility was horrible and looked and tasted like brown water. There was a disposable cup on R4's dresser with translucent, light brown water in the cup. R4 and R28 both stated the liquid was served that morning at breakfast as the facility coffee. Concern form, dated 12/3/25, shows R4 and R28 reported the coffee was not prepared properly. The form shows V1 (Administrator) met with V28 (Food Service Manager) to review the preparation process, the coffee was observed at dinner on 12/3/25, and a food committee was held on 12/4/25. The form also shows dietary staff were retrained on proper preparation of coffee. On 12/6/25 at 8:29 AM with V8 (Licensed Practical Nurse) during breakfast service, coffee being served to residents at breakfast from the coffee cart was sampled. V8 looked at…

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 provide certification for the acting Dietary Manager.This applies to all 177 residents receiving dietary services.Findings include:On 11/21/2025 at 12:12 PM, V1 Administrator confirmed 177 residents were receiving dietary service on the survey start date of 11/18/25.On 11/20/2025 at 3:14 PM, V32 Dietary Manager stated he could not find his certification for Food Service Manager certification. V32 stated he must retake the class.On 11/20/2025 at 3:14 PM, V33 Regional Dietary Director stated they are under a new company and the previous company took V32 certificate during the company changeover.V32 provided a Food Handler certificate dated 8/15/2024 valid through 8/15/27.The facility did not have a policy regarding the certification of dietary staff.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 177 residents receiving dietary services.Findings include:On 11/21/2025 at 12:12 PM, V1 Administrator confirmed 177 residents were receiving dietary service on the survey start date of 11/18/25.On 11/18/2025 at 10:10 AM, the kitchen tour was conducted with V32 Dietary Manager and V33 Regional Dietary Director.The high temperature dishwasher was run. The testing strip used was labeled to indicated when 160-degree Fahrenheit was attained. The rinse gauge temperature reached 172-degree Fahrenheit.The walk-in cooler contained:Ham in plastic wrap dated 11/10.A box 31.75 lb. (pound) of raw chicken parts stored over three 5lb bags of scrambled egg product.A sliver facility pan with 11 cooked hamburger patties with an expiration date of 11/17.A 10lb box of wilted wrinkled jalapenos with black spotsA box with 14 rotten limes.The dry storage contained:A dented 6lb 12 oz. (ounce) can of kidney beansA dented 6lb 10oz. can of diced…

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 interventions in place to prevent a resident from falling from bed. The facility also failed to store all smoking materials and failed to provide supervision to monitor residents for safe smoking. This affects 5 of 5 (R4, R53, R66, R106, R163) residents reviewed for falls and smoking in a sample of 36. The findings include: 1.On 11/20/2025 at 10:43 AM, R4 stated he had fallen out of the bed when he rolled himself over to his right side. R4 stated when he rolled there was nothing in place to keep him from rolling off right side of the bed. R4 stated he had been asking for a rail on the right side of his bed for a while, but none had been provided. On 11/20/2025 at 10:43 AM, V34 CNA (Certified Nursing Assistant) stated she was working the day R4 fell off the bed. V34 stated R4 fell face down on to the floor on the right side of the bed. V34 stated R4 had a right leg amputation prior to his fall. R4 only had a short rail on the left side…

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 contain and secure resident medications. This applies to 4 of 4 residents (R1, R65, R84, R183) reviewed for medications in a sample of 36. The findings include: 1 1. On 11/18/2025 at 10:50 AM, R84 was not in the room. R84 had a medication cup on the bedside table that contained a white pill and a tan pill. R84's admission Record showed R84 was admitted to the facility on [DATE]. R84 had multiple diagnoses which included Wernicke's Encephalopathy, alcohol abuse, benign prostatic hyperplasia, and weakness. R84's MDS (Minimum Data Set) dated 10/07/25 showed R84 had moderate cognitive impairment. R84's EMR (Electronic Medical Record) showed no orders for medications to be left at the bedside. 2. On 11/18/25 at 2:28 PM, inside R65's drawer there was an Icy Hot original no-mess roll and Visine eye drops. On 11/20/25 at 1:50 PM, R65 stated the medications are always kept in her room because she doesn't want to bother the nurse each time her eyes…

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 place call lights within reach. This applies to 1 of 1 resident (R31) reviewed for call lights in a sample of 36.The findings include:On November 18, 2025 at 11:33 AM, R31 was lying in bed and said the left side of her body was paralyzed. R31's call light was on the floor on the left side out of her reach. R31 said if she could not reach the call light, she would have to yell out for the CNAs (Certified Nurse Assistant) to get help. R31 said she had asked for the staff to put a clip on the call light so that it could be attached to her sheet. On November 19, 2025 at 8:40 AM, R31 was lying in bed, and her call light and bed remote were on the floor next to the left side of the bed. On November 19, 2025 at 2:57 PM, the call light was on the floor after R31 was provided incontinence care. On November 19, 2025 at 3:45 PM, R31 was heard yelling from her room, CNA? CNA? Upon entering the room, R31 was lying in bed, and the call light and bed remote were on the floor out of reach. R31 said she could not reach 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 provide ADL (Activities of Daily Living) care to residents who were dependent on staff for care. This applies to 2 of 2 residents (R31, R11) reviewed for ADLs in a sample of 36.The findings include: 1. On November 18, 2025 at 11:33 AM, R31 said the staff do not cut her nails and she did not receive shower. R31's hair was greasy, and her nails were 0.5 to 0.75 inches long. R31 said she wanted her nails cut short and really wanted a shower. R31's left hand was contracted, and her nails were long. R31 said the staff were supposed to get her dressed and in her chair for breakfast, which they never did. R31 said she was supposed to be in the dining room. R31 said she did not remember the last time she was taken out of bed. R31 said she had requested to be ready to go to mass on Sundays, but they do not get her ready in time to go. On November 19, 2025 at 8:40 AM, R31 was lying in bed and said she did not get a shower yesterday, and her shower days were Tuesdays and Fridays. R31's nails were still long and her hair…

