Majestic Care Of Goshen

Based on observation, record review and interview, the facility failed to store and prepare food under sanitary conditions related to foods not sealed appropriately, outdated foods, and dirty kitchen equipment for 1 of 1 kitchen observed. This issue had the potential to affect all 101 residents who resided in the facility and received food from this kitchen. Findings include: On 1/15/2025 at 9:45 A.M., a kitchen tour was conducted with the Dietician. The following was observed in the walk-in freezer: - A opened bag of green beans not sealed appropriately. - A opened bag of corn not sealed appropriately. - A opened bag of sausage patties not sealed appropriately. - A opened bag of eggs not sealed appropriately. The following was observed in the dry storage area: - a opened bag of cream soup base with no open date. During an interview on 1/15/2024 at 9:50 A.M., the Dietician indicated the items in the walk-in freezer should have been sealed appropriately and the bag of cream soup base should have had an open date. During a follow-up tour of the kitchen, on 1/16/2025 at 8:50 A.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure infection control practices were followed related to glove use and handwashing for 3 of 3 residents reviewed for perineal/catheter care and for 1 of 1 residents reviewed for nephrostomy care and during 1 of 3 medication administration passes. In addition, the facility failed to follow their policy regarding Enhanced Barrier Precautions (EBP) to ensure residents with wounds and catheters were placed in isolation for 3 of 5 residents reviewed for EBP isolation. Finally, the facility failed to report an illness outbreak to the State Department of Health. These deficient practices potentially affected 101 of 101 residents in the facility. (Residents 18, E, 98, G, 96, 314 & H) Findings include: 1. During an observation, on 1/17/2025 at 9:56 A.M., Certified Nursing Assistant 11 was observed to provide perineal care to Resident 18. CNA 11 obtained a basin with warm water and washcloths. She then applied gloves and washed the Resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the physician was notified of abnormal blood sugar levels and insulin refusals for 2 of 2 residents reviewed for insulin (Resident 4 & 96) and of new skin issues for 1 of 6 residents reviewed for skin (Resident 5). Findings include: 1. The record for Resident 4 was reviewed on 1/17/2025 at 9:30 A.M. Diagnosis included, but were not limited to: Type 2 diabetes. A Physicians' order, dated 7/1/2024, indicated the physician was to be notified if Resident 4's blood glucose levels were above 400. - On 9/3/2024 at 4:26 P.M., Resident 4's blood glucose level was 403 mg/dl. - On 10/12/2024 at 5:26 P.M., the residents blood glucose level was 411 mg/dl. - On 10/29/2024 at 8:37 P.M., the residents blood glucose level was 479 mg/dl. During an interview, on 1/21/2025 at 9:39 A.M., RN 15 indicated a nursing progress note should have been in Resident 4's chart for the days the physician had been notified of an elevated blood glucose level. A review…

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 corrective action adequately addressed a response to resident council grievances of call light and shower concerns and readily provided grievance forms for residents to utilize anonymously. This practice had the potential to affect 101 of 101 residents. Findings include: 1. During a resident/surveyor meeting, on 1/17/2025 at 1:00 P.M., the residents in attendance, 10 of 12, indicated their grievances brought forward during the monthly meetings were addressed , but the grievances went unchanged . The residents who regularly attended resident council meetings indicated they usually shared their grievances at the monthly meetings. During the resident council meeting with the surveyors, conducted on 1/17/2025 at 1:08 P.M., grievances were voiced about routine showers not being completed and call lights not illuminating outside of their rooms. They indicated they were given bells and whistles to alert staff when assistance was needed. They indicated a laptop was placed at the nurse's station that indicated when a call…

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 1 of 2 resident's Level One PASARR (Preadmission Screening and Resident Review) assessment was completed accurately and failed to ensure an updated Level 1 review was completed for 1 of 27 residents reviewed for MDS assessments . (Resident 18) Finding includes: The record for Resident 18 was reviewed on 1/21/2025 at 3:28 P.M. Diagnoses included, but were not limited to: depression, anxiety, post traumatic stress disorder, dementia and on 9/14/2024 a new diagnoses of psychotic disorder with delusions. Resident 18's current medications include: trazadone (antidepressant) 150 mg (milligram) 1 tablet at bed time; Fluoxetine (antidepressant) 20 mg 1 tablet daily; Haloperidol (antipsychotic) 10 mg 1 tablet two times a day and Haloperidol 5 mg 1 tablet once a day. A Preadmission Screening and Resident Review form, dated 4/14/2020, indicated Resident 18's diagnoses included adjustment disorder with mixed anxiety and depressed mood, post traumatic stress disorder, and insomnia. The form indicated there were no known mental…

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 preventative measures were implemented timely to prevent pressure ulcer development for 1 of 3 residents reviewed for facility-acquired pressure ulcers (Resident 96). Finding includes: The record for Resident 96 was reviewed on 1/21/2025 at 10:09 A.M. Diagnosis included, but were not limited to: diabetes mellitus type 2 (DM) with chronic kidney disease, iron deficiency anemia, legal blindness, hypertensive heart disease without heart failure, and vitamin D deficiency. Review of the most recent MDS (Minimum Data Set) assessment for Resident 96, completed on 12/2/2024 for a Significant Change in Condition indicated Resident 96 was alert and oriented, required substantial/maximal staff assistance for dressing, transferring and bathing needs and had one unstageable pressure ulcer. A Braden Scale for Predicting Pressure assessment, completed 6/14/2024, indicated Resident 96 was at risk for developing pressure sores. Resident 96's chart lacked documentation of any further Braden risk assessments having been…

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 provide nephrostomy dressing changes for 1 of 4 residents reviewed for catheter care. (Resident G) Finding includes: During an interview with Resident G, on 1/15/2025 at 10:30 A.M., she indicated her nephrostomy dressings had not been changed in some time and a new dressing had just been applied She indicated the staff did not know how to apply the dressings. During an interview on 1/21/2025 at 9:46 A.M., Resident G indicated a certified nursing assistant (CNA) had changed her nephrostomy tube dressings yesterday because the dressings had fallen off. A record review for Resident G was completed on 1/17/2025 at 9:18 A.M. Diagnoses included, but were not limited to: nephrostomy, obstructive and reflexive uropathy, overactive bladder and carcinoma of the bladder. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident G was cognitively intact and had an indwelling catheter. Physician Order's, dated 8/14/2024, indicated to monitor the left and right nephrostomy tube site every shift.…

