Park Terrace Village

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. Finding includes: On 2/12/24 at 10:13 A.M., Resident 51 indicated she was one of the last residents to get served food and her breakfast was not always hot. On 2/12/24 at 10:56 A.M., Resident 15 indicated the food was occasionally cold when it arrived to her room. On 2/12/24 at 11:29 A.M., Resident 60 indicated she had an issue with the temperature of the food. On 2/12/24 at 11:29 A.M., Resident 17 indicated the food was not always hot when it arrived to his room. On 2/12/24 at 1:27 P.M., Resident 45 indicated the food was not hot when served. On 2/12/24 at 1:47 P.M., Resident 52 indicated that the food was occasionally cold when it arrived to his room. On 2/13/24 at 2:30 P.M., Resident 32 indicated the food didn't taste good and the temperatures weren't consistently palatable. On 2/15/24 at 12:56 P.M., a test tray was obtained from the C Hall. The following temperatures were observed and recorded: Baked beans - 112…

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 that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications in their room. (Resident 32, Resident 30) Findings include: 1. On 2/15/24 at 10:15 A.M., QMA (Qualified Medication Aide) 7 was observed taking medication into Resident 32's room. QMA 7 left the medication cup with pills in it on the resident's bedside table without watching the resident take the medication. On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, congestive heart failure, hyperlipidemia, and major depressive disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/21/23, indicated Resident 32 was cognitively intact. The clinical record lacked an order or evaluation for self administration of medications. On 2/16/24 at 9:16 A.M., LPN (Licensed Practical Nurse) 14 indicated there weren't any residents…

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 MDS (Minimum Data Set) Assessment was completed accurately for 1 of 3 residents reviewed for MDS discrepancy. (Resident 32) Finding includes: On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, acquired absence of right leg above knee, and generalized muscle weakness. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/21/23, indicated Resident 32 was cognitively intact, was dependent on 2 or more staff for transfers, and had no falls since the prior assessment on 8/21/23. Progress notes indicated Resident 32 sustained falls on 8/25/23, 8/26/23, 10/25/23, and 11/5/23. On 2/20/24 at 10:45 A.M. the Administrator indicated the 11/21/23 MDS quarterly assessment should be marked yes for falls for Resident 32 and was unsure why it had been marked no. At that time, she indicated the facility…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan interventions were implemented for 1 of 1 residents reviewed for urinary catheter care. (Resident 57) Findings include: On 2/12/24 at 2:54 P.M. Resident 57 was observed sitting near the front door. Resident 57's catheter bag was hanging from the back of the wheelchair. There was no protective pouch covering the bag. On 2/15/24 at 7:34 A.M. Resident 57 was observed in the hall with the catheter bag hanging on the armrest of the wheelchair above waist level. There was no protective pouch covering the bag. On 2/16/24 at 8:47 A.M., Resident 57 was observed in the hall with the catheter bag hanging on the armrest of the wheelchair above waist level. There was no protective pouch covering the bag. On 2/14/24 at 9:15 A.M., Resident 57's clinical record was reviewed. Resident 57's diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), and type 2 diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment was completed…

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 prevent a friction abrasion from occurring for 1 of 2 residents observed for facility acquired skin alterations. (Resident 29) Findings include: During an observation on 2/12/24 at 2:12 P.M., Resident 29's mattress was observed to have a deep impression, and the metal bar of the bed frame beneath the mattress could be felt through the dip in the mattress. The resident expressed the wound on her bottom had occurred multiple times as a result of transferring over the spot in the mattress where the bar was palpable. She indicated the staff were aware of the defective mattress and the pressure it was causing against her skin. A new or different mattress was not provided. No grab bar was observed on the left side of Resident 29's bed. On 2/14/24 at 8:27 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and type 2 diabetes mellitus. Resident 29's most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/2/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received supervision and consistent implementation of interventions to prevent falls for 2 of 4 residents reviewed for accidents related to falls. Fall interventions were not consistently implemented, thorough assessments of post fall needs was lacking, and care plans were not updated following falls. (Resident 32, Resident 60) Findings include: 1. On 2/13/24 at 2:30 P.M., QMA 12 was observed transferring Resident 32 from a chair to his bed using a slide board and no gait belt. On 2/15/24 at 10:58 A.M., Resident 32's clinical record was reviewed. Resident 32 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, acquired absence of right leg above knee, and generalized muscle weakness. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 11/21/23, indicated Resident 32 was cognitively intact, was dependent on 2 or more staff for transfers, and had no falls since 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 monitor for behaviors in 1 of 2 residents reviewed for resident to resident altercations. (Resident 37, Resident 3) Findings include: On 2/12/24 at 9:48 A.M., Resident 3 indicated there was another resident (Resident 37) who was verbally aggressive with him, followed him around, and bothered him during the one time verbal altercation. He indicated the other resident (Resident 37) made him feel scared at that time but feels nervous sometimes now when he sees him in the hallway. At that time of the altercation, he indicated that he had made staff aware. On 2/16/24 at 1:16 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, mild intellectual disability, generalized anxiety, and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/12/24, indicated Resident 3 was cognitively intact and had no behaviors. A progress note on 1/30/2024 at 7:57 P.M. indicated Resident heard hollering at another resident in the smaller dining area. Per resident, another resident…

