McGivney Health Care Center

Based on observation, interview and record review, the facility failed to ensure spoiled food was discarded in 1 of 2 dry food storage areas reviewed for food storage. (the basement food storage area)Findings include:During an observation, on 8/19/25 at 11:12 a.m., bananas, with a received date of 8/6/25, were brown and black with a white growth substance on the stem. The bananas had spots which were oozing liquid and some bubbles forming.During an interview, on 8/21/25 at 11:40 a.m., the kitchen manager indicated the bananas needed to be thrown away as they were spoiled.A current facility policy, titled Expired Food, dated as last revised on 3/2/21 and received from the Activity Director on 8/22/25 at 11:30 a.m., indicated .DISPOSING OF SPOILED FOOD OR POSSIBLY CONTAMINATED: Place the food, i.e. expired, swollen metal cans or suspected glass jar in a heavy opaque or black garbage bag 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were in place and followed for 2 of 2 residents reviewed for enhanced barrier precautions. (Resident 12 and 31)Findings include: 1. During an observation, on 8/19/25 at 10:53 a.m., Resident 12 had a urinary catheter.The clinical record for Resident 12 was reviewed on 8/20/25 at 10:31 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia (prostate gland enlargement causing difficulty urinating) with lower urinary tract symptoms, prediabetes, and age-related physical debility.A physician's order, dated 8/6/25, indicated flush the urinary catheter daily with 40 milliliters (ml) of fluid.A physician's order for enhanced barrier precautions was not located in the medical record.There were no signs related to enhanced barrier precautions in the room or on Resident 12's door.During an observation, on 8/21/25 at 1:23 p.m., Licensed Practical Nurse (LPN) 3 completed catheter care for Resident 12. A gown was not worn during the procedure.During an…

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 at least 80 square feet (sq. ft.) per resident in 1 of 18 rooms. (room [ROOM NUMBER])Findings include:During an observation, on 8/19/25 at 3:04 p.m., room [ROOM NUMBER] was found to have two beds, two nightstands, two clothing wardrobes, and one dresser. Two residents were occupying the room.During an interview, on 8/19/25 at 3:04 p.m., Resident 21 indicated he liked his room and had no concerns with the size.During an interview, on 8/19/25 at 3:07 p.m., Resident 23 indicated he liked this room and had no concerns with the size of the room.During an interview, on 8/25/25 at 11:05 a.m., the Executive Director indicated there had been no physical changes to the room which had a previous room waiver since the last survey.A bed inventory form, dated 8/25/25, indicated room [ROOM NUMBER] contained two beds.A review of the facility measurements for room [ROOM NUMBER] indicated the bedroom did not provide 80 square feet per 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.

Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for Based on interview and record review, the facility failed to develop a comprehensive care plan which addressed constipation, insomnia, hyperlipidemia, and pain for 2 of 2 residents reviewed for comprehensive care plans. (Resident 11 and 26) Findings include: 1. During an interview, on 9/25/24 at 10:59 a.m., Resident 11 indicated he was often constipated. The clinical record for Resident 11 was reviewed on 9/27/24 at 11:01 a.m. The diagnoses included, but were not limited to, muscle weakness, abnormal weight loss, and chronic idiopathic constipation. A physician's order, initiated on 2/20/23, indicated to give Linzess Oral Capsule (a medication for constipation) 145 micrograms (mcg) once a day related to chronic idiopathic constipation. A physician's order, initiated on 3/2/22, indicated to give Miralax Powder (a medication for constipation) 17 grams/scoop in the morning for constipation.…

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 laboratory results for the monitoring and effectiveness of a cholesterol medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 26) Finding includes: The clinical record for Resident 26 was reviewed on 9/26/24 at 2:25 p.m. The diagnoses included, but were not limited to, pain in an unspecified joint, insomnia, and mixed hyperlipidemia. A physician's order, initiated on 8/27/21, indicated to give Lipitor (a medication for high cholesterol) 10 milligrams daily at bedtime for mixed hyperlipidemia. A laboratory result, dated 2/11/22, indicated the resident had a high triglyceride level of 188. There were no other laboratory results in the record to indicate a lipid profile (a blood test to monitor the lipid levels in the blood) had been monitored after 2/11/22. There were no entries in the record to indicate laboratory orders had been received and/or were pending. During an interview, on 10/2/24 at 10:07 a.m., the Minimum Data Set (MDS) Nurse indicated the facility did not have a policy…

