River Bend Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 5 resident reviewed for unnecessary medications. (Resident 6)Finding includes:On 1/23/26 at 1:46 P.M., Resident 6's clinical record was reviewed. Resident 6 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/25, indicated Resident 6 was cognitively intact, was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, and received antianxiety medication during the seven day lookback period. Physician orders included, but were not limited to: hydroxyzine HCl Oral Tablet 25 MG (milligrams) Give one tablet by mouth every eight hours as needed for itching, Start Date 12/23/25.The electronic medication administration record (eMAR) indicated Resident 9 was given zero doses of hydroxyzine during December 2025.During an interview…

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 care plan interventions were implemented for 1 of 2 residents reviewed for falls and 1 of 1 residents reviewed for pressure ulcers. Fall interventions were observed out of place and wound treatment was not completed according to physician orders. (Resident S and Resident N)Findings include: 1. On 1/22/26 at 11:06 A.M., Resident S was observed sitting in her wheelchair in the small tv room next to the nurse's station wearing white socks. The socks did not have nonskid tread on the bottoms.On 1/23/26 at 2:20 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, senile degeneration of the brain and muscle weakness. Resident S's most current Significant Change Minimum Data Set (MDS) Assessment, dated 12/15/25, indicated Resident S was not assessed for cognitive impairment because she was rarely or never understood, was independent in eating, and had no falls since the prior assessment on…

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

Based on observation, interview, and record review, the facility failed to revise residents' care plans to reflect changes in condition for 1 of 2 residents reviewed for advanced directives and 1 of 2 residents reviewed for falls. An advanced directive care plan was not revised to reflect a full code status, and a fall intervention was not revised following a change of equipment. (Resident 18 and Resident 29)Finding includes:1. On 1/23/26 at 2:07 P.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, chronic pain syndrome and peripheral vascular disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/1/25, indicated Resident 18 was cognitively intact and was independent in all Activities of Daily Living (ADLs).A care conference was completed on 12/23/25 at 5:02 P.M. with the resident in attendance. Notes indicated to continue with the current plan of care. Notes also indicated that the resident was a full code and wished to remain that way.Current care plans included, but were not limited to:Resident 18 has an advanced…

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 an order and care plan for oxygen, tubing was properly dated, and there was an administration posted on door for 1 of 2 residents reviewed for oxygen administration.(Resident W) Finding includes:During a random observation on 1/22/26 at 10:27 A.M., Resident W was observed lying in bed with Oxygen (O2) tubing connected to concentrator with no date on the tubing or water bottle along with the nebulizer, and there was no oxygen administration sign on the door. During a random observation on 1/27/26 at 9:05 A.M., Resident W was observed lying in bed without oxygen on. The nebulizer face mask was observed on the floor and lacked a date on the tubing. Current physician orders lacked documentation of an oxygen order The current clinical record lack documentation of a care plan for oxygen.During an interview on 1/27/26 at 9:30 A.M., Hospice Provider 2 indicated residents on oxygen will have an order for the resident with them but should also have an order with the facility for O2.During an interview…

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 consistently provide coordination between facility staff and hospice staff to meet residents' nursing needs for 1 of 1 residents reviewed for falls. Fall interventions were not installed on a resident's wheelchair which resulted in a fall with injury. (Resident S)Finding includes:During a confidential interview on 1/22/26 at 2:08 P.M., it was indicated that Resident S used to receive hospice services but did not receive hospice services any longer. The resident utilized Hospice Provider 1 for a while and then switched to Hospice Provider 2 due to communication issues. The resident discontinued hospice services altogether after Resident S fell in December and broke her hip.On 1/23/26 at 2:20 P.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, senile degeneration of the brain and muscle weakness. Resident S was admitted to the facility on [DATE].Resident S's most current Significant Change Minimum Data Set (MDS)…

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 performed on 2 of 2 random observations. Staff observed not utilizing the proper use of PPE of donning and doffing a gown when entering and exiting a room on Enhanced Barrier Protocol (EBP), did not utilize proper hand hygiene and changing gloves when performing tracheostomy suctioning, and locating a glucometer that was not cleaned after use. (Resident N, glucometer) Findings include:Findings include:1. On 1/22/26 at 9:30 A.M., during a random observation of the Insulin Cart, was observed to have a glucometer noted to have 2 spots of blood on the machine.2. On 1/23/2026 at 8:25 A.M., during a random observation of tracheal suction of Resident N, the following was observed:Resident N was noted to be on Enhanced Barrier Protocol due to a tracheostomy.Registered Nurse (RN)11 did not wash hands prior to donning gloves and did not place a gown of Personal Protective Equipment.2 Certified Nurses Assistants (CNA) 12 and 13 entered the room to help pull 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 notify a resident's emergency contact of an injury and subsequent x-ray order in 1 of 3 residents reviewed for falls. (Resident B)Finding includes:On 11/24/25 at 9:54 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, age-related osteoporosis, and protein-calorie malnutrition.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated that Resident B was not assessed for cognitive function because she was rarely or never understood, was dependent on staff for transfers and toileting, required partial to moderate assistance of staff (staff does less than half of the effort) for eating, had no falls since in the prior assessment, and weighed 104 pounds (lbs) with no significant weight loss.Physician orders included but were not limited to:May obtain 4 views of right knee for pain and swelling, dated 9/4/25An incident note, dated 8/30/25 at 1:15 A.M., indicated Resident B was found on the floor on her fall mat. An assessment was completed with no…