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

Based on interview, observation and record review, the facility failed to ensure follow up speciality appointments and referrals (gynecological/oncology/hematology/vascular surgeon/nephrology) were made for 2 of 2 residents reviewed for physician orders. (Residents G & 64) Findings include: 1. During an interview on 1/15/2025 at 10:32 A.M., Resident G cried while talking about a need for a gynecological oncology appointment as her uterine cancer had returned, according to the most recent hospital testing. She indicated it had been eleven weeks since she had a follow up ultrasound and an appointment had not been secured. She indicated a mass had been found, during the ultrasound. She was concerned about the possible growth of the cancer cells. A record review for Resident G was completed on 1/17/2025 at 9:18 A.M. Diagnoses included, but were not limited to: cancer and carcinoma of the bladder. A Quarterly Minimum Data Set (MDS) assessment, dated 12/23/2024, indicated Resident G was cognitively intact and had moderate depression. A pelvic transvaginal ultrasound, dated 11/18/2024,…

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 record review and interview, the facility failed to ensure the physician documented a clinical contraindication when a gradual dose reduction (GDR) was declined for 2 of 5 residents reviewed for unnecessary medications (Residents 18 & 101). Findings include: 1. The record for Resident 18 was reviewed on 1/21/2025 at 3:28 P.M. Diagnoses included but were not limited to: renal insufficiency, diabetes, depression, anxiety, dementia and Post Traumatic Stress Disorder (PTSD). A Pharmacy Recommendation, dated 2/3/2024, indicated Resident 18 had been receiving Haloperidol (antipsychotic) 1 mg (milligram) four times a day since 7/12/2023. The recommendation was to decrease from 1 mg four times a day to 1 mg three times a day. The form indicated: if a gradual dose reduction was contraindicated, please review the following and check if appropriate. 1. The residents target symptoms returned or worsened after the most recent attempt at a tapering dose. 2. Past reduction attempts have resulted in problematic behavior and/or staff inability to provide care. 3. Past reduction attempts…

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

Based on observation, interview and record review, the facility failed to ensure medications were kept in a locked cart when unattended, were dated and labeled, medication carts were without loose pills and failed to store treatment creams separate from oral medications during medication storage review for 2 of 3 storage units. (200 hall middle medication cart and 100 hall medication cart) Findings include: 1. During a medication storage observation of the 100 hall medication cart, on 1/22/2025 at 1:24 P.M., with QMA 16 the following was observed: - a bottle of Latanoprost eye drops with no resident identifier. - an opened and unlabeled bottle of Timolol eye drops. - an opened bottle of Lactulose with no opened date. - four loose pills in 2 drawers. During an interview, on 1/22/2025 at 1:51 P.M., QMA 16 indicated the medications should have an opened date, the eye drops should have been labeled and the loose pills should not have been in the cart. 2. During a medication storage observation of the 200 hall middle cart, on 1/22/2025 at 2:24 P.M., with RN 2 the following 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete laboratory testing as ordered by the physician for 1 of 1 residents reviewed for laboratory services. (96) Finding includes: The record for Resident 96 was reviewed on 1/21/2025 at 10:09 A.M. Diagnosis included but were not limited to: diabetes mellitus type 2 (DM) with chronic kidney disease, iron deficiency anemia, legal blindness, hypertensive heart disease without heart failure and vitamin D deficiency. A current Care Plan, initiated on 6/26/2024 and updated 1/16/2025, indicated Resident 96 was risk for complications and symptoms of hypoglycemia or hyperglycemia due to a diagnosis of diabetes. Interventions, included but not limited to: diabetes medication as ordered by Medical Doctor (MD). observe for side effects and effectiveness, diet as ordered, educate and remind resident importance of medications and compliance with dietary restrictions, observe for signs or symptoms of hyperglycemia, observe for signs or symptoms of hypoglycemia,…

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 bathing opportunities and oral care were provided for 2 of 3 residents, who required assistance and who were dependent on staff for Activities of Daily Living (ADL). (Residents B and G) Finding includes: 1. During an observation/interview, on 11/13/24 at 9:05 A.M., Resident B was observed lying in his bed. His hair appeared greasy and had flakes of white throughout his scalp. The resident's teeth had a white film on them. The resident was alert and oriented to self, place and time. He indicated he does not get his showers on Mondays and Thursdays and he had to shave himself with an electric razor but explained he had difficulty holding the razor and only parts of his face got shaved. He indicated staff never offered him a tooth brush and he thought he had two toothbrushes somewhere in his room but staff were unable locate them. On 11/13/24 at 9:40 A.M., a review of the clinical record for Resident B was conducted. The resident's diagnosis included, but were not limited to: neurogenic bladder, end stage…

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 interventions to prevent falls, for 1 of 3 residents reviewed for falls. (Resident C) Finding includes: On 11/12/24 at 7:50 A.M., Resident C was observed, seated in a wheelchair, near the nurse's station. The wheel chair had a padded seat cushion. On 11/12/24 at 8:23 A.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's Disease, dementia, anxiety and depression. A current Care Plan for risk of falls, intiated 9/3/24, indicated the resident was at risk for a fall related to a history of falls, impaired cognition and poor safety awareness. The interventions included but were not limited to: offer/encourage to get up later in the morning, no chux pad in wheelchair and offer to assist resident to bed or recliner after meals A Morse Fall Risk Assessment, dated 10/7/24, indicated the resident had scored a 75. The Morse Fall scoring indicated a score of 45 or high indicated resident had been a high risk for a fall. 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 observation, interview and record review, the facility failed to ensure urinary catheters were emptied for 2 of 3 residents and urine output had been documented for 3 of 3 residents reviewed for urinary catheter use. (Residents B, E and G) Findings include: 1. On 11/12/24 at 10:45 A.M., Resident B was observed in his room, in bed, with his eyes closed. The resident's urinary (Foley) catheter had approximately 350 milliliters (ml) in the collection meter which could only hold 350 ml and then would spill into the collection bag. The collection bag had approximately 200-250 ml (milliliters) of urine. During an interview, on 11/1/2/24 at 10:47 A.M., RN 2 indicated urinary Foley was placed while Resident B had been in hospital and the collection meter would spill over into the collection bag, if more than 350 in collection meter. She indicated those type of catheters were used if someone needed to know the output every hour or whatever the order indicated. On 11/13/24 at 9:05 A.M., Resident B was observed in…