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

Based on observation, interview, and record review, the facility failed to provide splints as ordered.This applies to 2 of 5 residents (R31, R180) reviewed for splints in a sample of 36. The findings include: 1. 1. On 11/18/25 at 11:27 AM, R180 was lying in bed. He was nonverbal. His right hand was severely contracted. There was no splint or restorative device to his right hand. On 11/19/25 at 10:31 AM, R180 was lying in bed. R180 had no palm protector to his right hand. On 11/20/2025 at 11:37 AM, V10 (LPN—Licensed Practical/ Restorative Nurse) stated that restorative aides and CNA's (Certified Nursing Assistants) are supposed to put the splints on resident to prevent contractures and manage range of motion. R180's face sheet shows diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, contracture, right shoulder. Contracture of right elbow, right wrist, and right hand, and abnormal posture. R180's November POS (Physician Order Sheet) shows an order dated 11/6/25 to apply right hand palm protector…

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 residents received the physician-ordered amount of tube feeding to prevent weight loss, and failed to ensure a resident's weight loss was identified in a timely manner. This applies to 2 of 2 residents (R19, R31) reviewed for nutrition in a sample of 36.The findings include: 1. R19's POS (Physician Order Sheet) dated November 21, 2025 showed an order for Enteral Feed Order one time a day Enteral Feeding Formula Glucerna 1.2 Rate 75ml/[hour] x 18 [hour] total volume 1350ml starting on November 11, 2025 at 5 PM (which would have it turned off at 11 AM to equal the 18 hours on). On November 18, 2025 at 10:45 AM, R19 was not hooked up to a G-Tube (Gastrostomy) feed and there was a full bottle of tube feeding on the bedside table. R19 appeared thin. On November 19, 2025 at 10:31 AM, R19's feed was paused as she received patient care. At 10:39 AM, V3 (DON/Director of Nursing) came to R19's room to provide wound care and checked how much of the feed was infused, which showed 118 mL (Milliliters). V3…

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 verify gastrostomy tube (G-tube) placement before administering medications and to date/label open gastrostomy tube feedings. This applies to 3 of 3 residents (R148, R180, and R196) reviewed for tube feeding management in the sample of 36. The findings include: 1. On 11/19/2025 at 9:07 AM, V8 (RN/Registered Nurse) placed a stethoscope on R196's abdomen before administering a water flush and medications. V8 did not inject air into the tube and auscultate the abdomen with the stethoscope prior to the initial water flush and medication administration to verify tube placement. V8 also did not aspirate gastric secretions prior to the initial water flush and medication administration to verify tube placement. V8 administered an aspirin, multivitamin, and stool softener via gastrostomy tube. On 11/19/2025 at 9:12 AM, V8 stated tube placement must be verified before administering medications and water flushes. V8 stated she forgot to verify…

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 coordinate outpatient appointment scheduling and transportation arrangements for resident. This applies to 1 resident (R45) reviewed for social services in a sample of 36.Findings include:R45's Face sheet shows the following diagnoses: hemiplegia and hemiparesis following cerebrovascular accident affecting the left dominant side, neuromuscular dysfunction of bladder, unspecified protein calorie malnutrition, and encounter for attention to gastrostomy. R45's POS (Physician Order Sheet) shows an order dated 6/17/25 to change indwelling urinary catheter, bag and tubing system as needed when malfunctioning; an order dated 10/17/25 urology referral appointment ASAP; an order dated 11/5/25 for GI consult for removal of G-tube (gastrostomy tube); and an order dated 11/19/25 okay to remove the G-tube. R45's MDS (Minimum Data Set) dated 9/1/25 shows his cognition is intact, he uses a wheelchair and is completely dependent on staff for transfer assistance. R45's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications for newly admitted residents were available for timely administration. This applies to 1 of 3 residents (R1) reviewed for pharmacy services.The findings include:R1's Face Sheet showed he was admitted to the facility on [DATE]. R1's admission nursing progress note was timed at 12:30 PM. On 9/10/2025 at 11:00 AM, V2 DON (Director of Nursing) stated there are two pharmacy deliveries daily, one in the afternoon around 3:00-5:00 PM, and one in the morning between 3:00-6:00 AM.R1's September 2025 Active Physician Orders as of 9/10/2025 showed orders for Carvedilol twice daily for hypertensive heart disease with heart failure, and Entresto twice daily for hypertensive heart disease with heart failure. R1's September Medication Administration Record (MAR) showed both medications were scheduled for administration at 9:00 AM and 5:00 PM.On 9/10/2025 at 11:58 AM, V5 (Pharmacy Technician) stated most of R1's medications were delivered at 4:30 AM…

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 observations, interviews, and record reviews, the facility failed to provide ADL (Activities of Daily Living) care to meet the needs of the residents. This applies to 3 of 3 residents (R1 - R3) reviewed for ADLs care in a sample of 3.The findings include: 1. On 08/26/25 at 12:12 pm, R1, who is alert and oriented, said that she has had to wait for 2 to 4 hours for staff to provide incontinence care for her. R1's call light was on at the time of the interview and R1said that she was waiting to go to bed and to have her brief changed. V3 CNA (Certified Nurse's Assistant) came in the room and put R1 in bed and provided incontinence care for R1. R1 said the last time her brief was checked and changed was at 9:30 AM. V3 acknowledged that that was correct. R1's perineal area, her inner thighs, and her buttocks were red when the brief was removed. R1's 8/13/25 Care Plan showed that R1 has a focus on skilled services needed with interventions including ADL care to be provided each shift. R1's care plan also showed that R1 has a focus on R1 being incontinent of both bowel and bladder…

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

Based on observation, interview, and record review the facility failed to implement fall prevention interventions for a high-fall risk resident. This applies to 1 out of 3 (R1) residents reviewed for falls. The findings include: On 5/24/2025 at 9:40 AM, R1 was in bed sleeping. R1 was confused and non-interviewable. R1 did not have floor mats in place. Then at 10 AM, V16 (Certified Nurse Assistant/CNA) and V17 (CNA) provided R1 with her morning care and transferred her into her wheelchair. R1's wheelchair had a regular black cushion with no non-slip device in place. V17 said R1 was confused and a high-fall risk. V17 said R1 had recently slid from her wheelchair. V17 said residents had posted Caregiver communication sheets to inform staff how to care for them. V17 said R1's posted Caregiver communication sheet included fall interventions. R1's Caregiver communication sheet dated 5/09/2025 said R1 should have fall prevention devices including floor mats, dycem (non-slip device), and specialized positioning wheelchair cushion. On 5/28/2025 at 10:40 AM, V10 (Activity Aide) said he was…