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 for falls and weight loss. An x-ray of an emergent injury was delayed 24-hours and weekly weights were not completed as ordered. (Resident B)Findings include:On 11/24/25 at 9:54 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, age-related osteoporosis, and protein-calorie malnutrition.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/12/25, indicated Resident B was not assessed for cognitive function because the resident was rarely or never understood. Resident B was dependent on staff for transfers and toileting, required partial to moderate assistance of staff (staff does less than half of the effort) for eating, had no falls since the prior assessment, and weighed 104 pounds (lbs) with no significant weight loss.A. Physician orders included, but were not limited to:May obtain 4 views of right knee for pain…

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 alternative supplements were provided to accommodate a resident's allergies. (Resident D) Findings include:On 11/24/25 at 10:48 A.M., Resident D's clinical record was reviewed. Resident D was admitted on [DATE]. Diagnoses included, but were not limited to, Type 2 Diabetes Mellitus.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated Resident D was severely cognitively impaired and completely dependent on staff (staff do more than half of the work) for eating, bathing, toileting, and transfers.Resident D's allergy list included, but was not limited to, milk and milk related products. Current physician orders included, but were not limited to:MedPass 2.0 (a dietary supplement) one time a day for weight; Start date 10/29/25A Registered Dietitian progress note, dated 10/2/25 at 10:39 A.M., indicated Resident D should not consume milk or milk related compounds due to a hives reaction, to consider this 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide notification of transfer and bed hold policy to residents or their representative in 4 of 4 residents reviewed for hospitalizations. (Resident 7, Resident 51, Resident 53, Resident 57) Findings include: 1. On 11/08/24 at 7:34 A.M., Resident 7's clinical record was reviewed. Diagnoses included but were not limited to fracture of neck and disorders of bone density. The Current Quarterly MDS (Minimum Data Set) Assessment indicated Resident 7 is moderately cognitively impaired. The clinical record lacked any transfer paperwork and bed hold policy when Resident 7 was emergently transferred to the hospital after a fall that resulted in a fractured neck on 7/27/24. During an interview on 11/8/24 at 2:00 P.M., the DON (Director of Nursing) indicated that she could not locate any transfer forms and that there should have been papers sent with resident to the hospital. 2. On 11/08/24 at 2:08 P.M. Resident 51's clinical record was reviewed. The most…

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 proper storage of medications for 3 of 3 medication carts observed. Loose pills were observed in the medication cart drawers. (300 Hall, 400 Hall, 200 Hall) Findings include: 1. On 11/7/24 at 10:15 A.M., the medication cart for rooms 310 to 317 was reviewed. The following loose pills were observed in the bottom of the drawers: 1 blue oval capsule with marking RDY493 2 red circle pills with marking PH32 1 light blue circle pill with marking F3 1 light blue circle pill with marking M64 1 white circle pill with marking G5 1 white circle pill with marking 489 1 yellow circle pill with marking LUPIN 1 red circle pill with marking US5 1/2 white rectangle pill with partial marking 5 2. On 11/7/24 at 10:30 A.M., the 400 hall medication cart was reviewed. The following loose pills were observed in the bottom of the drawers: 1 small white pill with marking P10 1 small white pill with marking HP23 1 red oval pill with marking 894 1 white oval pill with marking A6 1/2 white circle pill with partial marking 8 3. On…