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 monitor and document a resident's delusions related to the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 28) Finding includes: The clinical record for Resident 28 was reviewed on 10/1/24 at 9:21 a.m. The diagnoses included, but were not limited to, unspecified dementia, psychotic disorder with delusions, alcohol abuse, and hyperlipidemia. A physician's order, with a start date of 4/5/24, indicated to give Zyprexa (an antipsychotic medication) 7.5 milligrams (mg) by mouth at bedtime for a psychotic disorder with delusions. A care plan, with a revision date of 1/28/21, indicated the resident displayed at times delusions he believed he was incarcerated and he planned to discharge. A care plan, with a revision date of 4/12/24, indicated the resident used the psychotropic medication Zyprexa related to psychosis with delusions. During an interview, on 10/1/24 at 9:58 a.m., the Director of Nursing (DON) indicated Resident 28 did have delusions. Behaviors should be…

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 and interview, the facility failed to ensure food was properly stored in a kitchen refrigerator for 1 of 1 kitchen reviewed for food service safety. (the refrigerator) Finding includes: During an observation, on 9/27/24 at 11:02 a.m., there was thawing meat stored above a gallon of milk, next to yogurt and a grocery sack of green bell peppers which belonged to a resident and were unlabeled in a kitchen refrigerator. During an interview, on 9/27/24 at 11:09 a.m., the Kitchen Manager indicated the milk should be stored on the top rack and not under the thawing meat. They should not store residents' food in the kitchen refrigerator. They have a refrigerator for storing residents' food downstairs in storage. A current policy, titled McGivney Health Care Center Food and Nutrition Policy, dated as last revised 3/1/17 and received from the Executive Director on 10/2/24 at 10:30 a.m., indicated .Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods .All foods belonging to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in 1 of 18 rooms reviewed for living space. (room [ROOM NUMBER]) Finding includes: During the entrance conference, on 9/25/24 at 10:12 a.m., the Director of Nursing indicated room [ROOM NUMBER] continued to have a room size waiver. During an observation of room [ROOM NUMBER] with Maintenance Staff 4, on 9/25/24 at 9:44 a.m., the room was found to contain two beds and two free standing wardrobes which were used for clothing and storage of personal items belonging to the two occupants of the room. A review of the facility measurement indicated room [ROOM NUMBER] was 153.83 square feet and according to Life Safety code the double occupancy of the room allowed 76.9 square feet of living space per resident. During an interview, on 9/30/24 at 2:34 p.m., Resident 29 indicated he liked his room and felt he had enough space for himself and his roommate. During an interview, on 9/30/24 at 2:49 p.m.,…

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 residents were offered bedtime snacks each evening. There was a 15-hour time lapse between the supper meal and breakfast. This deficient practice had the potential to affect 35 of 35 residents who resided in the facility. Finding includes: A dining schedule, provided at entrance, indicated the facility supper time was 5:00 p.m., and breakfast was at 8:00 a.m., which was a 15-hour time lapse between these meals. During an interview, on 9/20/23 at 11:00 a.m., CNA 10 indicated the cook on the evening shift would gather a cart of snacks including peanut butter and jelly sandwiches and crackers. The facility staff did not pass out the snacks although they were available for any resident who wanted them. Usually, the residents who wandered and were up all night would get the snacks. During an interview, on 9/20/23 at 11:41 a.m., Resident 6 indicated she did not get a snack at night and the facility staff did not ask her if she wanted a snack. When she did ask for a snack, the staff would tell her they did not have any…