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 routine medications were available and dispensed according to physician's orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 15) Finding includes: On 2/12/24 at 10:59 A.M., Resident 15 indicated that on the evening of 2/7/24 she started having uncontrollable tremors and couldn't breathe. At that time, she learned from a nurse that she was out of lorazepam. She indicated the nurse left the room to retrieve lorazepam out of the emergency drug kit (EDK), but never returned. She began screaming for someone to come back, and after about an hour of no one coming, she called 911 for help. An ambulance arrived at the facility and she was transported to the hospital where she was diagnosed and treated for withdrawal. The resident indicated during that time she felt the most lonely she had ever felt in life and wondered if she was going to die. On 2/16/24 at 8:28 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder and…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices and standards were in 2 of 2 residents observed during care. Staff was observed not performing hand hygiene, changing gloves during care.( Resident 55, Resident 29) Findings include: 1. On 2/19/24 at 12:59 P.M., RN (Registered Nurse) 3 was observed during tracheostomy care on Resident 55. The following was the observation of the procedure: RN 3 did not wash hands after gloves were removed following the cleaning of the aerosol collar for the tracheostomy and the inner cannula. RN 3 placed sterile gloves on hands and handles the yankauer (suction tool) with both sterile hands. RN 3 did not wash hands prior to the application of clean gloves, before the trach stoma was cleaned with sterile water and Q-tip. RN 3 did not change gloves prior to the application of ointment on the 4 x 4 dressing around the stoma. RN 3 did not wash hands after the removal of soiled gloves and applying sterile gloves, before the changing of the inner cannula. 2. On 2/20/24 at 9:58 A.M., RN (Registered…

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 were followed for 1 of 3 residents reviewed. A resident was not made NPO (Nothing by Mouth) before an ordered medical test. (Resident B) Finding includes: On 1/11/24 at 9:28 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, other specified diseases of liver-hepatic hilum mass, atrial fibrillation, rhabdomyolysis, unspecified dementia. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact. Care plans were reviewed and included, but were not limited to, Resident requires assistance with ADL's (activities of daily living), including bed mobility, transfers, eating, and toileting related to .hepatic hilum mass . September and October 2023 physicians orders were reviewed and included, but were not limited to: September 2023: Appointment with [name] MRI (Magnetic Resonance Imaging) date/time : 9/25/23 12:30 p.m. Location: [name] diagnostic…

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 provide ADL's (activities of daily living), care to 3 of 3 resident's reviewed for bathing. Bathing was not provided to residents. ( Resident B, Resident E, Resident F ) Finding includes: 1. On 1/11/24 at 9:29 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, other lack of coordination, unsteadiness on feet, other abnormalities of gait and mobility. A quarterly MDS (Minimum Data Set), assessment dated [DATE], indicated Resident B's cognition was intact, shower/bathe self- partial/moderate assistance. Resident B no longer resided at the facility. Care plans were reviewed and included, but were not limited to: Resident requires assistance with ADL's (Activities of Daily Living), including bed mobility, transfers, eating and toileting related to: weakness, decreased mobility, impaired balance, incontinence , HX of falls, fall risk, atrial fibrillation, dementia, hepatic hilum mass, HTN,…