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

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures and taste for 1 of 1 tray tested for temperature. Findings include: On 11/06/24 10:38 A.M., Resident 6 indicated food is not appetizing, often very similar or the same over and over. On 11/06/24 at 12:16 P.M., Resident 15 indicated they get a lot of sandwiches. On 11/8/24 at 12:39 P.M., a test tray was obtained from 200 Hall: Grilled Cheese 117 Degrees Fahrenheit Fruit Cocktail 60.2 Degrees Fahrenheit The grilled cheese was cool to taste The fruit cocktail was cool to taste On 11/8/24 at 2:30 P.M., the Ombudsman indicated after the resident council there were several anonymous complaints about food and meals. During an interview on 11/08/24 at 11:58 A.M., the Interim Dietary Manager indicated hot food temperatures should be served at a minimum of 155 Degrees Fahrenheit and cold food is served at minimum of 41 Degrees Fahrenheit. On 11/14/24 at 8:15 A.M., the DON (Director of Nursing) provided a current policy Temperatures dated 7/2023. The policy 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 food was stored, labeled, and dated properly in accordance with professional standards for food service and refrigerator temperature were recorded for 3 of 3 kitchen observations. Findings include: 1. On 11/6/24 at 8:47 A.M., an initial tour of the kitchen was conducted. The following items were located In the Dry Storage area at 8:50 A.M., 1 Box of onion dated 8/2/24 that had an onion sprouted 2. Drink Refrigerator at 9:05 A.M., 3 bags of lettuce not dated 12 pitchers of tea not dated 1 box of thick and easy open date of 1/4/23 with best by dated 1/26/23 1 box of thick and easy open date 4/9 best by 3/29/24 1 pitcher of orange juice not dated 1 jar of chicken base not dated 1 open bag of lettuce wilted open dated of 10/25/24 1 container of cottage cheese with no open date Temperature Log for the Drink Refrigerator lacked temperatures for the following shifts Nights 3/4/24 Days 3/5/24 Nights 3/5/24 3. Walk in freezer at 9:25 A.M. 1…

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 provide a safe and sanitary environment for residents, staff, and the public for 9 random observations on 6 of 6 days. Urine smells in unit hallways and conference room, pests flying in resident room and nurses' station, and condition of resident air conditioners. (Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], Resident 308, Conference Room, Hallway 400 Unit, 200 Unit Nurses Station) Findings include: 1. On 11/6/24 at 8:47 A.M., a strong smell of urine was observed in the conference room and the 400 Unit Nurse's Station Hallway. 2. On 11/7/24 at 8:47 A.M., a strong smell of urine was observed in the 400 Unit Nurse's Station and the conference room. 3. On 11/08/24 at 3:11 P.M. heating and air window until in room [ROOM NUMBER] observed to have had paint flaking off and moderate amounts of rust. 4. On 11/12/24 9:08 A.M., a strong smell of urine was observed outside of the conference room. 5. On 11/13/24 8:05 A.M., 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 SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) Forms were provided following the end of Medicare skilled services for 2 of 2 residents who discharged from Medicare services and remained in the facility. (Resident 9 and Resident 215) Findings include: 1. On 11/12/24 at 10:35 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form indicated Resident 9 received Medicare Part A Skilled Services starting 8/26/24. The form indicated the last covered day of Part A services was 10/18/24. The form indicated Resident 9 did not receive a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form because she skilled out of therapy services. Resident 9 was provided a Notice of Medicare Non-Coverage (NOMNC) Form, dated 10/14/24, which indicated Resident 9's Medicare coverage would end on 10/18/24. On 11/12/24 at 10:40 A.M., the Social Services Director (SSD) indicated that Resident 9 remained in the…

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

Based on record review and interview the facility failed to provide the proper work for a resident emergently transferred to the hospital in 1 of 1 residents reviewed for hospitalization. (Resident 7) Findings include: On 11/08/24 at 7:34 A.M., Resident 7's clinical record was reviewed. Diagnoses included but were not limited to fracture of neck and disorders of bone density. The clinical record lacked any transfer paperwork when Resident 7 was emergently transferred to the hospital after a fall that resulted in a fractured neck. During an interview on 11/8/24 at 2:00 P.M., the DON (Director of Nursing) indicated that she could not locate any transfer forms and that there should have been papers sent with resident to the hospital. During an interview on 11/14/24 at 10:30 A.M., the DON indicated that the face sheet, bed hold policy, and other information should be sent when a resident was sent to the hospital. 3.1-12(a)(5) 3.1-12(a)(9)(A)(B)(C)