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

Based on observation, interview, and record review the facility failed to ensure they employeed a qualified social worker on a full time basis. This has the potential to affect all residents residing in the facility. The findings include: The Facility Data Sheet dated 3/18/24 showed the facility census was 175. On 3/18/25 at 1:24 PM, V6 (Social Services) said she just found out V5 (Social Services) was terminated. V6 stated, I'm the only Social Services now. [V2 - Assistant Administator] had been helping me out, but she has a lot of other responsibilities. I was hired to cover a specific unit. When I started in August there were three of us. Myself, [V5 and V10]. There isn't a Social Services Director. There hasn't been since V25 (previous Social Services Director) left and V5 has been gone since October 2024. I am not a Licensed Social Worker. I have an Associates Degree in Healthcare Management and Human Resources and years of experience in long-term care. On 3/18/25 at 2:14 PM, V2 (Assistant Administrator) said she was helping Social Services with MDS (Minimum Data Set)…

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 timely and thorough incontinence care was provided to 1 of 3 residents (R3) reviewed for incontinence care in the sample of 11. The finding include: R3's admission Record, provided by the facility on 3/19/25, showed R3 had diagnoses including, but not limited to, protein-calorie malnutrition, morbid obesity, dermatitis, vitamin B12 deficiency, anemia, hypertension, adjustment disorder, and abnormal uterine and vaginal bleeding. R3's facility assessment dated [DATE], showed R3 was cognitively intact with no behaviors, always incontinent of bowel and bladder, and dependent on staff for toileting hygiene. R3's care plan, with a revision date of 11/21/2024, showed R3 is at risk of alteration in skin integrity related to protein-calorie malnutrition, morbid obesity, anemia, history of falls, and incontinence. One of the interventions listed was Provide skin care after each incontinent episode.R3's care plan initiated on 6/7/2022 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.

Based on interview and record review the facility failed to coordinate with an outside agency in a timely manner to complete guardianship paperwork for a resident with severe mental illness for 3 of 3 residents (R1) reviewed for medically related social services in the sample of 11. The findings include: On 3/14/25 at 2:59 PM, V14 (Case Manager for APS (Adult Protective Services)) said R1 was admitted to the facility in November 2024. V14 said she made a referral for state guardianship on 12/6/24. V14 said R1 was homeless, prior to admission to the facility. V14 said she had been in contact with V7 (Business Office Manager - BOM) about the status of R1's state guardianship because the facility was not receiving payment for R1. V14 said she received a call from the facility wanting us to approve medication changes and I told them I was not her guardian and could not do that. The office of state guardianship emailed me in the beginning of January and said they needed an updated physician's report. I visited [R1] at the facility on 1/8/25 and informed [V5 - Social Services] that I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinent care to dependent residents. This applies to 2 of 5 residents (R2 and R5) reviewed for activities of daily (ADL) care in a sample of 5. The Findings Include: 1. R2 is 69-years-old with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. MDS also documents that R2 is substantial/maximal assistance on toileting hygiene. On 1/15/24 at 9:30 AM, R2 stated, Last Saturday on 1/11/25, I was sitting on my urine and feces for hours since 8:15 AM. Nobody didn't answer my call light or changed me for hours until 10:45 AM. I have my phone to note the time. R2 continued, Last night, I wasn't changed until 4: 00 AM. I put the call light at 10:30 PM. The night Certified Nursing Assistant (CNA) shows up around 11:00 PM and turned the call light off saying that she will come back after making rounds with all of her residents. Meantime, I fell asleep. I was sitting on my dirty brief until 4:00 AM. A review of R2's ADL…

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 follow physician orders to administer diabetic, antihypertensive and heart medications to a resident (R16) with diagnoses of type 2 diabetes mellitus, CAD (coronary artery disease) and hypertension. This applies to 1 of 4 residents (R16) reviewed for significant medications in the sample of 16. The findings include: The EMR (Electronic Medical Record) shows R16 is a [AGE] year-old with diagnoses that includes CHF (congestive heart failure), stage 4 chronic kidney disease, ESRD (end stage renal disease) and dependent on dialysis, diabetes mellitus type 2, diabetic neuropathy, metabolic encephalopathy, asthma, anemia, CAD (Coronary Artery Disease), HL (hyperlipidemia), HTN (hypertension) lumbar spinal stenosis, glaucoma, PAD (peripheral arterial disease), poor vision, cerebral infarction, malnutrition, urinary retention, chronic wound right foot, and ischemic tissue right great toe with osteomyelitis. The MDS (Minimum Data Set) dated November 25,2024…

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 obtain vital signs as ordered by a physician for 1 of 3 residents (R3) reviewed for quality of care in the sample of 8. The findings include: R3's electronic face sheet printed on 10/20/24 showed R3 has diagnoses including but not limited to multiple sclerosis, COVID-19, peripheral vascular disease, and paraplegia. R3's physician's orders dated 11/10/22 showed, Vital signs q (every) shift, every 12 hours. R3's care plan dated 10/18/24 showed, COVID-19 positive: (R3) has infection related to failure to avoid pathogen secondary to exposure to COVID-19 .Monitor vital signs as ordered. Monitor the patient's temperature; the infection usually begins with a high temperature; monitor the respiratory rate of the patient as shortness of breath is another common symptom. R3's medication administration record for October 2024 showed R3's vital signs were not taken on 10/4/24, 10/8/24, and 10/12/24 at 9:00PM as ordered. R3's physician's orders dated 10/14/24 showed, Vital signs every 4 hours for 10 days. R3's medication administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement transmission-based precautions for a resident (R2) who was COVID-19 positive. This applies to 1 of 3 residents reviewed for COVID-19 in the sample of 8. The findings include: R2's electronic face sheet printed on 10/20/24 showed R2 has diagnoses including but not limited to anxiety disorder, hemiplegia and hemiparesis affecting left non-dominant side, major depressive disorder, and type 2 diabetes. R2's facility assessment dated [DATE] showed R2 has no cognitive impairment. R2's care plan dated 10/15/24 showed, COVID-19 positive: infection related to failure to avoid pathogen secondary to exposure to COVID-19 .maintain contact and droplet isolation including N95 mask and eye protection . R2's physician's orders dated 10/15/24 showed, Contact/droplet isolation related to COVID for 10 days. R2's progress notes dated 10/15/24 showed, Resident tested positive for COVID-19 via rapid nasal swab. Positive finding for COVID-19 noted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer wound care treatments as ordered by the physician. This applies to 2 of 3 residents (R1, R4) reviewed for improper nursing care in the sample of 4. The findings include: 1. On October 2, 2024 at 10:01 AM, R1 was sitting in a wheelchair. R1's gown was pulled down away from her neck, and a dressing over her left chest area could be seen. The dressing appeared clean and dry. R1 was not able to answer questions due to her cognitive status. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including, chronic kidney disease, left breast open wound, diverticulosis, dysphagia, peripheral vascular disease, anemia, and dementia. R1's MDS (Minimum Data Set) dated September 20, 2024 shows R1 has severe cognitive impairment, requires supervision with eating, substantial/maximal assistance with oral and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer pressure ulcer treatments as ordered by the physician. This applies to 1 of 3 residents (R2) reviewed for improper nursing care in the sample of 4. The findings include: On October 2, 2024 at 9:54 AM, R2 was lying in bed in her room. V7 (CNA-Certified Nursing Assistant) removed R2's incontinence brief. R2's brief was clean and dry. No stool was present. A clean and dry dressing was over R2's sacrum. R2 was not able to answer questions due to her cognitive status. The EMR (Electronic Medical Record) shows R2 was admitted on [DATE] with multiple diagnoses including sacral pressure ulcer, dysphagia, dementia, abnormal weight loss, anorexia, and anxiety disorder. R2's MDS (Minimum Data Set) dated July 23, 2024 shows R2 has severe cognitive impairment and is dependent on facility staff for all ADLs (Activities of Daily Living). R2 is frequently incontinent of bowel and bladder. R2's care plan created on February 6, 2018 shows R2 has alteration 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 assist residents identified as needing assistance with personal hygiene. This applies to 5 of 7 residents (R27, R39, R109, R115, and R453) reviewed for ADL (activities of daily living) in the sample of 33. The findings include: 1. R109 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and visuospatial deficit and spatial neglect following cerebral infarction, based on the face sheet. R109's quarterly MDS (minimum data set) dated September 18, 2024 showed that the resident was moderately impaired with cognition and required maximum assistance from the staff with personal hygiene. On September 23, 2024 at 10:48 AM, R109 was in bed, alert and verbally responsive. R109 had accumulation of long, unkempt facial hair. R109 stated that he wanted the staff to shave him because he cannot do it himself. On September 24, 2024 at 9:14 AM, R109 was in bed, alert and verbally…