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

Based on interview and record review, the facility failed to ensured bowel protocol was followed 1 of 3 residents reviewed for bowel movements, (Resident B). Finding includes: The clinical record for Resident B was reviewed on 9/9/24 at 12:28 P.M. Diagnoses included, but were not limited to: right femur fracture, cardiomyopathy and chronic kidney disease. Resident B's hospital Inpatient Transfer Report form, dated 7/19/24 at 9:56 A.M., indicated Resident B had been treated for fractures of the left fifth, sixth and eighth ribs, and fracture of the right femur with surgical repair following a fall on 7/13/24. The resident had been receiving Hydrocodone 5 mg-acetaminophen 325 mg tablet for pain management, (narcotic pain medication with a potential adverse side effect of constipation) and Docusate Sodium 100 mg daily for constipation. The discharge physician orders from the hospital, included orders for Docusate Sodium 100 mg capsule daily as needed for constipation. A Nursing Admission/readmission Evaluation assessment, dated 7/19/24 at 12:35 P.M. for Resident B, 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 record review and interview, the facility failed to ensure 1 of 3 residents reviewed for pressure wounds, received timely care and treatment to prevent the development of a pressure wound, (Resident B). Finding includes: The clinical record for Resident B was reviewed on 9/9/24 at 12:28 P.M. Diagnoses included, but was not limited to: right femur fracture, cardiomyopathy and chronic kidney disease. An admission Minimum Data Set (MDS) assessment, dated 7/26/24, indicated Resident B was severely cognitively impaired, had no pressure wounds and required extensive assistance for bed mobility, transfers, and toilet use. The portion of the MDS to assess bowel and bladder continence was not completed. Resident B's hospital Inpatient Transfer Report, dated 7/19/24 at 9:56 A.M., indicated Resident B had been treated for a fracture of the right femur with surgical repair following a fall on 7/13/24. There was no documentation of any pressure wounds in the report. The facility Nursing Admission/readmission Evaluation assessment for Resident B, dated 7/19/24 at 12:35 P.M., indicated…

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

Based on interview and record review, the facility failed to ensure pain management was provided and a pain assessment was completed upon admission for 1 of 3 residents reviewed for pain, (Resident B). Finding includes: The clinical record for Resident B was reviewed on 9/9/24 at 12:28 P.M. Diagnoses included, but were not limited to, a right femur fracture, cardiomyopathy and chronic kidney disease. Resident B's hospital Inpatient Transfer Report, dated 7/19/24 at 9:56 A.M., indicated Resident B had fractures of the left fifth, sixth, eighth ribs, and fracture of the right femur with a surgical repair following a fall on 7/13/24. Hospital discharge orders included, but were not limited to the following: 1. Hydrocodone 5 mg-Acetaminophen 325 mg (a narcotic pain medication) one tablet every six hours as needed for pain. The medication had last been administered by the hospital on 7/19/24 at 4:00 A.M. In addition, the report indicated Resident B had been treated with Morphine Sulfate (a narcotic pain medication) 2mg every two hours for pain. The last documented dose of Morphine…

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 resident rights were honored when bathing preferences were not accommodated for 1 of 6 residents reviewed for Resident Rights, (Residents C) Finding includes: 1. During an observation and interview on 8/15/24 at 9:48 A.M., Resident C was noted to be lying in bed, wearing a night gown with uncombed hair and general unkempt appearance. The resident indicated her preference was to receive showers every Monday, Thursday, and Saturday on the day shift, but the facility changed her shower days to Tuesdays and Thursday. Resident C indicated the facility staff told her if she had showers on Thursday, she was not eligible to have another shower on Saturday. Resident C indicated she did not get her showers per her preference and she did not get all of the showers she was scheduled to receive. Resident C indicated she liked to participate in Sunday worship services, but did not feel comfortable attending church if she had not been showered in…

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

Based on record review and interview, the facility failed to ensure a comprehensive and person centered care plan was developed for urostomy care for 1 of 3 residents reviewed for urostomy care, (Resident C). Finding includes: During an observation and interview, on 8/15/24 at 9:48 A.M., Resident C's urostomy was noted to the mid-right abdominal are with a ostomy bag connected to a cathere bag. The catheter bag, hanging at the bedside had 600 ccs of urine. Resident C indicated staff did not empty her urostomy bag regularly Resident C's record was reviewed on 8/15/24 at 1:16 P.M. Diagnoses included, but were not limited to, spina bifida, chronic respiratory failure, paraplegia, and obstructive and reflux uropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 9/30/23, indicated Resident C was cognitively intact, required substantial to maximal assistance for most activities of daily living, and required a urostomy for the removal of urine from the body. A Physician's Order for Resident C, dated 7/1/24 with no end date, indicated, Urostomy bag empty q [every] shift. 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 observation, interview, and record review, the facility failed to provide showers/bathing opportunities as scheduled for for 6 of 6 residents reviewed for Resident Rights, (Residents B, C, D, J, K, and M). Findings include: 1. During an observation of Resident B on 8/14/24 at 2:43 P.M., the resident was observed in his room in a wheelchair, dressed in a t-shirt with food debris on his shirt. Resident B's clinical record was reviewed on 8/14/24 at 1:00 P.M. Diagnoses included history of stroke, hemiplegia and a speech deficit. An Annual Minimum Data Set (MDS,) dated 6/3/24, indicated Resident B was mildly cognitively impaired, required substantial to maximal assistance for showing and bathing and indicated it was very important to him to make choices about his showering and bathing needs. A current Care Plan, initiated on 9/26/19 and revised on 6/18/24 indicated Resident B required assistance for activities of daily living related to but not limited to hemiparesis, and muscle weakness. An intervention…

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 urostomy orders, care, and monitoring orders were in place for the care of 1 of 3 residents reviewed for urostomy care, (Resident C). Finding includes: During an observation and interview on 8/15/24 at 9:48 A.M., Resident C was observed in her bed, dressed in a gown. The resident's urostomy was noted to the mid-right abdominal area with the ostomy bag connected to a catheter bag hanging at the bedside, holding 600 CCs of urine. Resident C indicated staff did not empty her urostomy regularly. She indicated she often did not get her catheter bag emptied on the day shift. During an interview on 8/15/24 at 2:00 P.M., the Administrator, indicated the facility hired a new medical director around 7/1/24, and all orders had to be resubmitted in the resident's Electronic Medical Records (EMR). The Administrator indicated Resident C's urostomy orders were not put in the the EMR system as they should have been. Resident C's record was reviewed on 8/15/24 at 1:16 P.M. Diagnoses included , but were not limited to, spina bifida,…