Based on record review and interview the facility failed to notify the Ombudsman office in 1 of 4 residents reviewed for hospitalization. (Resident 7) Findings include: On 11/08/24 at 7:34 A.M., Resident 7's clinical record was reviewed. Diagnoses included but were not limited to fracture of neck and disorders of bone density. The Current Quarterly MDS (Minimum Data Set) Assessment indicated Resident 7 is moderately cognitively impaired. The clinical record lacked any transfer paperwork when Resident 7 was emergently transferred to the hospital after a fall that resulted in a fractured neck on 7/27/24. The clinical record lacked any transfer information sent to the ombudsman for the hospitalization on 7/17/24. During an interview on 11/8/24 at 2:00 P.M., the DON (Director of Nursing) indicated that she could not locate any transfer forms and that there should have been papers sent with resident to the hospital. During an interview on 11/12/24 at 1:03 P.M., the Social Service Director indicated she needs to send the list after each of the d/c or transfer 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the development of a resident's comprehensive care plan for 3 of 3 residents reviewed for behaviors, accidents, and nutrition. (Resident 39, Resident 15, Resident 58) Findings include: 1. On 11/6/23 at 11:15 A.M., Resident 39 was observed sitting in wheelchair in dining room eating puzzle pieces. On 11/7/24 at 2:42 P.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance and cognitive communication deficit. The Current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 39 was severely cognitively impaired. Resident 39 needs substantial assistance with transferring and mobility. There were no behaviors noted during the 7 days look back period. Current Physician Orders included, but were not limited to: Monitor for Side Effects of Anti-Depressant Medications which may include but not limited to: Dystonia Tremors…

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 care plan conferences were completed quarterly for 2 of 2 residents reviewed for quarterly care plan conferences. (Resident 13 and Resident 29) Findings include: 1. On 11/8/24 at 10:15 A.M., Resident 13's clinical record was reviewed. Resident 13's diagnoses included, but were not limited to, dementia and anxiety. A Significant Change MDS (Minimum Data Set) Assessment, dated 10/8/24, indicated Resident 13's cognition level was not assessed due to diminished cognition level and Resident 13 was dependent on staff for toileting, bathing, and transfers (staff do all of the work). On 11/13/24 at 3:23 P.M., the Social Services Director provided documents titled Care Conference Note, and indicated, during the past year, a quarterly care plan conference had not been held for Resident 13 between 3/20/24 and 9/25/24. 2. On 11/8/24 at 12:48 P.M., Resident 29's clinical record was reviewed. Resident 29's diagnoses included, but were not limited to, multiple sclerosis, involuntary eye movements, and calculus of the kidneys. 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.

Based on observation, interview, and record review, the facility failed to provide person centered engagement activities for 1 of 1 resident reviewed for dementia care. (Resident 13) Finding includes: On 11/6/24 at 10:51 A.M., Resident 13 was observed in the common area. Resident 13's wheelchair was positioned in a way her vision was parallel with the television screen with a large plant blocking the view of the television. On 11/7/24 at 10:45 A.M., Resident 13 was observed in the common area. Resident 13's wheelchair was positioned with the back of her wheelchair was facility the television screen. On 11/8/24 at 10:08 A.M., 10:32 A.M., 10:48 A.M., and 11:47 A.M., Resident 13 was observed in the common area. Resident 13's wheelchair was facing the television screen and the television was on the menu screen. On 11/13/24 at 2:20 P.M, the the activities assistant was hosting bingo in the dining room. Resident 13 was not offered to attend activities in the dining room and remained in the common area in front of the television. On 11/8/24 at 10:15 A.M., Resident 13's clinical record 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, observation, and record review, the facility failed to ensure a resident received proper treatment to maintain vision abilities by assisting in arrangements for vision services for 1 of 1 residents reviewed for vision impairment. (Resident 29) Finding includes: During an interview on 11/6/24 at 10:39 A.M., Resident 29 was observed wearing cloudy glasses and indicated she had not been assessed by vision or dental services in over a year and was having difficulty with her current prescription. On 11/8/24 at 12:48 P.M., Resident 29's clinical record was reviewed. Resident 29's diagnoses included, but were not limited to, multiple sclerosis, diplopia (double vision), involuntary eye movements. An Annual MDS (Minimum Data Set) Assessment, dated 8/13/24, indicated Resident 29 was cognitively intact, was dependent on staff (staff do all of the work) for eating, toileting, bathing, and transfers, has vision impairment, and wears corrective lenses. Care plan interventions included, but were not limited to: Arrange consultation with eye care practitioner as required. Date…

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

Based on observation, record review, and interview the facility failed to appropriately care for and maintain a resident's suprapubic catheter leading to infection at the catheter insertion site and multiple urinary tract infections for 1 of 1 resident reviewed for urinary tract infections and urinary catheter. (Resident 47) Finding includes: On 11/8/2024 at 10:19 A.M., Resident 47's clinical record was reviewed. Resident diagnoses included, but was not limited to, hemiplegia from cerebral vascular event, hemiparesis, cancer of prostate, diabetes mellitus type 2, coronary artery disease, and peripheral vascular disease. An Annual MDS (Minimum Data Set) Assessment, dated 10/26/2024, indicated the resident was mild to moderately cognitively impaired, had no behaviors regarding rejection of care, required extensive assistance by 2 staff members in bed mobility, transferring, and toileting. The MDS also indicated Resident 47 had an indwelling suprapubic catheter and a history of prostate cancer. Physician orders for Resident 47 included, but was not limited to: Change suprapubic…