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 mechanical soft and pureed cubed beef steak portions as shown on menu spreadsheet for the lunch meal. This applies to 7 of 7 residents (R1, R24, R27, R36, R50, R81, R88) observed for dining in the sample of 33. On September 23, 2024 at 9:43 AM, V7 (Cook) stated that the meal prepared for the lunch meal that day was cubed steak (Salisbury steak), carrots and mashed potatoes. V7 stated that this meal was supposed to be served on Saturday but got switched as the residents chose to have the meal of the month on Saturday instead. Diet order spreadsheet for the above meal showed to serve #6 scoop of ground cubed steak with onion and gravy for mechanical soft diet and #6 scoop of the pureed steak with broth for the pureed diet. On September 23, 2024 at 11:44 AM, during tray line service, V9 (Dietary Aide) and V8 (Cook) were platting the food on the tray line. The mechanical soft cubed steak had a green colored scoop which was identified as #12 scoop and R1, R24 and R36 received 1 scoop of the same. The pureed…

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 pureed consistency vegetables to the residents on pureed diets. This applies to 8 of 8 residents (R2, R27, R33, R37, R50, R57, R81, R88) reviewed for pureed diets in the sample of 33. Facility Week at a Glance Menu for September 24, 2024 showed Capri Mix Vegetables as the vegetable option for the lunch meal. On September 24, 2024 at 10:31 AM, the pureed meal prep by V10 (Assistant Food Service Manager) was observed in the facility kitchen. V10 stated that he is making about 12 servings as some of the residents on pureed diets have orders for double portions. V10 measured out twelve 4 oz (ounce) scoops of cooked zucchini into a [NAME] and processed the same. V10 continued to blend the mixture for several minutes, stopping in between to open the lid and stir the product with a spatula. V10 added 1 tablespoon of thickener into the mixture and continued to blend the contents for a few more minutes. V10 then opened the blender lid 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 interview and record review, the facility failed to follow their policy to offer the pneumococcal vaccine. This applies to 5 of 5 residents (R56, R71, R7, R34, and R68) in the sample of 33. The findings include: 1. The EMR (Electronic Medical Record) showed R56 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, heart failure, hypertensive heart disease, and peripheral vascular disease. R56's Immunization Report provided by the facility on September 24, 2024, at 5:14 PM, did not show R56 had previous pneumococcal immunizations or refused the pneumococcal vaccine. On September 25, 2024, at 2:17 PM, V2 (DON/Director of Nursing) said she had provided all R56's immunization records. The facility does not have documentation to show R56 was offered or refused the pneumococcal vaccine. On September 25, 2024, 1:20 PM, V2 said R56 should have been offered the pneumococcal vaccine upon admission to the facility. V2 continued to say the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders for life sustaining treatment reflected the resident's POLST (Physician Ordered Life Sustaining Treatment) form. This applies to 2 of 2 residents (R8 and R95) reviewed for advanced directives in the sample of 33. The findings include: 1. The EMR (Electronic Medical Record) showed R8 was admitted to the facility on [DATE], with multiple diagnoses including stroke, immunodeficiency, chronic obstructive pulmonary disease, chronic diastolic heart failure, chronic kidney disease, and epilepsy. R8's POLST form dated August 1, 2017, showed R8 selected DNR (Do Not Resuscitate) and the POLST was signed by a provider on August 1, 2017. R8's EMR showed an order dated July 18, 2024, for Full Code. On September 25, 2024, at 9:38 AM, V21 (Social Services) said he is not sure who is in charge of advanced directives since the SSD (Social Services Director) left a few months ago. V21 continued to say checking advanced directives is a group…

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 refer a resident with a new diagnosis of a mental disorder to the appropriate state-designated authority for level II PASARR (Preadmission Screening and Resident Review). This applies to 1 of 8 residents (R95) reviewed for PASARR in the sample of 33. The findings include: The EMR showed R95 was admitted to the facility on [DATE]. R95's MDS (Minimum Data Set) dated January 19, 2022, showed R95 did not have any psychiatric or mood disorders. R95's MDS dated [DATE], showed R95 had diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia. R95's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen dated January 13, 2022, showed R95 did not have a mental illness at the time of the screening. On September 24, 2024, at 3:05 PM, V15 (admission Director) said if a resident has a change in condition, like suicidal ideation requiring hospitalization, the resident should be rescreened. On September 25, 2024, at 2:25 PM, V2 said R95…