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 infection control practices were maintained to mitigate the spread of COVID-19 for 2 of 4 observations. Staff were observed to enter COVID- 19 positive resident rooms without the proper PPE (Personal Protective Equipment). ( room [ROOM NUMBER], room [ROOM NUMBER] ) Findings included: On 12/14/23 at 8:29 a.m., LPN 1 was observed to have on a surgical mask and gown. LPN 1 was observed to don gloves and enter room [ROOM NUMBER]. LPN 1 did not have on a N95 or eye protection before entering the room. room [ROOM NUMBER] had an isolation sign on the door and a sign with instructions on how to don and doff PPE (Personal Protective Equipment). The isolation sign included, but was not limited to: Isolation -Droplet/Contact Precautions. In addition to standard precautions, staff and providers must : Hand hygiene: when entering and exiting and wear all PPE listed below: Gown, N95 Respirator, Eye Protection ( face shield or goggles), Gloves.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the plan of care was followed for 2 of 3 residents reviewed for residents receiving dialysis services. Physician orders were not followed and routine assessments were not completed for residents receiving peritoneal dialysis (PD). (Resident B, Resident C) Findings includes: 1. During record review on 9/5/23 at 11:000 A.M., a facility reported incident, dated 8/27/23, included that Resident B received PD treatment while the treatment was on hold. Resident B's diagnoses included but was not limited to end stage renal disease, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease. Resident B's most recent admission MDS (Minimum Data Set), dated, 8/13/23 , indicated the resident's cognition was moderately impaired and that they had not received dialysis treatments during the prior 7 day look back period. Resident B's physician orders included, but was not limited to; daily weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who required assistance with ADL's received a shower for 7 of 9 residents reviewed. (Resident C, Resident F, Resident B, Resident D, Resident G, Resident J, Resident H) Findings include: 1. On 9/21/22 at 1:48 P.M., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, major depressive disorder, anxiety, and osteoarthritis. The Significant Change MDS (Minimum Data Set) assessment, dated 5/21/22, indicated the resident required the extensive assistance of two staff members for bed mobility, transfers, and was dependent on staff for bathing. Resident C was always incontinent of bowel and bladder. Resident C's care plan included, but was not limited to, resident will have ADL (Activities of Daily Living) needs med, initiated on 11/19/19. The interventions included, but were not limited to, morning and afternoon care including bathing. Resident C's bathing…

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 kitchen staff followed recipes for 4 of 4 pureed meals observed. Kitchen staff failed to measure ingredients in accordance with the recipes. Finding includes: During an observation on 9/22/22 at 11:31 A.M., Dietary Manager prepared 4 (four) pureed meals. The Dietary Manager indicated he was preparing lasagna, Caesar salad, garlic bread, and peaches. The recipe binder was set on the table, closed. The meals were prepared as follows: Lasagna- The Dietary Manager added 4 (four) 6 (six) ounce scoops of lasagna and an undetermined amount of beef broth to the food processor. At that time, the Dietary Manager indicated it was probably about 1 (one) teaspoon of beef broth that was added. Caesar Salad- The Dietary Manager added an unknown amount of lettuce and salad dressing in the food processor, and 4 packets of parmesan cheese. At that time, the Dietary Manager indicated it was about 4 ounces of lettuce and about 1/3 cup of salad dressing. Garlic Bread- The Dietary Manager added 1 cup of pureed bread mix to…

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

Based on interview and record review, the facility failed to ensure Quarterly MDS (MDS) assessments were completed timely for 2 of 22 residents reviewed. (Resident C, Resident 23) Findings include: 1. During record review on 9/21/22 at 1:15 P.M., Resident C's most recent Quarterly MDS assessment due 8/21/22 was still in progress. The last completed MDS assessment was a Significant Change assessment completed 5/21/22. 2. During record review on 9/23/22 at 10:40 A.M., Resident 23's most recent Quarterly MDS assessment due 9/14/22 was still in progress. Resident 23's last completed MDS assessment was a Significant Change assessment completed 6/14/22. During an interview on 9/23/22 at 11:32 A.M., the MDS Coordinator indicated they were new to the position and were trying to get caught up on the late assessments and that assessments should be completed every 3 months or during a significant change. On 9/23/22 at 11:50 A.M., the DON (Director of Nursing) supplied a facility policy titled, Resident Assessment (RAI) OBRA Required Assessments, dated 8/2019. The policy included, It is 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 implement the plan of care for 1 of 1 residents reviewed for pain and 1 of 4 residents reviewed for falls. A resident didn't receive a topical pain relieving gel as ordered by the physician and a resident's fall interventions were not in place. (Resident 49, Resident G) Findings include: 1. During an observation on 9/20/22 at 11:04 A.M., Resident 49 was lying in bed. A tube of ointment was lying on the bedside table next to the resident. Resident 49 indicated the tube on the bedside table was her Voltaren Gel (topical pain relieving gel), and that staff did not routinely apply the gel. Resident 49 indicated she had knee pain. During record review on 9/23/22 at 8:49 A.M., Resident 49's diagnoses included, but were not limited to, peripheral vascular disease, polyneuropathy, pain in right shoulder, and pain in left shoulder. Resident 49's most recent Quarterly MDS (Minimum Data Set) assessment dated , 7/24/22, indicated the resident had no cognitive impairment and received scheduled pain medications. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident care conferences with residents and family members were held at least quarterly for 4 of 6 residents reviewed for participation in care planning conferences. (Resident F, Resident 50, Resident 19, Resident 21) Findings include: 1. During an interview on 9/20/22 at 9:45 A.M., Resident F indicated they had not recently had a care planning conference. During record review on 9/22/22 at 12:00 P.M., Resident F's diagnoses included, but were not limited to, anxiety and dementia. Resident F's most recent Significant Change MDS (Minimal Data Set) assessment, dated 7/26/22, indicated the resident had no cognitive impairment. During an interview on 9/23/22 at 12:29 P.M., the Social Service Director (SSD) indicated Resident F had been scheduled to have a care planning conference and that their last care planning conference was held on 4/26/22. 2. During an interview on 9/19/22 at 12:50 P.M., Resident 50 indicated they had not had a care planning…