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, observation, and record review, the facility failed to ensure a resident was offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 residents reviewed for hydration. (Resident 29) Finding includes: During an observation on 11/6/24 at 10:41 P.M., Resident 29 was laying in bed. Resident 29's call light (touch pad) was laying on the dresser to the right of her bed out of her reach. An empty cup labeled 11/5/24 NOC was on the bedside table. Resident 29 indicated she did not feel she received enough fluids and had to call for staff to give her drinks because of her physical condition, but was unable to call for staff assistance when her call light is out of reach. On 11/8/24 at 12:48 P.M., Resident 29's clinical record was reviewed. Resident 29's diagnoses included, but were not limited to, multiple sclerosis, hydronephrosis, and calculus of the kidneys. An Annual MDS (Minimum Data Set) Assessment, dated 8/13/24, indicated Resident 29 was cognitively intact, was dependent on staff (staff do all of the work) for eating, toileting, 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 routine medications were available and dispensed according to physician's orders and stored in an organized manner for 2 of 2 residents reviewed for medication storage. (Resident 15, Resident 47) Findings include: 1. On 11/13/24 at 2:00 P.M., during an observation of medication cart for 200 unit there was no Prostat (protein supplement) for Resident 15. On 11/08/24 at 3:05 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, dysphagia and gastro-esophageal reflux disease without esophagitis. Current physician orders included, but were not limited to: ProStat (protein supplement) 30 ml (Mil liters) BID (Two times a day), dated 8/15/24. Mighty Shake at lunch dated 8/15/24. Centrum Silver multivitamin daily dated 8/15/24. During an interview on 11/13/24 at 2:05 P.M., QMA (Qualified Medicine Aide) 9 indicated Resident 15 did not have the medication. QMA 9 indicated the medication was from [Resident Name] and [Resident Name] both discharged from the facility. 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.

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 5 residents (Resident 50 and Resident 6) observed during medication pass. Two medication errors were observed during 25 opportunities for error in medication administration. This resulted in a medication error rate of 8%. Findings include: 1. On 11/8/24 at 11:53 A.M., Licensed Practical Nurse (LPN) 3 was observed preparing a Humalog Insulin Pen for insulin administration for Resident 50. An AccuCheck (blood glucose test) indicated the resident had a blood glucose of 198 milligrams per deciliter (mg/dL). LPN 3 indicated the resident received sliding scale insulin and was to receive 3 units of insulin lispro (a fast acting insulin) for a blood glucose reading of 198 mg/dL. LPN 3 set the insulin pen to 3 units. She cleaned the tip of the pen, attached the needle, and administered 3 units of insulin to Resident 50 in her abdomen. LPN 3 did not prime the insulin pen before administration of the medication. 2. On 11/8/24 at 12:02 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 record review and interview, the facility failed to ensure consistent documentation for wound care treatments on 1 of 3 residents reviewed for pressure injury. (Resident 47) Findings include: On 11/8/2024 at 10:19 A.M., Resident 47's clinical record was reviewed, the diagnoses included, but were not limited to, pressure ulcer of right buttock- stage two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister), and pressure ulcer of right heel- stage three (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.), hemiplegia (one-sided muscle paralysis) from cerebral vascular event, hemiparesis (one-sided muscles weakness), cancer of the prostate, diabetes mellitus type 2, coronary artery disease, and peripheral vascular disease. An Annual Minimum Data Set (MDS) Assessment, dated 10/26/2024,…