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 document and hold interdisciplinary care plan conferences, at required intervals, in accordance with facility policy. This applies to 3 of 6 residents (R52, R87, and R116) reviewed for care plan conferences in the sample of 33. The findings include: 1. R116's EMR (Electronic Medical Record) showed R116 was admitted to the facility on [DATE], with multiple diagnoses including seizure disorder, presence of neurostimulator, bipolar disorder and anxiety disorder. R116's MDS (Minimum Data Set) dated July 25, 2024, showed R116 was cognitively intact, and required only supervision with all ADLs (Activities of Daily Living). On September 23, 2024, at 10:56 AM, R116 stated she had been in the facility for 3 months and hadn't gotten any therapy and was waiting to be discharged back home with her brother, where she lived prior to her hospitalization and subsequent admission to the facility. On September 25, 2024, at 1:30 PM, V19 (Social Services) and V20…

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 treatment recommendations for a resident who was assessed to require the use of a hand splint to prevent further decrease of ROM (Range of Motion) and contractures in that extremity. This applies to 1 of 1 residents (R74) reviewed for splints in the sample of 33. The findings included: R74's EMR (Electronic Medical Record) showed R74 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following non-traumatic intracerebral hemmorhage affecting the right dominant side and chronic respiratoy failure. R74's MDS (Minimum Data Set) dated September 5, 2024 showed R74 was cognitively impaired. R74 was dependent on staff for all ADLs (Activities of Daily Living) care. R74's care plan showed R74 required the use of a splint relate to right hemiplegia/hemiparesis, chronic respiratory failure, alcoholic cirrhosis, epilepsy, anemia, and hypertension. Interventions included .Staff assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and administer pain medication to the residents as ordered by the physician, to manage pain. This applies to 2 of 5 residents (R20 and R82) reviewed for pain management in the sample of 33. The findings include: 1. R20 had multiple diagnoses including paraplegia, severe morbid obesity and chronic pain syndrome and right hip pain, based on the face sheet. R20's quarterly MDS (minimum data set) dated July 23, 2024 showed that the resident was cognitively intact and required maximum to total assistance from the staff with most of her ADLs (activities of daily living). On September 23, 2024 at 12:10 PM, R20 was in bed, alert, oriented and verbally responsive. R20 stated that on September 20, 2024 during the second shift (3:00 PM - 11:00 PM), an agency nurse (does not know the name) refused to give her the oxycodone pain medication for her back and right leg pain. R20 stated that she asked for the oxycodone pain medication around 9:00 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 interview and record review, the facility failed to document any information pertaining to a resident's death, in the medical record, in accordance with facility policy. This applies to 1 of 33 residents (R150) reviewed for documentation in the sample of 33. The findings include: R150's EMR (Electronic Medical Record) showed R150 admitted to the facility on [DATE], and died in the facility on [DATE]. 2024. R150 was [AGE] years old and had multiple diagnoses including unspecified dementia, chronic diastolic and systolic congestive heart failure, lymphedema, morbid obesity, and pressure ulcer of the right heel. R150's EMR showed the last entry dated [DATE], 07:01 AM, showed follow up dropper for medication found by prior AM nurse [NAME]. Please follow up with hospice regarding gurgling. There was no further clinical assessment, notifications to family, hospice or the physician, no time of death, and no disposition of the body or final discharge note in the medical record. On [DATE], at 12:01 PM, V2…

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 were trained on how to care for a resident with a LVAD (Left-Ventricular Assist Device) prior to admission, failed to obtain orders upon admission for a resident's LVAD, and failed to implement the LVAD orders once they were received for 1 of 1 resident (R4) reviewed for quality of care in the sample of 10. The findings include: On 8/28/24 at 10:51 AM, R4 was laying in bed. R4 had an LVAD device in place. R4's Face Sheet shows that she admitted to the facility on [DATE] with the diagnoses of: cerebral infarction, diabetes mellitus, malnutrition, dysphagia, stage 4 pressure ulcer, weakness, anemia, anxiety, hypertensive heart, chronic kidney disease, atherosclerotic heart disease, ischemic cardiomyopathy, atrial fibrillation, heart failure, presence of heart assist device, thrombosis of atrium and ventricular tachycardia. R4's Physician's Order Sheet printed on 8/28/24 shows orders dated 7/14/24 (5 days after admission) for:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a sink was secured safely to the wall for 1 of 3 residents (R2) reviewed for furnishings in the sample of 11. The findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include paroxysmal atrial fibrillation, multifocal motor neuropathy, osteoarthritis, chronic pain, essential tremor, and hypertension. R2's facility assessment dated [DATE] showed she has no cognitive impairment. R12's face sheet showed she was admitted to the facility on [DATE]. R12's facility assessment dated [DATE] showed she has no cognitive impairment. R13's face sheet showed she was admitted to the facility on [DATE]. R13's facility assessment dated [DATE] showed she has moderate cognitive impairment. On 8/11/24 at 10:25 AM, R2 said the sink in her bathroom fell on her. R2 said she was unable to reach the emergency cord so it took awhile for staff to come in and assist her. R2 said the sink had broken into several…

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 maintain a universal updated list of residents identified as high risk for elopement and failed to train its staff on its elopement policy. The facility also failed to update resident elopement care plans based on their elopement assessments. This applies to 20 out of 21 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) reviewed for safety and supervision. The findings include: On 6/22/2024 at 12:30 PM, V2 (Director of Nursing/DON) said the facility had nine residents identified as wanderers. V2 said social workers were responsible for assessing residents at risk for elopement who were displaying purposeful exit-seeking behaviors. Then at 1:30 PM, V2 said the facility had three residents (R5, R6, and R9) identified as high risk for elopement. Then on 6/25/2024 at 3:00 PM, V2 said she reviewed the residents at high risk for elopement and now there were three residents (R5, R7, and R8) at risk. On 6/25/2024 at 3:38 PM, V22 (Receptionist) said she looked at the list…

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 had a physician's order for suctioning, was assessed prior to and after suctioning, and was suctioned in a manner that maintained the comfort of the resident for one of three residents (R1) reviewed for hospice services in the sample of three. The findings include: On 06/17/2024 R1 was not in the facility. R1's Medical Record on 06/17/2024 shows, R1 was re-admitted to the facility on [DATE]. R1 was provided a physician's order for hospice and comfort care 05/29/2024. R1 was discharged [DATE]. On 06/17/2024 at 1235PM, V7 R1's Family said, on 06/08/2024 my brother and I was visiting with R1. R1 was wearing oxygen. There was a suction device in the room with a hard plastic tube. V5 RN-Registered Nurse decided to change the long hard plastic tube for a thin plastic tube. V5 RN then suctioned down to the back of R1's throat causing him to gag. The hospice staff said he should only be suctioned just around the mouth. The…