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 an environment free of accident hazards for 1 of 4 residents reviewed for accidents. (Resident 11) Finding includes: On 9/19/22 at 9:24 A.M., an empty box of cigarettes was observed lying on the resident's bed with a yellow lighter in it. On 9/22/22 at 9:52 A.M., 2 (two) cigarettes that had been lit and put out were observed in Resident 11's room. One on the bedside table and another one on the resident's nightstand. The room also smelled like smoke. During record review on 9/21/22 at 1:27 P.M., Resident 11's most recent quarterly MDS (Minimum Data Set) assessment, dated 8/21/22, indicated the resident had severe cognitive impairment. Resident 11's diagnoses included, but were not limited to, psychotic disorder (not schizophrenia), unspecified intellectual disabilities, unspecified psychosis not due to a substance or known physiological condition, and nicotine dependence. Resident 11's care plan included, but was not limited to, resident chooses to smoke (initiated on 3/18/22). It indicated the…

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

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident received an antipsychotic medication every evening without having an adequate indication for its use. (Resident 19) Finding includes: During record review on 9/22/22 at 1:59 P.M., Resident 19's diagnosis included, but was not limited to, unspecified dementia without behavioral disturbance. Resident 19's most recent admission Minimum Data Set (MDS) assessment, dated 6/28/22, indicated Resident 19 received antipsychotics on a routine basis. Resident 19's current physician orders included, but were not limited to, Seroquel (quetiapine) (antipsychotic medication) 25 milligrams (mg) oral at bedtime for a diagnosis of unspecified dementia without behavioral disturbance. During an interview on 9/23/22 at 2:14 P.M., the Director of Nursing (DON) indicated that Resident 19 was admitted with the antipsychotic order and she does not have an appropriate diagnosis for the order. On 9/23/22 at 2:15…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were maintained for 1 of 7 residents observed during medication pass, 1 of 6 resident rooms on contact/droplet isolation precautions, and during 1 random observation. Staff was observed entering an isolation room with an N95 over the surgical mask, staff handled medications with their bare hands, and staff was observed eating in the hall without a mask on within arms length of a resident. (CNA 3, CNA 4, LPN 5, Resident 109, Resident 11) Findings include: 1. On 9/20/22 at 11:06 A.M., LPN 5 popped two tablets out of medication cards into his bare hand and then placed the tablets into a medication cup. LPN 5 then administered the medications to Resident 109. 2. On 9/21/22 at 7:41 A.M., Certified Nurse Aide (CNA) 3 entered a resident room on contact/droplet precautions and placed an N95 mask over her surgical mask. CNA 3 then exited the room wearing a gown, gloves, faceshield, N95 over the surgical mask, and proceeded to put the gown and gloves in a clear bag…

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 all staff received the COVID-19 vaccination and failed to follow the facility's contingency plan for 1 of 1 partially vaccinated staff. (Staff 2) Finding includes: On 9/21/22 at 8:34 A.M., Staff 2's COVID-19 vaccination status was reviewed. Staff 2 was elgible for the second dose of a 2 (two) dose Covid-19 vaccination on 6/19/22. During an interview on 9/21/22 at 12:24 P.M, the Infection Preventionist (IP) indicated Staff 2 was currently working on getting a medical exemption. On 9/22/22 at 10:18 A.M., Staff 2's work schedule was reviewed. Staff 2 was actively working with residents in the facility. On 9/21/22 at 10:20 A.M., a current COVID-19 Employee Vaccination Requirement, dated July 8, 2022, was provided and indicated All Current Employees, unless granted an exemption must, receive vaccines as per that below: .Received all shot doses .to be considered fully vaccinated by March 15, 2022 in order to meet the vaccine requirement .Please note that employees who are unvaccinated and whom do not have an approved…

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.