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 observation, record review, and interview the facility failed to follow proper infection prevention and control practices for 1 of 1 resident reviewed for urinary tract infection and urinary catheter care, 1 of 1 resident reviewed for pressure injury, and 1 of 1 resident reviewed for a urinary catheter. (Resident 47, Resident 8, and Resident 29) Findings include: 1. On 11/7/2024 at 2:38 P.M., CNA (Certified Nurses Aide) 15 and CNA 21 were observed to be putting Resident 47, whom had multiple open wounds and an indwelling suprapubic catheter, back to bed from wheel chair. A mechanical lift was used to assist the resident's transfer. The mechanical lift sling that was used, was previously used on Resident 47's room mate and not washed between use. Both CNAs caring for Resident 47 did not wear a gown for enhanced barrier precautions during care. 2. On 11/12/24 at 9:20 A.M., CNA (Certified Nurse Aide) 25 and CNA 21 were observed providing incontinence care for Resident 8. Both CNA's sanitized hands and donned plastic gowns and gloves prior to placing Resident 8 on right 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, record review, and interview, the facility failed to provide a safe environment free of pests based on 3 of 3 random observations of flies and gnats during the survey. (Resident room [ROOM NUMBER], Second Floor Nurses Station) Findings include: 1. On 11/6/24, at 12:11 P.M., during a random observation 2 flies and a gnat were observed flying in Resident's 15 room. During an interview on 11/6/24 at 12:12 P.M., Resident 15 complained of having other incidences gnats and flies flying around in the room. 2. On 11/08/24 at 8:47 A.M., during a random observation a fly was observed flying around the Second Floor Nurse's Station flying around. 3. On 11/12/24 at 10:02 A.M., during a random observation a fly was observed flying around in Resident 15 room while a dressing change was performed. During an interview on 11/12/24 at 10:30, A.M., the Administrator indicated that he was not aware of bugs in the resident room. On 11/13/24 at 4:15 P.M., the DON (Director of Nursing) provided a current 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medications were disposed of in a timely manner for discharged residents, medications that had been discontinued were disposed of, controlled medications were double locked, refrigerator temperature logs in place, ice removal in refrigerator freezer, a system was in place for documentation of medication disposition, for 2 of 2 medication rooms observed, and 5 of 5 residents reviewed for medications. ( Resident D, Resident E, Resident G, Resident H, Resident J, Stocker unit medication room, North/South unit medication room) Findings include: On [DATE] at 8:29 a.m., an observation of the Stocker unit medication room was done. The following was observed: 1. The refrigerator containing, but not limited to controlled medications, was observed to have a padlock that was not locked. On [DATE] at 12:33 p.m., the Stocker unit medication refrigerator was observed to have a padlock that was not locked. 2. The refrigerator freezer was observed…

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 plan of care was developed and implemented for 1 of 1 resident with an enteral feeding tube. A plan of care was not created timely for an enteral feeding tube and physician orders for enteral tube feeding and treatments were not completed as ordered by the physician. (Resident B) Finding includes: During an observation on 5/13/24 at 9:55 A.M., Resident B was lying in bed in his room. An enteral feeding tube pump and pole were next to Resident B's bed. During record review on 5/13/24 at 1:15 P.M., Resident B's diagnoses included but were not limited to dysphagia, speech and language deficits, and muscle weakness. Resident B's admission date to the facility was 3/29/24. Resident B's admission MDS (Minimum Data Set), dated 4/4/24, indicated that the resident was cognitively intact, displayed coughing or choking during meals or when swallowing medications, had a feeding tube, and received at least 51 percent of calories through a feeding tube. Resident B's physician orders included but were not limited…

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 were free of abuse for 1 of 3 residents reviewed for abuse. A resident was inappropriately touched by another resident. ( Resident D, Resident E) Finding includes: On 2/29/24 at 9:50 a.m., the DON indicated the facility had one state reportable that police were involved in. She had received a phone call reporting that Resident D had been observed by a staff member inappropriately touching Resident E. At 10:30 a.m. a state reportable was reviewed and included, but was not limited to: Incident date : 2/8/2024 at 6:20 p.m. Description added: Resident [name (Resident D)] was noted to touch resident [name (Resident E)] inappropriately. Type of injury added: 2/8/2024 Residents immediately separated, MD's, families, and police notified of incident. Resident [name(Resident D)] immediately placed on 1 to 1 supervision. Follow up: 2/14/2024 Resident [name(Resident D)] continues to be on 1 to 1 supervision. Police made aware of 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 effective interventions to prevent the development of a stage 2 pressure ulcer on the left great toe for 1 of 3 residents who met the criteria for review of wounds. Due to lack of assessments and not following the plan of care, the resident acquired a pressure ulcer. (Resident G) Finding includes: During an observation of LPN 4 on 11/2/23 at 9:10 A.M., Resident G's dressing was changed. Resident G had a small red area on his left great toe. On 11/2/23 at 9:00 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure, diabetes mellitus type II, and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/23/23, indicated Resident G was cognitively intact and required extensive assistance of 2 or more persons for bed mobility and toileting. A current Pressure Ulcer Care Plan, revised on 7/17/23, included, but was not limited to, the following intervention: Administer treatments as ordered and observe for effectiveness, initiated…