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

Based on interview and record review the facility failed to ensure a resident was sent to dialysis on time. This applies to one (R1) of three residents reviewed for dialysis in the sample of seven. The findings include: On 5/22/2024 at 9:39AM, R1 said facility staff transport him to dialysis. R1 said his treatments are early and gets up around 3:30AM to get ready for his dialysis treatments. R1 said he has been so late to dialysis that his treatments have been cut short sometimes. R1 said it's happened in the last couple of weeks. On 5/22/2024 at 12:11PM, V6 Dialysis Nurse said [R1's] start time is 5:15AM, but sometimes he comes later, and his treatments are cut short. V6 said she has not known [R1] to cut his treatments short or refuse treatment. V6 said [R1] does his time whatever is ordered. V6 said [R1's] treatment time is 4 hours and 15 minutes. V6 said [R1] was late on 5/13/2024. V6 said [R1] only received 3.55 hours of treatment that day. V6 said since [R1] transferred to his current floor transport has been an issue. V6 said it is important for a resident to receive 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.

Based on interview and record review, the facility failed to file a grievance and follow up on the grievance for a resident who notified staff of a concern. This applies to one of three residents (R3) reviewed for improper nursing care in a sample of eight. The findings include: On April 23, 2024 at 03:17 PM, R3 said V12 (CNA/Certified Nurse Assistant) took him to the washroom, and when he came back, his phone screen was shattered. R3 said he asked V12 what happened to his phone while he was in the bathroom, and R3 said V12 said she did not know. R3 showed the surveyor his old phone with the shattered screen. R3 said he purchased a new phone because there was no follow up from the facility. R3 said he spoke to V10 (Social Services) and she said she would speak to the staff, and a week had passed. R3 said he also called V1 (Administrator) and left a voicemail and had not heard back from anyone regarding his broken phone. On April 24, 2024 at 10:15 AM, V10 said R3 told her when he came out of the bathroom, his phone was shattered. V10 said R3 showed her his phone and the phone was…

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

Based on observation, interview, and record review the facility failed to ensure resident's bedding was clean for 2 of 17 residents (R1, R7) reviewed for clean comfortable and homelike environment in the sample of 17. The findings include: On 1/8/24 at 10:15 AM, R7 was sitting at the edge of is bed, in the middle of the bed. There was a dried coffee spot on the bed sheet on either side of R7. R7 said the stains were coffee and they had been there awhile. R7 said it had been 4-5 days since his sheets have been changed. R7 said he asked for his sheets to be changed over the weekend but they still were not changed. R7 said his only complaint about the place is the sheets not being changed, who likes to sleep in clean sheets. On 1/8/24 at 11:08 AM, R1 was in bed, curled up on his left side sleeping. R1's sheet near, the foot of the bed, had a twist top lancet piece and half of an alcohol packet laying on the sheet. There was also a red round stain and another orange round stain on the bed sheets along with scattered food crumbs. On 1/10/24 at 11:21 AM, V2 Director of Nursing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve residents breakfast at their preferred time. This applies to 6 of 7 residents (R1, R2, R5, R6, R7, R8) reviewed for late meal service in the sample of 9. The findings include: The facility's undated Dining Schedule, posted on the wall outside of the first-floor dining room shows the following dining times for residents: First Floor: Breakfast 7:45-8:30 AM Lunch 12:00-12:45 PM Dinner 5:45-6:30 PM Second Floor: Breakfast 7:30-8:15 AM Lunch 11:45-12:30 PM Dinner 5:30-6:15 PM On December 14, 2023 at 8:42 AM, V9 (LPN-Licensed Practical Nurse) was standing outside of R1's room and said breakfast trays had not been delivered to residents wishing to eat in their rooms. V9 continued to say 30 of the 40 residents residing on the same unit as R1, R2, R5, R6, R7, and R8 prefer to eat in their rooms and do not eat in the dining room. On December 14, 2023 at 8:55 AM, V8 (CNA-Certified Nursing Assistant) said the kitchen had not delivered…

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 promptly respond to residents' call lights when residents require assistance. This applies to 2 of 3 residents (R3, R4) reviewed for timely call light response in the sample of 9. The findings include: The facility's call light monitor mounted to the wall over the nurse's station shows the amount of time call lights are illuminated before a staff member responds to the call light and turns the call light off. Multiple observations were made of call lights being illuminated by residents and the facility staff response time. The time shown on the call light monitor coincided with the amount of time it took the facility staff to respond and turn off the residents' call light. On December 18, 2023 at 9:50 AM, call lights were illuminated over the doors of R3 and R4. The call light response monitor mounted to the wall above the nurse's station showed R3's call light had been illuminated 45 minutes and R4's call light had been illuminated 25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to promptly address and provide treatment for a pressure wound that re-opened. This applies to 1 of 3 (R2) residents reviewed for pressure wounds from a total sample of 6. Findings include the following: R2 is an [AGE] year-old male admitted on [DATE] with diagnosis of Hypertension, Gout, and Pain. R2 was noted to test positive for COVID 19 on 11-24-2023. R2 is also noted to have mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R2 was admitted to the facility with a pressure injury and record review on skin and wound evaluation dated 8/20/23 documented a stage 3 pressure ulcer (2.7 x 1.38 x 0.1 cm). The record also documents that R2's wound was noted as healed on 10/17/2023 per the skin and wound evaluation. On 12/5/23 at 9:15 AM, R2 was observed in his Covid isolation room with V4 (Certified Nursing Assistant/CNA). R2 was observed with a mildly wet incontinent brief and an open sacral wound. Barrier cream was noted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide personal hygiene to dependent residents in a timely manner. This applies to 2 of the 3 residents (R10, R11) reviewed for personal care from the total sample of 20. The findings include: 1. On 11/28/23 at 6:15 AM, V18 (Certified Nursing Assistant) rendered incontinence care to R10. There was a strong urine odor coming from R10's bed. V18 was observed wiping/cleaning the damp mattress of R10 before he placed a clean linen sheet underneath R10. V18 stated that the mattress was wet with urine. The bedding that was removed from R10's bed were observed to be wet with urine with brown ring stain at the edges of the wetness. R10's Quarterly MDS (Minimum Data Set) assessment dated [DATE] shows that R10 is cognitively impaired and requires extensive assistance for toileting and hygiene. 2. On 11/28/23 at 6:25 AM, V18 rendered incontinence care to R11 who was lying in bed. there was a pervasive urine odor coming from R11. The flat sheet that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident with sacral pressure injury was kept clean and dry of urine to promote wound healing. This applies to 1 of 3 residents (R10) reviewed for pressure ulcer in the sample of 20. The findings include: Face sheet shows that R10 is 79 years-old who has multiple medical diagnoses which include stage 4 pressure ulcer in the sacrum, type 2 diabetes mellitus, and Alzheimer's disease. On 11/28/23 at 6:15 AM, V18 (Certified Nursing Assistant) rendered incontinence care to R10. There was a strong urine odor coming from R10's bed. V18 was observed wiping/cleaning the damp mattress of R10 before he placed a clean linen sheet underneath R10. V18 stated that the mattress was wet with urine. The beddings that were removed from R10's bed were all wet and saturated with urine with brown ring stain formation at the edges of the wetness. On 11/28/23 at 9:10 AM, V21 (Wound Care Nurse) and V22 (Wound Care Nurse Practitioner/NP) rendered…