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 complete follow up assessments for changes in condition related to urinary tract infections for 3 of 3 residents reviewed for urinary tract infections. (Residents B, D, and E) Findings include: 1. A record review was completed for Resident B on 7/31/2024 at 11:22 A.M. Diagnoses included, but were not limited to, acute cystitis with hematuria, urinary tract infection (UTI), multiple sclerosis, and chronic kidney disease. The resident was discharged to the hospital on 6/26/2024 due to hematuria and an UTI. She was readmitted to the facility on [DATE]. A Discharge Minimum Data Set (MDS) assessment, dated 6/26/2024, indicated Resident B's short term memory recall was intact and she had modified independence for making decisions regarding daily life. Resident B was frequently incontinent of her bowel and bladder, required substantial to maximal staff assistance for toileting and was currently receiving both an antibiotic and a diuretic medication. The…

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

Based on observation, record review and interviews, the facility failed to ensure food was stored, prepared and served in a sanitary manner in 1 of 1 kitchens observed. (Main Kitchen) This had the potential to affect 113 residents who received food from the kitchen. Finding includes: 1. During a tour of the kitchen, conducted on 2/25/2024 at 1:40 P.M. and accompanied by the Food Service Supervisor (FSS) the following was noted: a. There was a large accumulation of debris, food items and dust underneath the food storage shelving in the dry storage room. There was a wall air conditioner unit above an open cart utilized to store bread items, with a heavy accumulation of dark gray dust. b. Two buckets of sanitizing water were noted in use. The first bucket had not been changed since before the breakfast meal. The second bucket had just been changed, but Employee 17 had not placed the sanitizing tablet in the water and it did not test properly. The FSS indicated the automatic chemical system was not functioning and staff were supposed to use the chemical tablets for the water and she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure comfortable water temperatures were provided for showers and/or peri care, even after grievances had been filed, for 2 of 3 units observed. (Cedar and Birch units) Findings include: 1. On 2/29/24 at 9:25 A.M., Resident G was observed in his room, in bed. The resident was alert to self. The resident's bathroom was observed and the water facet would only dispense cold water, even after leaving it on for more than 3 minutes. Resident G made no comment when asked about the cold water, just covered his head with his blanket. During an interview, on 2/29/24 at 9:46 A.M., Resident G's wife indicated the facility had been without warm or hot water for a month. She had observed staff to continually use cold water on him, and when they cleaned him up around his private parts, he would cry out. The wife indicated once, a CNA (not named) told him she was sorry the water was so cold. He went without showers due to no hot water. She had filed 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 observation, record review, and , the facility failed to ensure food was served at a palatable temperature on 2 of 3 nursing units. (Cedar & Dogwood units) Findings include: 1. During observation of the noon meal, on 2/28/2024 at 11:10 A.M., stacks of warmed pallet plate cover bottoms were noted stacked on the outside shelf of the steam table. The hot food temperatures were checked by the FSS (Food Services Supervisor) at 11:20 A.M., and were as follows: Fried chicken - 172 F, Mashed potatoes - 178 F, Gravy - 160 F, Malibu mixed vegetables -184 F, Mechanical ground chicken made from cooked diced chicken pieces - 152 F, Pureed chicken made from cooked diced chicken - 155 F, Baked chicken breast (only made a few) - 144 F - the FSS put back in the oven and later temped at 169 F, Pureed vegetable blend- 143 F, precooked hamburger patties - 147 F, hot dogs - 106 F - put back in the oven and retempted at 163 F. 2. The first meal cart was sent to the Cedar unit at 11:44 A.M. The second meal cart was sent to the Cedar unit at 11:54 A.M. The temperature from a meal tray was assessed…

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 observation, record review, and interview, the facility failed to ensure the menu for therapeutic diets was prepared and offered. This deficient practice had the potential to affect residents receiving therapeutic diets from the kitchen. Finding includes: During an observation of the meal service, on 2/26/2024 at 11:14 A.M., there were large amounts of fried chicken pieces prepared, only one type of gravy, regular mashed potatoes, a vegetable blend, a small pan of green beans, regular dinner rolls, mechanically ground chicken, pureed chicken, pureed vegetable blend and a small pan with a few pieces of baked chicken prepared. During an interview with [NAME] 23, on 2/26/2024 after the meal had been served and review of the Modified Diet Spreadsheet for the meal was completed, she indicated she had not prepared enough backed chicken breast as was menued for the reduced carbohydrate, heart healthy, and renal diet residents. She had prepared only a few pieces. Additionally, she indicated she had prepared a packaged gravy from the store room, and did not know if is was salt free.…

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 walls and floors were maintained in a sanitary and comfortable condition for 2 of 3 nursing units observed. (Cedar and Birch units) Finding includes: During an environmental tour of the facility, on 2/29/2024 at 1:30 P.M., accompanied by the Administrator, the following was noted: 1. Birch unit a. room [ROOM NUMBER]-2: the bed linens in bed 1 had some light brown spots. The bed linens for Bed 2 had yellow staining in the middle of the bed sheets. b. room [ROOM NUMBER] -1: the wallpaper around and above the television was loose and falling down. There was also dark brown paint around the room door handle. The Administrator indicated she was unaware if they fixed the door knob and used a different colored paint or why there was such a difference in color. - c. room [ROOM NUMBER]-2: there were two quarter sized areas above bed 2 with missing paint. There were also two nail holes on the wall across from bed one and a quarter sized area…

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 staff failed to report alleged abuse allegations immediately to the administrator for 3 of 4 residents reviewed for abuse. (Residents 43, 218 and 68) Findings include: 1. During a dining observation, on 2/25/2024 at 12:24 P.M., Residents 218 and 43 were sitting at the assisted dining table, and sitting side by side. Resident 218 was observed yelling at Resident 43. CNA 5 attempted to intervene verbally, but did not move Resident 218 from the table. Resident 218 kept yelling at Resident 43 to get up and walk so they could get out of here. Resident 43 looked at Surveyor 11942, and stated, Can you at least tell her I can't walk so she will stop? Resident 218 continued to escalate at yelling at Resident 43. This resulted in Resident 43 crying. During an interview, on 2/25/2024 at 2:01 P.M., Resident 43 indicated that lady screamed at me, and it made her feel terrible. At 2:28 P.M., Resident 43 continued to cry. A record review for Resident 43 was completed on 2/27/2024 at 11:20 A.M. 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.