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 interviews and record review, the facility failed to maintain 8 hours of Registered Nurse (RN) coverage in a 24-hour period a total of 10 days from 1/1/23 to 3/31/23 for 1 of 1 quarters reviewed for sufficient staffing. Findings include: On 9/5/23 at 9:00 A.M., the Certification And Survey Provider Enhanced Reports (CASPER) for second quarter 2023-2024 was reviewed. The CASPER indicated that one-star staffing rating was triggered for further investigation during the survey. On 9/13/23 R 12:00 P.M., the records of RN coverage hours were reviewed: 1/11/23 - 0 1/16/23 - 0 1/17/23 - 0 1/24/23. - 4.25 2/4/23 - 0 2/7/23 - 0 2/8/23 - 4.5 2/22/23 - 4.5 3/14/23 - 5.75 A facility nurse staffing policy was requested but not received. 3.1-17(b)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medication regimen recommendations were reviewed or addressed by a Physician for 6 of 6 residents reviewed for unnecessary medications. (Resident 22, Resident 53, Resident 12, Resident 37, Resident 6, Resident 56) Findings Include: 1. On 9/6/23 at 2:02 P.M, Resident 53's clinical record was reviewed. The resident's profile included a diagnosis, but was not limited to, Type 2 Diabetes Mellitus. A quarterly quarterly Minimum Data Set (MDS) assessment, dated 7/12/23, indicated Resident 53's cognition level was unable to be assessed and received insulin injections for seven days during the seven day assessment. A Physician's order, dated 8/28/23, indicated Lantus (an insulin medication) 20 units two times a day. Physician orders, dated 8/29/23, indicated Novolin R (an insulin medication) 6 units before meals, and Novolin R sliding scale, when blood sugar readings were above 150, before meals. A pharmacy recommendation received on 9/11/23 at 11:11…

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 GDRs (gradual dose reductions) were completed for psychotropic medications and PRN (as needed) antianxiety medications were evaluated every 14 days for 4 of 7 residents reviewed for unnecessary medications (Resident 12, Resident 37, Resident 25, Resident 22). Findings include: 1. On 9/7/23 at 9:53 A.M., Resident 12's clinical record was reviewed. Resident 12's diagnoses included, but were not limited to, spinal stenosis, chronic kidney disease, diabetes mellitus, generalized anxiety disorder, and major depressive disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 8/14/23, indicated Resident 12 was cognitively intact and received an antianxiety medication, antidepressants, insulin, opioids, and a diuretic during the 7 day look back period. Current physician orders included, but was not limited to: Hydroxyzine HCl (an antianxiety medication and an antihistamine) 25 MG (milligrams) - Give 1 tablet by mouth every 8 hours as needed for itching, dated 2/28/23 The August 2023 MAR…

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 that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for 2 of 2 medication carts reviewed for medication labeling and storage. Findings include: During an interview with LPN 6 on 9/6/23 at 8:38 A.M., the second floor medication cart was found to contain loose pills in the bottom of the medication drawers. There were 2 large round red pills, 1 small white pill, 1 square orange pill, and 2 large round white pills. LPN 6 disposed of the loose pills in the sharps container. During an interview with LPN 18 on 9/6/23 at 8:55 A.M., the first floor medication cart was found to contain loose pills in the bottom of the medication drawers. There were 1 large red pill, 1 red gel cap, 3 round brown pills, 2 oblong gold pills, 1 large round pink pill, 4 small white pills, 1 large oblong pill, 2 large round white pills, 3 small oval white pills, 1 small…

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 observation, the facility failed to provide each resident with food and drink that was served at a safe and appetizing temperature. Food that was supposed to be served hot was served at below the recommended temperature; food that was supposed to be cold was served above the recommended temperature for 1 of 1 trays reviewed for temperature. Findings include: During an observation on 9/5/23 at 11:55 A.M., in the second floor dining room, food was observed being served in Styrofoam containers with plastic tableware. During an interview with the Dietary Manager on 9/5/23 at 12:06 P.M., Styrofoam containers were being used because the elevator had been broken for more than 2 weeks and there was no good way to get the heavy dishes up to the second floor dining room. The staff formed a line going up the stairs and passed the trays up the stairs. Parts to repair the elevator are not expected to arrive before October. Additional interviews were obtained from residents. On 9/5/23 at 10:10 A.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 observation and interview. the facility failed to store, distribute, and serve food in accordance with professional standards for food services safety for 3 of 3 observations of the kitchen. Findings Include: During a tour of the kitchen beginning on 9/5/23 at 8:46 A.M., the Dietary Manager (DM) indicated the kitchen had been very short staffed and they had recently hired new staff in the past 2 weeks but they needed to be trained. During an interview with the DM on 9/5/23 at 9:00 A.M., she indicated the dishwasher uses hot water to sanitize the dishes. On 9/5/23 at 9:35 A.M., the dishwasher was observed during the wash/rinse cycle. The wash was 150 degrees F(Fahrenheit), rinse was 165 degrees F. On 9/7/23 at 9:56 A.M., the dishwasher was observed during the wash/rinse cycle. The wash was 140 degrees F, the rinse was 175 degrees F. On 9/5/23 at 9:36 A.M., the kitchen floor was observed to be dirty and sticky, especially near the dishwasher. During observation of the two reach-in refrigerators in the kitchen on 9/5/23 at 9:09 A.M. The reach-in refrigerator on the right had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to properly prevent and contain COVID-19 for 3 of 7 residents reviewed for infection control and providing safe and sanitary environment for 9 resident rooms and Stocker unit. (Resident 6, Resident 56, Resident 115) Findings include: 1. On 9/8/23 at 8:14 A.M., RN (registered nurse) 28 was observed coming out of a Covid resident 6 room and only wearing a regular face mask. She indicated she forgot to but on the PPE. The precautions were marked on the door as a red zone and for donning the proper PPE in order. She then, did not wash hands, but changed to N-95 face mask, placed clean gloves. She did not use eye protection. Proceeded into the resident's room and gave medication. She came out of the room and indicated the PPE was taken off in the room and she had washed her hands in the room. 2. On 9/05/23 at 10:48 A.M., RN 15 was observed suctioning Resident 115's mouth using clean gloves then proceeded to do trach care and changing inner…