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 thaw out meat safely and have the sanitizing solution (used to disinfect tables and counters) bucket levels at the recommended range to kill bacteria. This deficient practice had the potential to affect 35 of 35 residents who received food from the kitchen. Findings include: During the kitchen observation, on 9/17/23 at 11:00 a.m., with the Dietary Staff 19 the following were observed: a. The sink contained 2 large plastic bags of frozen chicken. The sink had no cold water in the sink and the chicken was thawing at room temp. b. The red sanitizer bucket was tested three times. Dietary Staff 19 placed a test strip into the bucket and the testing strip did not change colors. She tested the bucket again using a strip from a different container and the testing strip did not change color. She then took a third container, and the testing strip did not change colors. The containers for all three sanitizing solution testing strips indicated the ranges for the solution were numbered 10, 25, 50, 100 and 200 and should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Executive Director (ED) failed to ensure the Director of Nursing (DON) was completing the infection surveillance and antibiotic stewardship for the infection control program, to ensure the facility had policies for infection surveillance and antibiotic stewardship, to ensure policies were reviewed annually, to ensure QAPI (quality assurance and performance improvement) meetings had documentation of items reviewed during the meetings, to ensure the facility was staffed according to the needs listed in the facility assessment and to ensure the facility environment was clean and in good repair. Findings include: 1. During an interview, on 9/19/23 at 11:12 a.m., the Director of Nursing (DON) indicated she did not have an infection control binder. There was no infection surveillance or map of the type of infections at the facility or documentation if there were any trends of infections. She indicated she was not familiar with any type of criteria for the appropriate use of…

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

Based on interview and record review, the facility failed to document an annual review of the infection control policies, to ensure multiple use glucometers were clean and to ensure soiled clothing was not thrown on the floor for 1 of 1 residents reviewed for incontinence care (Resident 6). Findings include: 1. A current policy, titled COVID-19 Vaccination Requirements, received from the Executive Director (ED) at entrance did not have an effective date or a date reviewed. A current policy, titled Influenza and Pneumococcal Immunizations, received from the ED at entrance had an effective date of 2016 and no revision or date reviewed. During an interview, on 9/19/23 at 12:21 p.m., the Executive Director (ED) indicated the facility did not date their policies to show they had reviewed them annually. 2. During a medication storage observation, on 9/18/23 at 3:00 p.m., the long hall medication storage cart was observed to have the following: a. There was one glucometer sitting on top of the sticky top drawer and it was not in any type of wrapping or container. 3. During a medication…

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 establish policies and a program for antibiotic stewardship, to monitor the use of antibiotics including the use of standardized tools for the appropriateness of antibiotics prescribed and to have a system of surveillance for residents with repeated urinary tract infections (UTIs) for 2 of 2 residents reviewed for UTIs. (Resident 186 and 32) Finding includes: 1. During the entrance conference, the facility failed to provide a policy on antibiotic stewardship and infection surveillance. The Infection Control binder provided by the facility at entrance was dated 2022 and June 2022 was the last entry in the binder. The facility had monthly logs printed by the pharmacy which included the resident name, type of infection, signs and symptoms, and antibiotic utilized. The log did not include if the infection and signs and symptoms met the standardized criteria for the use of the antibiotic. The log did not include if the antibiotic was appropriate for the culture and sensitivity reports for UTIs. During an interview, on 9/19/23…

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

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) was knowledgeable, had completed the facility infection surveillance and antibiotic stewardship documentation, and was not also the acting Director of Nursing (DON) for 1 of 1 Infection Preventionist reviewed. (The DON) Finding includes: During the entrance conference, the Executive Director (ED) provided an IP certificate for the DON which was completed on 6/14/23. During an interview, on 9/18/23 at 4:20 p.m., the ED indicated there was no job description for the IP nurse. The DON job description included the duties of the IP. During an interview, on 9/19/23 at 11:12 a.m., the Director of Nursing (DON) indicated she did not have an infection control binder and only had an antibiotic log which was printed out by the pharmacy monthly. She did not have any type of monitoring for infections other than the monthly log printed from the pharmacy. There was no surveillance or map of the type of infections at the facility or documentation if there were any trends of infections. She indicated…