Based on observation, record review, and interview, the facility failed to investigate allegations of abuse for 3 of 4 residents reviewed for abuse prevention. (Residents 43, 218 and 68) Findings include: 1. During a dining observation, on 2/25/2024 at 12:24 P.M., Residents 218 and 43 were sitting at the assisted dining table, and sitting side by side. Resident 218 was observed yelling at Resident 43. Certified Nursing Assistant (CNA) 5 attempted to intervene verbally, but did not move Resident 218 from the table. Resident 218 continued yelling at Resident 43 to get up and walk so they could get out of here. Resident 43 looked at Surveyor 11942, and stated, Can you at least tell her I can't walk so she will stop? Resident 218 continued to escalate at yelling at Resident 43. This resulted in Resident 43 crying. During an interview, on 2/25/2024 at 2:01 P.M., Resident 43 indicated that lady screamed at me, and it made her feel terrible. As the interview continued at 2:28 P.M., Resident 43 continued to cry. A record review of Resident 43 was completed on 2/27/2024 at 11:20 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide required resident information to the receiving facility for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10) Findings include: 1. During an interview, on [DATE] at 1:35 P.M., Resident 96 indicated she had been hospitalized for ketoacidosis, kidney failure due to diabetes, and two stents. A record review was completed on [DATE] at 8:47 A.M. Diagnoses included, but were not limited to: hypoglycemia, diabetes mellitus type 1, chronic obstructive pulmonary disease, and chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 96 was cognitively intact. A Nurse's Note, dated [DATE] at 2:56 A.M., indicated Resident 96 was persistent in needing to be transferred to the emergency room for dropping blood sugars, vomiting, severe abdominal pain, and right mouth pain. The Nurse Practitioner agreed to transfer to the Emergency Room. A call was placed to the hospital for report of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide the required transfer and discharge form to the resident or resident representative for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10) Findings include: 1. During an interview, on [DATE] at 1:35 P.M., Resident 96 indicated she had been hospitalized for ketoacidosis, kidney failure due to diabetes, and two stents. A record review was completed on [DATE] at 8:47 A.M. Diagnoses included, but were not limited to: hypoglycemia, diabetes mellitus type 1, chronic obstructive pulmonary disease, and chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 96 was cognitively intact. A Nurse's Note, dated [DATE], 2:56 A.M., indicated Resident 96 was persistent to be transferred to the emergency room for dropping blood sugars, vomiting, severe abdominal pain, and right mouth pain. The Nurse Practitioner agreed to transfer to the Emergency Room. A call was placed to the hospital…

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 interviews and record reviews the facility failed to provide the required bed hold form to the resident or resident representative for 3 of 3 residents reviewed for hospitalizations. (Residents 96, 68, and 10) Findings include: 1. During an interview, on [DATE] at 1:35 P.M., Resident 96 indicated she had been hospitalized for ketoacidosis, kidney failure due to diabetes, and two stents. A record review was completed on [DATE] at 8:47 A.M. Diagnoses included, but were not limited to: hypoglycemia, diabetes mellitus type 1, chronic obstructive pulmonary disease, and chronic kidney disease. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 96 was cognitively intact. A Nurse's Note, dated [DATE], 2:56 A.M., indicated Resident 96 was persistent to be transferred to the emergency room for dropping blood sugars, vomiting, severe abdominal pain, and right mouth pain. The Nurse Practitioner agreed to transfer to the Emergency Room. A call was placed to the hospital for report of…

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

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed, related to PASARR (Pre-admission Screening and Resident Review) coded incorrectly, for 1 of 27 MDS assessments reviewed. (Resident 7) Finding includes: A record review was completed on 2/28/2024 at 12:26 P.M. Resident 7's diagnoses included, but were not limited to: Major depressive disorder, dementia without behavioral, psychotic mood and anxiety, delusional disorder, aphasia, anxiety disorder, expressive language disorder, pseudobulbar affect, hydrocephalus, and mild cognitive impairment. A Quarterly MDS (Minimum Data Set) assessment, dated 12/15/2023 indicated Resident 7 had intact cognition. The admission MDS assessment, dated 8/30/2022, indicated the section for PASARR Level 2 needed was checked no. On 9/25/2019, Resident 7 had a PASARR Level 1 completed, and it determined Resident 7 had a serious mental illness and/or intellectual disability and required a Level II PASARR to be completed. During an interview, on 2/29/24 at 2:47 P.M., the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an individualized comprehensive care plan was developed for 2 of 2 residents reviewed for bowel and bladder incontinence (Residents D and 90) and failed to ensure fall care plans were followed for 1 of 4 residents reviewed for falls. (Resident 267) Findings include: 1. During an observation and interview with alert and oriented Resident 90, on 2/26/2024, she indicated she used to get out of bed and go to the bathroom, but now, due to pain in her legs, she was incontinent. She indicated sometimes the aides brought her a bed pan. The record for Resident 90 was reviewed on 2/27/2024 at 11:11 A.M. Diagnoses included, but were not limited to: morbid obesity, cirrhosis of the liver, chronic kidney disease, stage 4, muscle weakness, major depressive disorder and overactive bladder. The admission Minimum Data Set (MDS) assessment, dated 3/2/2023, indicated she required only supervision for in room ambulation and transfers, and was…

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

Based on interview and record review, the facility failed to include or invite residents' family members or responsible parties to participate in Care Plan conferences and failed to revise Care Plans timely for 5 of 5 residents reviewed for care planning. (Residents 95, C, 30, 64 and 27). Findings include: 1. During an interview, on 2/25/2024 at 11:17 A.M., Resident 95's daughter indicated she has not had a care planning meeting since her mother was admitted . A record review was completed on 2/26/2024 at 10:23 A.M. Resident 95's diagnoses included, but were not limited to: metabolic encephalopathy, chronic obstructive pulmonary disease, dementia, hypertensive heart disease, heart failure and hyperlipidemia. An admission MDS (Minimum Data Set) assessment, dated 1/5/2024, indicated Resident 95 had severe impaired cognition. During an interview, on 2/28/2024 at 9:16 A.M., the Assistant Social Service Director (ASSD) indicated Resident 95 had not had a care conference with the family and she should have had one. 2. During an interview, on 2/25/2024 at 2:01 P.M., Resident C indicated…