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 interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 3 of 3 observations of the second floor dining room and 1 of 1 observations of the first floor hallways. Findings include: 1. During an observation of the second floor dining room on 9/5/23 at 11:43 A.M., dead bugs were observed in 6 of the 7 fluorescent light covers. There were brown water marks on 5 ceiling tiles. Tables and chairs were scattered throughout the room in no particular order. Baseboards were missing on every side of the room. Paint was smeared on the chair rail on every wall of the room. During an observation of the second floor dining room on 9/6/23 at 12:00 P.M., the same was observed. During an observation of the second floor dining room on 9/8/23 at 12:15 P.M., the same was observed. 2. During an observation on 9/7/23 at 9:36 A.M., 10 of 10 ceiling vents on the 400 hall were rusty. An environmental cleaning policy was requested but not received. 3.1-19(f)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the completion of resident assessment on 1 of 2 closed records reviewed for comprehensive assessment. (Resident 9) Findings include: On 9/11/23 at 10:00 A.M., Resident 9's clinical record review was done. Diagnoses included but were not limited to atrial fibrillation and hypertension. The most recent admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 9 was cognitively intact. On 4/27/23, Resident 9 had a resident initiated discharge. There was no MDS Assessment discharge done or discharge summary completed. During an interview on 9/11/23 at 1:45 P.M., the regional clinical support nurse indicated the MDS assessment should have been done for this resident and was apparently overlooked. During and interview on 9/11/23 at 10:00 A.M., the regional clinical support nurse indicated the facility lacked a current policy but followed the RAI (Resident Assessment Instrument). The RAI indicated . the OBRA-Required Tracking Records…

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 care plans were revised after a change in status for 3 of 7 residents reviewed for comprehensive care plans (Resident 36, Resident 37, Resident 23). Findings include: 1. On 9/8/23 at 8:51 A.M., Resident 36's clinical record was reviewed. Resident 36's diagnoses included, but were not limited to, Parkinson's Disease and dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 7/20/23, indicated Resident 36 was severely cognitively impaired, had 2 or more falls without injury, and required extensive assistance of 2 staff for transfers and extensive assistance of 1 staff for toileting. A current falls care plan, revised 4/4/23, indicated a toileting program had been implemented starting 11/15/21. The toileting program was to toilet upon rising, toilet before and after each meal, toilet HS (at bedtime), and toilet with rounding at night. The clinical record indicated Resident 36 fell 16 times between 9/21/22 and 8/12/23. 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 ensure proper tracheal suctioning and oxygen services were provided according to physician orders for 2 of 2 residents reviewed for respiratory care. (Resident 56, Resident 115) Finding includes: 1. On 9/6/23 at 10:05 A.M., Resident 56's oxygen concentrator tubing and humidified water bottle was observed to not be dated. On 9/7/23 at 9:52 A.M., the suction canister and tubing were observed to be undated. On 9/08/23 at 2:40 P.M., RN (Registered Nurse) 10 was observed suctioning a tracheotomy using clean gloves with an alleged sterile suction catheter. She replaced the catheter in the same package. Removed the clean gloves. The resident needed to be suctioned again and donning clean gloves and removed the used suction catheter and reused it to suction the resident. She used tap water to clear the suction catheter when full of mucus. On 9/7/23 at 3:32 P.M., Resident 56's clinical record was reviewed. Diagnoses included, but were not limited…

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.