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 notify the physician of a weekly weight gain and a blood sugar outside the call parameters for 2 of 2 residents reviewed for notification of change. (Resident 1 and 12) Findings include: 1. The record for Resident 1 was reviewed on 9/21/23 at 11:34 a.m. Diagnoses included, but were not limited to, type 2 diabetes myelitis, dementia, and hypertension. A care plan, revised 2/9/17, indicated the resident was on a diuretic (furosemide) due to hypertension. The interventions included, but were not limited to, weekly weight and notify the physician per protocol. A physician's order, dated 10/1/20, indicated to weigh the resident weekly and if there was a greater than 3-pound weight gain notify the physician. A facility vital sign documentation indicated the following weights: a. The weight, on 8/25/22, was 209 pounds (lbs.). b. The weight, on 9/1/22, was 216 lbs. The resident had a 7 lb. weight gain in one week. There was no documentation to indicate the physician was notified of the 7-pound weight gain. During an interview, on…

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

Based on interview and record review, the facility failed to ensure a significant medication error which resulted in a resident requiring an intensive care stay of 5 days in the hospital was reported to the State Agency for 1 of 1 resident reviewed for reporting. (Resident 20) Finding includes: The record for Resident 20 was reviewed on 09/19/23 at 2:01 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbance, bradycardia, abnormal weight loss, mood disorder, chronic pain syndrome, and hypertension. A progress note, dated 6/30/23 at 9:25 am, indicated the resident was noted to be lethargic. The skin was cool to touch, he had increased slurring speech, and his speech was garbled. The provider was notified and requested a transfer to the emergency department. An SBAR (situation, background, assessment, and recommendation form), dated 6/30/23 at 9:36 a.m., indicated the resident had a change in mental status and was given another resident's medications. A hospital patient summary report, dated 6/30/23 at 2:46 pm, indicated the admitting diagnosis 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 interview and record review, the facility failed to ensure a new diagnosis of systolic heart failure was included in the MDS (Minimum Data Set) under medical diagnoses for 1 of 1 resident reviewed for assessments. (Resident 32) Finding includes: The record for Resident 32 was reviewed on 9/19/23 at 11:31 a.m. Diagnoses included, but were not limited to, dementia, depressive episode, psychotic disorder with delusions due to known physiological condition, restlessness and agitation, pain in the right leg, and delusional disorders. A progress note, dated 4/4/23 at 12:09 p.m., indicated the resident had swollen arms, pitting edema to both ankles and abdomen. She had diminished lung sounds noted throughout the lobes. The provider was notified, and a new order was received to send the resident to the emergency department for evaluation and treatment. A hospital discharge summary note, dated 4/9/23 at 1:25 p.m., indicated a new diagnosis of acute systolic heart failure exacerbation. The echocardiogram indicated an ejection fraction (percentage of blood pumped out with 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 another PASARR (Preadmission Screening and Resident Review) level I was completed when the resident was prescribed an antipsychotic medication for 1 of 2 residents reviewed for PASARR. (Resident 29) Finding includes: The record for Resident 29 was reviewed on 9/20/23 at 4:30 p.m. Diagnoses included, but were not limited to, unspecified dementia, mood disturbance, anxiety disorder, and psychotic disorder with delusion. A PASARR level I, dated 9/4/20, indicated the resident had no mental health medication and no level II was required due to situational symptoms. The level I screen indicated a PASARR disability was not present because of the following reason: Low level behavioral health symptoms were present. However, those appear to be situational. If the individual's symptoms or behaviors did not improve or resolve within 30-60 days of this screen, then the nursing facility must submit an updated status change level I screen to reevaluate the need for a PASARR level II behavioral health evaluation. A physician'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.

Based on record review and interview, the facility failed to ensure a resident with a new seizure diagnosis had a care plan for 1 of 1 resident reviewed for care plans. (Resident 22) Finding includes: The record for Resident 22 was reviewed on 9/19/23 at 12:19 p.m. Diagnoses included, but were not limited to, unspecified intracranial injury with loss of consciousness of unspecified duration, nontraumatic subarachnoid hemorrhage, epileptic seizures, and fracture of nasal bone. A physician's order, dated 7/14/23, indicated lacosamide (a seizure medication) 150 mg (milligrams) twice daily for seizures. A progress note, dated 7/14/23 at 12:12 a.m., indicated the resident was walking down the hall going to the shower. He was noted hitting the wall and banister while starting to seize. He had issues breathing and a seizure with full tonic-clonic movement. The seizure activity lasted 3 minutes. A hospital discharge note, dated 7/17/23, indicated the resident had a 3-minute grandmal seizure witnessed at the extended care facility. Facility staff indicated the resident had no previous…