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

Based on observation, record review, and interview, the facility failed to ensure 5 of 5 dependent residents reviewed for Activities of Daily Living received needed assistance related to AM care, showers, and shaving. (Residents E, D, B, C, & G) Findings include: 1. During an interview with alert and oriented Resident E on 2/26/24 at 9:17 A.M., he indicated the staff did not bring him any water or washcloths and towels to wash his face and hands in the mornings. Resident E indicated he could not walk or go into the bathroom, but could wash his face and hands with assistance if he was brought the proper supplies. The record for Resident E was reviewed on 2/27/2024 at 9:46 A.M. Diagnoses included, but were not limited to: paraplegia, thyrotoxicosis with diffuse goiter, history of multiple injuries, chronic pain and hypothyroidism. A Quarterly Minimum Data Set (MDS) assessment, dated 1/30/2024, indicated the resident was alert and oriented, had limited range of motion for both lower extremities, and required extensive staff assistance for dressing, bathing and personal hygiene needs.…

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 provide an individualized activity program for 1 of 2 residents reviewed for activities. (Resident 27) Finding includes: The record for Resident 27 was reviewed on 2/27/2024 at 10:33 A.M. Diagnoses included, but were not limited to: cerebral infarction, hemiplegia and hemiparesis, pseudobulbar affect, , unspecific dementia and vascular dementia. Resident 27 was observed on 2/25/2024, 2/26/2024, 2/27/2024,, 2/28/2024, 2/29/2024 and 3/1/2024 lying in her bed for a majority of the day time hours, except during the meal time, when she was placed in a reclining wheelchair and taken to the dining room. After meals, she was placed in the hallway across from the nurse's station until she was pushed to her room and placed in her bed. There was no television or music playing in her room and no activity staff were observed to go into her room to provide any type of activity with Resident 27. A Significant Change Minimum Data Set (MDS) assessment, completed on 1/15/2024, indicated the resident was severely cognitively…

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 1 of 3 residents reviewed for vision needs received timely assistance to address visual impairment needs. (Resident 64) Finding includes: During the initial tour of the facility, conducted on 2/25/2024 between 9:30 - 11:00 A.M., Resident 64 was observed seated in her wheelchair in her room. The resident was noted to wear eyeglasses. During an interview with Resident 64, on 2/26/24 at 10:01 A.M., the resident indicated her current glasses were not strong enough and she needed new glasses. She had not seen an eye doctor since she had been admitted to the facility. The record for Resident 64 was reviewed on 2/27/2024 at 12:02 P.M. Diagnoses included, but were not limited to: chronic lymphocytic leukemia of B-Cell type, parkinsonism, atrial fibrillation, anemia, atrial flutter, presence of right and left artificial knee joint. The admission Minimum Data Set (MDS) assessment, dated 5/22/2023, indicated the resident's vision was adequate without any corrective lenses. A Quarterly MDS assessment, dated…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions were in place to ensure an area for a resident with a previous pressure ulcer remained closed and/or healed, for 1 of 4 residents reviewed for pressure ulcers. (Resident 17) Finding includes: On 2/28/24 at 1:54 P.M., an observation of a pressure wound dressing change for Resident 17 was conducted with LPN 9. The LPN washed her hands and then removed the left off-loading boot. She then sanitized her hands, donned gloves, and removed a dressing dated 2/28/24. The Stage III pressure wound was observed on the left lateral heel. The wound had serous drainage with granulation tissue, no odor, and the resident indicated it hurts a little when changing the dressing. LPN 9 removed her gloves and sanitized her hands, then applied new gloves. The wound was measured as 5.0 x 5.0 x 0.2 cm. The wound was cleansed with wound cleanser, then collagen and calcium algenate was applied to the wound bed, an abdominal dressing was placed over the wound area, and then wrapped in kerlix gauze 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 1 of 2 residents reviewed for bladder incontinence received timely care to prevent and treat a urinary tract infection. (Resident D) Finding includes: The record for Resident D was reviewed on 2/27/24 at 9:13 A.M. Diagnoses included, but were not limited to: Parkinson's disease with dyskinesia, Alzheimer's disease, anxiety disorder, overactive bladder and male erectile dysfunction. The Quarterly Minimum Data Set (MDS) assessment, dated 1/26/2024, indicated the resident had impaired Range of Motion on one side, was moderately cognitively impaired, required extensive staff assistance for toileting needs and was frequently incontinent of his bladder. A Functional Abilities Assessment, dated 2/19/2024, indicated the resident required substantial staff assistance for toileting needs. During an interview with the resident and a family member, on 2/27/2024 at 1:53 P.M. the resident indicated staff do not offer to assist him to the toilet and he often toilets himself, even though he knows he is supposed 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 observation, record review, and interview, the facility failed to ensure 1 of 1 residents observed for hydration was offered sufficient fluids to maintain proper hydration and health. (Resident 27) Finding includes: The room for Resident 27 was observed daily from 2/25/2024 - 3/1/2024. There was no large water cup for ice water observed in the resident's room. On 2/25/2024 there was a small Styrofoam cup 1/3 full of a thick brown liquid and on 3/1/2024 there was a store brand water bottle 1/2 full of water on her nightstand. The record for Resident 27 was reviewed on 2/27/2024 at 10;33 A.M. Diagnoses included, but were not limited to: cerebral infarction, hemiplegia and hemiparesis and unspecific dementia. A Significant Change Minimum Data Set (MDS) assessment, dated 1/15/2024, indicated the resident was severely cognitively impaired, had impaired upper and lower extremity mobility on one side, had a recent unplanned significant weight loss and had two stage 3 pressure ulcers. A Hydration Risk Assessment, dated 2/19/2024, scored the resident as a low or not at risk for…