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 administer a resident's medications as ordered by the physician. This applies to 1 of 3 (R2) residents reviewed for medications in the sample of 7. The findings include: On 11/1/2023 at 11:06AM, V2 Assistant Director of Nursing (ADON) said that medications should be administered as ordered by the physician and order parameters should be followed. V2 said the check mark symbol on the Mediation Administration Record (MAR) means the medication was administered. On 11/1/2023 at 10:30AM, V12 Registered Nurse (RN) said [R2] has an order for Midodrine and it should be held if his blood pressure is above 130. R2's MAR dated 9/1/2023 to 9/30/2023 shows an order Midodrine HCL Oral Tablet 5mg Give 1 tablet by mouth with meals for hypotension Hold if SBP >130 with an order date of 9/24/2023. On 9/30/2023 R2's MAR shows an 8:30AM dose of Midodrine was administered with a documented blood pressure of 139/88. R2's MAR dated 10/1/2023 to 10/31/2023 shows an order for Midodrine HCL Oral Tablet 5mg Give 1 tablet by mouth with meals for…

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

Based on observation, interview and record review the facility failed to provide timely incontinence care. This applies to 1 of 3 (R2) residents reviewed for incontinence care in the sample of 7. The findings include: On 11/1/2023 at 10:05AM, V11 Certified Nursing Assistant (CNA) said he had not changed [R2] since starting his shift at 7:30AM. On 11/1/2023 at 10:08AM, V11 provided incontinence care for [R2] and changed R2's soiled brief. R2's brief appeared swollen and full in the front prior to it being removed. When R2's soiled brief was removed by V11, approximately 75% of the brief was soiled with urine with a darker yellow color to it. R2's brief sagged when V11 turned to throw away R2's soiled brief. On 11/1/2023 at 11:06AM, V2 Assistant Director of Nursing (ADON) said residents who are incontinent should be changed every two hours or as needed. On 11/1/2023 at 10:30AM, V12 Registered Nurse (RN) said [R2] is incontinent sometimes and can not take care of himself independently. V12 said [R2] needs assistance when getting cleaned up. R2's Minimum Data Set (MDS) section H dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to store food items and maintain the kitchen in a manner that prevents food borne illness. This applies to 171 residents that are served food from the kitchen. The findings include: On 10/24/23 at 10:02 AM, the kitchen hand sink was dirty. The garbage can lid that is foot operated was broken. The trash lid could not be placed back to fully cover the can without blocking its use. The microwave was greasy on the outside and was dirty on the inside with dried spatters of food and particles on the inside. The table the microwave sat on had dried splatters of a red substance on it. On 10/24/23 at 10:07 AM, during the kitchen tour with V11 (Assistant Kitchen Manager) unlabeled items were observed in the stand up cooler #1. The contents of the clear plastic cups were identified by V11. Items in cooler did not have a label identifying the contents, prepared date or use by date. Eight cups of thickened milk, 5 cups of thickened water, 3 cups of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have call light accessible to dependent residents, failed to provide means that allows residents to turn overhead bed light on and off independently, and failed to provide easy accessibility to the bathroom for a wheelchair bound resident. This applies to 4 of 4 residents (R78, R109, R124 and R131) reviewed for accommodation of needs in a sample of 36. The findings include: 1. R109's face sheet (10/25/23) showed that R109 had the following diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty walking, epilepsy, and dementia. R109's Minimum Data Set (MDS) dated [DATE], showed that R109's cognition is moderately impaired and needs extensive assistance with one person physical assist with toilet use. R109's care plan (initiated 6/26/23) showed that R109 is at risk for falls related to generalized weakness and decreased mobility with the intervention for resident to use call light…

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 shave, provide nail care, and assist with dressing. This applies to 4 of 36 residents (R11, R12, R59, R66) reviewed for ADL's (Activities of Daily Living) in a sample of 36. The Findings include: 1. On 10/24/23 at 11:15 AM, during initial tour, R12 was sitting in his wheelchair in his room. R12's nails had grown approximately half an inch past his fingertips in both hands. There was a black substance underneath the nail. Surveyor asked R12 if he ever told staff that he wants them cut. R12 stated, The CNA's (Certified Nursing Assistants) ignore me when I ask them to cut my nails. I need them cut. It's way too long man. It's ridiculous. R12's face sheet documents the followings diagnoses: age-related osteoporosis without current pathological fracture and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R12's MDS (Minimum Data Set) dated 9/11/23 documents a BIMS…

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 store an oxygen cylinder and secure resident's smoking materials. This applies to 7 of 7 residents reviewed for safety (R11, R13, R37, R44, R83, R91 and R106) in a sample size of 36. The findings include: 1. On 10/24/23 at 04:24 PM, in a shared divided closet belonging to R13, R44 and R91, a cylindrical oxygen tank was not secured in a holder was observed in the section belonging to R44. R13, R44 and R91 reside in the room where the unsecured oxygen cylinder was observed. R11, R37 and R83 are in the room directly next to the room where the unsecured oxygen cylinder was observed. On 10/26/23 at 09:49 AM, V8 Respiratory Therapist stated the tank is under pressure and should be secured. On 10/26/23 at 10:12 AM, V9 Licensed Practical Nurse stated the tank should be in a holder because if it falls it is a hazard and may explode. On 10/26/23 at 02:23 PM, V7 (ADON--Assistant Director of Nursing) stated R91 is the only person in the room…