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 investigate a fall with a major injury for 1 of 4 residents reviewed for falls. (Resident 186) Finding includes: The record for Resident 186 was reviewed on 9/20/23 at 1:37 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, non-traumatic chronic subdural hemorrhage, generalized anxiety disorder, and cognitive communication deficit. A progress note, dated 7/22/23 at 3:13 p.m., indicated the resident was experiencing episodes of increased confusion, stumbling during ambulation, and did not feed himself during mealtimes. The resident was sent to the hospital. A hospital presenting symptoms details report, dated 7/22/23, indicated the resident had increased confusion. The resident was not eating on his own at the long-term care (LTC) facility as he usually did and had an unwitnessed fall. The emergency department work up showed the resident had an acute on chronic subdural hematoma (usually caused by a head…

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 being treated for a urinary tract infection was provided timely incontenent care and was free from wearing two incontinent briefs, failed to obtain a culture and sensitivity after a urinalysis, and failed to prevent a recurrent urinary tract infection for 2 of 3 residents reviewed for urinary tract infections. (Resident 6 and 32) Findings include: 1. During an interview, on 9/22/23 at 2:20 p.m., Resident 6 indicated she had been waiting two hours to have her wet brief changed and her buttock was hurting. The resident asked the Certified Nursing Assistant (CNA) 13 at noon to be changed and was still waiting. During an observation, on 9/22/23 at 2:31 p.m., Qualified Medication Assistant (QMA) 11 and CNA 12 entered the resident's room to provide peri-care. QMA 11 indicated Resident 6 had a strong urine odor. QMA 11 opened the left side of the incontinent brief and tucked the end of the incontinence brief under the resident's left side. The resident was wearing two briefs. The staff turned 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, record review and interview, the facility failed to ensure there was 24 hours of CNA (Certified Nursing Assistant) coverage during the day and evening shift according to the facility assessment, failed to ensure staff were able to complete documentation on the Medication Administration Record (MAR), and failed to ensure a resident was provided timely incontinent care for 8 shifts and 2 of 2 residents reviewed for sufficient staffing. (5/28/23 day shift, 5/27/23 evening shift, 5/21/23 evening shift, 5/7/23 evening shift, 5/6/23 day and evening shift, and 4/30/23 day and evening shift, and Residents 28 and 6) Finding includes: 1. A payroll Based Journal (PBJ) report, for the third quarter of 2023, indicated the facility triggered for low weekend staffing. During an interview, on 9/19/23 at 2:53 p.m., the Executive Director (ED) indicated the facility assessment showed the need for 24 hours Certified Nursing Assistant (CNA) coverage during the day and evening shifts. This would be a total of 3 CNAs for the day and evening shifts. If the facility was using agency…

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 Registered Nurse (RN) was in the facility for 8 hours each day during a 24-hour period for 27 days of the third quarter reviewed for sufficient staffing. (April 1, 2, 7, 8, 9, 15, 16, 22, 29, and 30, May 6, 7, 13, 14, 20, 21, 27, 28, and 29, June 3, 4, 10, 11, 17, 18, 24 and 25, 2023). Finding includes: A Payroll Based Journal (PBJ) report, for the third quarter of 2023, indicated the facility did not have RN coverage for April 1, April 2, April 7, April 8, April 9, April 15, April 16, April 22, April 29, April 30, May 6, May 7, May 13, May 14, May 20, May 21, May 27, May 28, May 29, June 3, June 4, June 10, June 11, June 17, June 18, June 24 and June 25, 2023. The facility assessment, received at entrance and updated on 6/6/2023, indicated the facility was to have 8 hours of RN coverage each day. During an interview, on 9/19/23 at 11:03 a.m., the Director of Nursing (DON) indicated she started working as the DON at the end of February. She was the only RN who worked at the facility. She was at the facility 4 days…