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

Based on observation, record review, and interview, the facility failed to provide sanitary nebulizer equipment for 1 of 2 residents reviewed for respiratory care. (Resident 68) Finding includes: During an observation, on 2/25/2024 at 11:05 A.M., Resident 68's nebulizer mask was observed sitting on the bedside table. On 2/26/2024 at 8:54 A.M., Resident 68's nebulizer mask was observed to be hanging from the call light outlet on the wall. A record review was completed on 2/27/2024 at 11:20 A.M. Diagnoses included, but were not limited to: sleep apnea, chronic respiratory failure, and pneumonia. A Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2024, indicated Resident 68 was cognitively intact. She special treatments of oxygen use and non-invasive mechanical ventilation. A Physician's Order, dated 2/12/2024, indicated Resident 68 received Albuterol Sulfate inhalation nebulizer solution 2.5 milligram per 3 milliliters via nebulizer every 6 hours as needed for shortness of breath. A Care Plan, dated 10/16/2023 and revised on 11/15/2023, indicated Resident 68 was at risk for…

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

Based on record review and interview, the facility failed to provide ongoing assessment for a 1 of 1 resident reviewed for dialysis. (Resident 109) Finding includes: During an interview, on 2/26/2024 at 9:32 A.M., Resident 109 indicated she received dialysis on Mondays, Wednesdays, and Fridays. A record review was completed on 2/28/2024 at 9:01 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, chronic kidney disease, and dependence on renal dialysis. A Care Plan, dated 1/2/2024, indicated Resident 109 had end-stage renal disease (ESRD), and required hemodialysis on Monday, Wednesday, and Friday with a chair time of 12:45 P.M. Interventions, dated 1/2/2024, included, observe for signs of infection to access site: redness, swelling, warmth or drainage; observe for signs of the following: bleeding, hemorrhage, bacteremia, septic shock; observe for symptoms of fluid volume deficit such as hypotension, postural changes in blood pressure, dizziness, thirst, dry oral mucosa, weight loss, nausea or muscle cramps; and, observe for symptoms of fluid volume excess…

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 monitor for the use of a thyroid medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 17) Finding includes: On 2/29/24 at 4:00 P.M., a review of the clinical record for Resident 17 was conducted. The resident's diagnoses included but were not limited to: diabetes, heart disease, heart failure, cerebrovascular accident and hypothyroidism. The Medication Administration Record (MAR) indicated the resident had been administered Levothyroxine (a thyroid replacing hormone) 150 milligrams daily, for hypothyroidism. The start date for this medication was 9/3/22. A Care Plan, dated 10/22/22 and revised on 2/21/24, indicated the resident had a diagnosis of hyperthyroidism and required medication. The interventions indicated for the facility to administer the thyroid replacement medication, monitor for effectiveness, watch for signs & symptoms of hyperthyroidism and obtain lab work as ordered. Lab work results indicated the resident's TSH (Thyroid Stimulating Hormone) levels were completed on 10/11/22 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 record review and interview, that facility failed to limit as needed (PRN) psychotropic medication to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 18) Finding includes: A record review was completed for Resident 18 on 2/27/2024 at 3:19 P.M. Diagnoses included, but were not limited to: major depressive disorder, post-traumatic stress disorder, palliative care, and adjustment disorder with mixed anxiety and depressed mood. A Quarterly Minimum Data Set (MDS) assessment, dated 11/27/2023, indicated Resident 18 had moderate cognitive impairment. She received anti-anxiety, antidepressant, and antipsychotic medications. No gradual dose reductions or documentation had been completed for the use of the antipsychotic, haloperidol. A Physician's Order, dated 4/18/2023, indicated haloperidol 2 milligrams mouth every 8 hours as needed for Psychosis. This order was discontinued on 5/12/2023. A Pharmacy Recommendation, dated 5/4/2023, indicated, .Per CMS [Centers for Medicare and Medicaid] regulations, orders must include a 14-day stop date. If use is…

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 1 of 2 residents reviewed for dental services received timely assistance. (Resident 90) Finding includes: During the initial tour of the facility, conducted on 2/25/2024 between 9:30 A.M. - 11:00 A.M., Resident 90 was observed lying in her bed. She was noted to be edentulous (without any teeth). During an interview with Resident 90, on 2/26/24 at 10:15 A.M., she indicated she had dentures but she did not wear them because they did not fit correctly. She had not seen a dentist since she was admitted to the facility. The record for Resident 90 was reviewed on 2/27/2024 at 11:11 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, type 2 diabetes, morbid obesity, cirrhosis of the liver, obstructive sleep apnea, hypertensive heart and chronic kidney disease and celiac disease. The admission Minimum Data Set (MDS) assessment, dated 3/2/2023, indicated the resident had no natural teeth. There was a care plan to address the resident's oral health issue of lingua villosa…

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 infection control standards during incontinence care, for 2 of 7 residents reviewed for activities of daily living. (Residents D and 27) The facility also failed to ensure transmission based precautions were implemented appropriately for 1 of 3 residents reviewed for infections. (Resident 11) Findings include: 1. During an observation of incontinence care for Resident 27, on 2/27/24 at 11:25 A.M., CNAs 7 and 8 were assisting the resident back into bed. The resident's incontinence brief was noted to be wet. CNA 8 donned gloves and removed the soiled brief from Resident 27. Next, without changing her gloves, CNA 8 took a premoistened washcloth and wiped both sides of the front of the resident's groin, however, CNA 8 did not wipe the middle of the resident's peri area or back side of the resident's peri area. After performing incontinence care, CNA 8 left her contaminated gloves on to remove the hoyer pad from underneath the resident, and pull up her outside pants. The resident was then assisted to roll…