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 remove over the counter medication from resident's rooms, properly secure resident's medication and failed to obtain order for residents that have medication stored in resident's room. This applies to 7 out of 7 residents (R46, R64, R66, R82, R126, R127 and R479) reviewed for medication in a sample of 36. The findings include: 1. On 10/25/2023 at 9:34 AM, Potassium Chloride half tablet was noted in a medicine cup on top of R64's bed side table. R64 said the nurse left it there so she can take it when she wanted to. On 10/25/2023 at 10:37 AM, V24 (RN-Registered Nurse) said she left medication to get water and prepare R64's roommate's medication. V24 (RN) said she needs to wait and make sure the resident takes all medication before she leaves. On 10/26/2023 at 9:18 AM, V7 (ADON) said nurses are expected to stay and make sure resident takes all their medications. V7 (ADON) said leaving medication by the bedside is a safety concern so 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 current standards of Infection Control during incontinence care and pressure wound dressing change. This applies to 5 of 5 residents (R35, R63, R108, R143, R480) reviewed for incontinence care and pressure wound dressing change in the sample of 36. The findings include: 1. On 10/25/2023 at 1:34 PM, R480 was lying on her bed. V5 (Wound Care Coordinator) and V31 (CNA-Certified Nurse Assistant) were preparing to do pressure wound dressing change on R480. V5 and V31 applied gowns, gloves, and face mask. V5 observed that R480 needed incontinence care. V5 unfastened R480's incontinent briefs, removed wound dressing on her sacrum and took off incontinent briefs soiled with feces. Wearing the same soiled gloves, V5 opened R480's nightstand drawer and took out a packet of wipes. With the same soiled glove, V5 cleaned R480's buttocks. V5 ran out of wipes and with the same soiled gloves, opened the nightstand drawer to get another pack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility to properly position indwelling catheter bag and follow current standards of infection control. This applies to 2 of 2 residents (R109 and R480) reviewed for indwelling catheter in a sample of 36. The findings include: 1. R109's face sheet (10/25/23) showed that R109 had the following diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty, benign prostatic hyperplasia with lower urinary tract symptoms, epilepsy, and dementia. R109's Minimum Data Set (MDS) dated [DATE], showed that R109's cognition is moderately impaired and needs extensive assistance with one person physical assist with toilet use. On 10/25/23 at 9:59 AM, R109 was sitting up by side of the bed eating breakfast. R109 was sitting on his indwelling catheter bag, and back flow of reddish urine was observed in the catheter tube. On 10/25/23 at 10:05 AM, V25 (LPN/Licensed Practical Nurse) said R109 had reddish urine because R109…

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, the facility to verify gastrostomy tube (G-tube) placement prior to administering medications through the G-tube. This applies to 1 of 1 resident (R148) reviewed for medication administration via G-tube in the sample of 36. The findings include: R148's face sheet (10/25/23) showed that R148 had the following diagnoses of aphasia, dysphagia, and encounter for attention to gastrostomy. On 10/25/23 at 1:06 PM, V16 (LPN/Licensed Practical Nurse) went in R148's room to administer medications via the G-tube. V16 informed R148 of the medication administration. V16 flushed R148's G-tube with 30 ml (milliliters) of water, then administered medications. V16 flushed with 15 ml of water between each medication and after medication administration. V16 failed to check placement of the g-tube by aspirating gastric contents, prior to administering medications. On 10/25/22 at 1:30 PM, V16 said he was supposed to check for g-tube placement by checking for residual prior to administering medication. On 10/26/23 at 8:54 AM, V7 (ADON/Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a safe and comfortable water temperature with the resident bathroom sinks. This applies to all 24 residents on the first floor C-wing. The findings include: R1 is an [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 10/10/23 at 9:40 AM, R1 (C-wing) stated that the sink water was cold. R2 is a [AGE] year-old female newly admitted on [DATE]. On 10/10/23 at 11:05 AM, R2 stated that the bathroom sink water is coldish and it takes a long time to get warm water. R3 is a [AGE] year-old female with cognition intact as per MDS dated [DATE]. On 10/10/23 at 11:10 AM, R3 stated, Oh yes, the sink water has been cold ever since I was admitted here. On 10/10/23 at 9:05 AM, V3 (Maintenance Direcror) checked the C-wing resident room (R3 and R22) bathroom sink temperature (temp), which was 70F even after three minutes. On 10/10/23 at 9:20 AM, V3 checked the water temperature in the C-wing resident room…

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 food to residents at a palatable temperature. This has the potential to affect all 173 residents consuming Food from the kitchen. The Findings include: On 9/24/23 at 10:20 AM, V8 (Assistant Dietary Manager) stated, We have 173 residents eating from the Kitchen. 1. R4 is a [AGE] year-old female with cognition intact as per MDS dated [DATE]. On 9/23/23 at 10:48 AM, R4 stated in her bed, The Food is not good, it is not tasty. It is terrible. Today's egg and oatmeal for Breakfast were ice cold. It's not true that Breakfast is always late. Sometimes it is late. 2. R5 is an [AGE] year-old female with moderately impaired cognition as per MDS 7/14/23. On 9/23/23 at 10:50 AM, R5 stated, Food is not good here. It is often cold and not tasty. Today's Breakfast was cold. The meat is always tough. 3. R6 is a [AGE] year-old female with cognition intact as per MDS dated [DATE]. On 9/23/23 at 10:15 AM, R6 stated, Breakfast was early today, but it…

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 3 of 5 residents (R9, R10, and R11) reviewed for activities of daily living (ADL) from a sample of 12. The Findings include: 1. R9 is an [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents one-person extensive assistance with toilet use. On 9/23/23 at 10:25 AM, R9 was on her bed and stated, They didn't change me yet. I am taking a water pill, and I am soaked in urine. One time, they took 90 minutes to change me. Sometimes, I hate to ask them. On 9/23/23 at 10:28 AM, V5 (Certified Nursing Assistant/CNA) opened the incontinent brief, which was noted wet. V5 stated, I checked R9 before, and she wasn't wet then. On 9/24/23 at 10:40 AM, the second-floor hallway (in front of R9's room) had a strong urine odor. On 9/24/23 at 10:42 AM, V11 (CNA) stated that she…

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