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 record review and interview, the facility failed to ensure performance reviews were completed for nurse aides at least every 12 months for 5 of 5 CNAs (Certified Nursing Assistants) reviewed for employee records. (CNA 14, CNA 15, CNA 16, CNA 17, and CNA 10) Finding includes: During a record review, on 9/18/23 at 1:55 p.m., the employee records indicated there were several missing in-services. During an interview, on 9/20/23 at 2:53 p.m., the DON (Director of Nursing) indicated she had not done any performance reviews for CNAs and could not provide any. A current position description, titled Director of Nursing, created on March 2019 and received from the Executive Director (ED) indicated .Evaluates the work performance of all nursing personnel During an interview, on 9/21/23 at 2:33 p.m., the ED indicated he had no policy for providing staffing performance reviews. 3.1-14(h)(1) 3.1-14(h)(2) 3.1-14(h)(3)

Based on observation, interview and record review, the facility failed to post nurse staffing information in an area which could be clearly seen for 35 of 35 residents and visitors reviewed for nurse staffing. Finding includes: During an observation, on 9/19/23 at 11:10 a.m., there was no posted nurse staffing sheet around the nurse's station or noted in the facility. During an interview, on 9/19/23 at 11:15 a.m., the Activities Director indicated the facility did not post nurse staffing data but kept it in a binder. During an observation, on 9/19/23 at 11:20 a.m., the daily staffing sheet was in a binder behind the nurse's station. The daily staffing sheet was not posted in an area easily visible for residents and visitors. During an interview, on 9/21/23 at 2:33 p.m., the ED (Executive Director) indicated he had no policy about posting nurse staffing but it should be posted in the facility. 3.1-17(b)

Based on observation, interview and record review, the facility failed to ensure by mouth (PO) medications, injectable medications and eye drops were stored separately, medications and food were not stored together, medications were labeled when opened and glucometers were stored in a separate bag for 2 of 2 medication carts reviewed and 1 of 1 medication rooms reviewed. (long hall cart, short hall cart and the medication room) Findings include: 1. During a medication storage observation, on 9/18/23 at 3:00 p.m., the long hall medication storage cart was observed to have the following: a. One bottle of lidocaine (a numbing injectable medication) was stored with a bottle of eye drops. b. The top drawer of the medication cart had lots of debris, dirt, and a brownish sticky substance all over the bottom. c. There was one glucometer sitting on top of the sticky top drawer and it was not in any type of wrapping or container. d. The bottom drawer on the right had lots of debris and dirt on it. e. The bottom drawer on the left had debris, dirt, and sticky substances on it. 2. During a…

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

Based on interview and record review, the facility failed to ensure the Medication Administration Records (MARs) were documented completely to identify if the residents did or did not receive the prescribed medication for 2 of 2 residents reviewed for medication administration documentation. (Residents 6 and 28) Findings include: 1. The record for Resident 6 was reviewed on 9/20/23 at 2:19 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, depressive disorder, type 2 diabetes mellitus, and anxiety disorder. A MAR, dated for the month of August 2023, indicated the following medications were not signed as administered or not administered: a. Aspirin (Nonsteroidal anti-inflammatory and blood thinner) 81 mg (milligram) one tablet daily on 8/25 and 8/31/23 at 9:00 a.m. b. Cyclobenzaprine (muscle relaxant) HCI 10 mg one tablet daily on 8/25 and 8/31/23 at 9:00 a.m. c. Doxepin (antidepressant) HCI 10 mg one tablet daily on 8/24/23 at 9:00 a.m. d. Famotidine (antacid) 40 mg one tablet daily on 8/25 and 8/31/23 at 9:00 a.m. e.…

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 the Quality Assurance and Performance Review (QAPI) committee had documentation of quarterly meetings, documentation of problem areas identified, documentation of staff feedback regarding identified problems and documentation if the problems had improved or worsened. Findings include: During an interview, on 9/21/23 at 2:32 p.m., the ED indicated the QAPI meets monthly although they only did QAPI reports 4 times a year. They would review falls, urinary tract infections (UTIs), activities and behaviors. They were also looking at staffing. He indicated there were no meeting minutes for the items reviewed. They were looking at falls and would communicate all the information verbally. There was no documentation about any processes being changed or implementation of new interventions or reports about the effectiveness of the changes. The QAPI meetings were used for the facility clinical meetings since they did not meet for daily or weekly clinical…

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 received the influenza vaccination after consenting to be vaccinated for 1 of 5 residents reviewed for infection control. (Resident 26) Finding includes: The record for Resident 26 was reviewed on 9/20/23 at 9:21 a.m. Diagnoses included, but were not limited to, Parkinson's disease, dementia, and heart disease. The record did not show he had received an influenza vaccine in 2022. An influenza vaccine consent was received by the resident's representative and was signed on 2/2/22. During an interview, on 9/20/23 at 10:54 p.m., the ED (Executive Director) indicated the resident did sign a consent for the 2022 influenza vaccine. He did not receive the vaccine because he slipped through the cracks. During an interview, on 9/21/23 at 2:33 p.m., the ED indicated he did not have a policy on providing influenza vaccinations to residents. A current policy, titled Influenza and Pneumococcal Immunizations, effective date 2016 and received at entrance conference indicated .The resident's medical record includes…

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 record review and interview, the facility failed to ensure a facility employee had documentation of receiving the Covid-19 vaccination or had obtained an exemption for the vaccine for 1 of 3 employees reviewed for Covid-19 vaccinations. (Activity Director) Finding includes: The Activity Director's record was reviewed on 9/20/23 at 9:21 a.m., which indicated the Activities Director did not have the Covid-19 vaccine or had documentation supporting refusal for the vaccine. During an interview, on 9/20/23 at 11:07 a.m., the ED (Executive Director) indicated the Activities Director was not Covid-19 vaccinated and did not have any documentation to support refusal or education for the vaccination. A current policy, titled COVID-19 Vaccination Requirements received at entrance conference, indicated .Providers participating in Medicare and Medicaid programs must ensure staff are fully vaccinated for COVID-19, unless exempt 3.1-18(b)(6)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft.) per resident in 1 of 18 rooms. (room [ROOM NUMBER]) Finding includes: During the entrance conference, on 9/17/23 at 1:07 p.m., the Executive Director indicated there had been no physical changes to the room which had a previous room waiver since the last survey on 7/26/22. He indicated room [ROOM NUMBER] had two beds, two residents, and currently had a waiver. During an observation, on 9/18/23 at 3:26 p.m., room [ROOM NUMBER] was found to have 2 beds. It was noted two residents were occupying the room. A review of the facility measurements for room [ROOM NUMBER] indicated the bedroom did not provide 80 square feet per resident. room [ROOM NUMBER] was 153.83 sq. ft., and according to Life Safety Code the double occupancy in room [ROOM NUMBER] measured out to 76.9 sq. ft. per resident. A Bed Inventory form indicated room [ROOM NUMBER] was a Title 19 NF (Medicaid) room and was certified for two…

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 interview, the facility failed to ensure resident rooms and the dining room were clean, painted, and free of debris and dirt for 4 of 36 rooms and 1 of 1 dining room reviewed for environment. (room [ROOM NUMBER], 1, 11, 13, and dining room) Findings include: 1. During an observation, on 9/17/23 at 1:55 p.m., the wall in room [ROOM NUMBER] had 4 brown round areas and 2 patches near the resident head of the bed which were painted the wrong color. 2. During an observation, on 09/17/23 at 11:23 a.m., room [ROOM NUMBER] had no closet in the room. There was a clothes basket and belongings on the floor in the room. There was 1 small 2-layer plastic bin for some clothes. 3. During an observation, on 9/18/23 at 3:25 p.m., room [ROOM NUMBER]'s-bathroom shower had a rusty drain and 3 spots where the shower floor was peeled. 4. During an observation, on 9/17/23 at 12:44 p.m., room [ROOM NUMBER] had approximately 2-foot black scuffs mark under the windows and missing trim by the closet. 5. During an…

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.