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 3 of 5 residents reviewed for immunizations/vaccine administration, had received them. (Residents 4, 95 and 51) Findings include: 1. On 3/2/24 at 9:13 A.M., the clinical record for Resident 4 was reviewed. The record indicated the resident had signed a consent form titled, 2023-2024 Covid-19 Vaccine Consent Form, on 10/25/23. The Medication Administration Record (MAR) indicated the resident was to have the vaccine, on 12/27/23. The MAR had no initials (blank) which indicated the vaccine had not been administered, as ordered. 2. On 3/2/24 at 9:16 A.M., the clinical record for Resident 95 was reviewed. The record indicated the resident had signed a consent form titled, Informed Consent for Influenza Vaccine, on 1/3/24. The Active Orders indicated the resident may have annual Flu vaccine and annual Pneumonia Vaccine. There was no documentation which indicated the resident had received those vaccines, at the facility. 3. On 3/2/24 at 9:22 A.M., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that an allegation of misappropriation of property was reported to the State Survey Agency (SSA) in a timely manner for 1 of 3 residents reviewed for misappropriation of property, (Resident B). Finding include: On 1/2/24 at 3:00 P.M., a facility's Report of Concern form was provided by the Administrator that indicated on 12/24/23, Resident B's responsible party reported Resident B's .wedding ring is missing. Resident and family have been visiting most days. Facility informed around 12 pm. Daughter [not] stating anyone has taken, but was missing .Police report made, room searched, resident unable to state what happened as she doesn't take off. No concerns of being stolen, but rather lost: Facility to continue search and update family as needed . The Report of Concern form indicated the incident occurred on 12/24/23, was reported to the facility on [DATE], and was written and signed by the Administrator on 12/26/23. The report 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 interview and record review, the facility failed to ensure an allegation of abuse was reported timely, in 1 of 3 residents reviewed for allegations of abuse. (Resident D) Finding includes: On 10/21/23 at 11:01 P.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to: heart failure, morbid obesity, diabetic and arthritis. A self-reported incident, dated 9/26/23 at 9:01 A.M., indicated .9/28/23 On this date resident stated to staff that QMA [Qualified Medical Assistant] noted was verbally inappropriate with her during care on 9/26/23 Resident D was immediately interviewed by Social Services Director and the Administrator and the QMA 2 was suspended pending the investigation. During an interview, on 10/21/23 at 11:33 AM, LPN 3 indicated QMA 2 came to her, on 9/26/23, with allegations of Resident D being verbally inappropriate to her and called her slang name. LPN 3 went to the Resident's room and assessed the situation and let Resident D tell her side of the story. She then told QMA 2 that she had to report…

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 provide a sanitary refrigerator and food storage for the residents' nutrition needs in 3 of 3 pantries observed. (Halls 100, 200, 300) Findings include: 1. During an observation, on 1/12/2023 at 2:30 P.M., the 100-unit nutrition pantry freezer had a dried substance in the bottom and a lower cabinet had a sticky orange spill on the bottom shelf. 2. The 200-unit freezer had a spill on the bottom. There was also a coat in the lower cabinet. 3. The microwave on the 300-unit had a dried brown liquid spilled on the plate. During an interview, on 1/12/2023 at 2:38 P.M., the Dietician indicated the spills should have been cleaned up and coats should not be stored in the nutrition pantry. On 1/13/2023 at 2:00 P.M., the Administrator provided a policy titled, Refrigerators and Freezers, dated November 2014. The policy indicated .Refrigerators and freezers will be kept clean, free of debris, and mopped with a sanitizing solution on a scheduled basis and more often as necessary 3.1-21(i)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure comprehensive, person centered, care plans were in place and accurate for 4 of 4 residents review for care plans. (Residents G, H, 72, 280). Findings include: 1. On 1/13/2023 at 1:30 P.M., Resident G's clinical record was reviewed. The resident's admission Record indicated an admission date of 12/05/2022. The residents' most recent comprehensive Minimum Data Set, dated [DATE] for admission Assessment indicated Resident G had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident required supervision with set-up help for eating. Diagnoses included, but were not limited to: diabetes, acquired absence of parts of digestive tract, femoral fracture, kidney failure, stroke, hemiplegia, and surgical wound for femoral fracture repair. Review of Resident G's physician dietary orders dated 12/05/2022, indicated a reduced carbohydrate diet regular texture, thin consistency. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide care plan meetings for 6 of 6 residents reviewed for care plan meetings.( Residents 16, 46, 47, 71, 22, & H) Findings include: 1. During an interview, on 1/9/2023 at 2:50 P.M., Resident 16 indicated she had not attended any care plan meetings. A clinical record review was completed, on 1/9/2023 at 3:18 P.M. Resident 16 diagnoses included, but were no limited to: hypertension, hemiplegia, anxiety, depression, diabetes and seizures. A Quarterly MDS ( Minimum Data Set) Assessment, dated 12/12/2022, indicated the residents' BIMS (Brief Interview for Mental Status) score was 15, cognition intact. The only electronic Care Conference sheet, was dated 1/4/2022. A review of the Progress notes, dated 1/2022 through 12/2022, lacked the documentation of any further Care Conference sheets indicating care plan meetings had not been held. During an interview,on 1/13/2023 at 9:32 A.M., Social Service staff 2 indicated she had gotten behind on the care plan…

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 showers were provided timely for 7 of 8 residents reviewed for Adl care (Activities of Daily Living). (Residents 16, 46, 44, D, L, 180) Findings include: 1. During an interview, on 1/9/2023 at 2:51 P.M., Resident 16 indicated she does not get showers. A clinical record review was completed, on 1/9/2023 at 3:18 P.M. Resident 16 diagnoses included, but were no limited to: hypertension, hemiplegia, anxiety, depression, diabetes and seizures. An annual MDS (Minimum Data Set) Assessment, dated 9/16/2022, indicated: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? The response checked was Very Important. A Quarterly MDS Assessment, dated 12/12/2022, indicated the residents' BIMS (Brief Interview for Mental Status) score was 15, cognition intact. Required extensive assist of 2 staff for bed mobility, dressing, toilet use, total assist of 2 staff for transfers and bathing and limited assist for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a correct physician order for the resident's resuscitation wishes for 1 of 2 residents reviewed for advanced directives. (Resident 69) Finding includes: An initial record review on [DATE] at 3:06 P.M., indicated Resident 69 had a physician's order for a resuscitation choice of a full code on [DATE]. A POST (Physician Orders for Scope of Treatment) form on [DATE], indicated Resident 69's wish was to have a do not resuscitate physician's order. An interview with Resident 69 on [DATE] at 9:35 A.M., indicated Resident 69's wish was to have an order for do not resuscitate. On [DATE] at 9:34 A.M., a record review was completed. Diagnoses included, but were not limited to: displaced fracture of the second and sixth cervical vertebra, fracture of the forearm, osteoporosis, and hypertension. An admission MDS (Minimum Data Set) Assessment on [DATE], indicated Resident 69 was cognitively intact. A Care Plan on [DATE], indicated Resident 69 had established…

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 prevent mental anguish to 1 of 3 residents reviewed for abuse. (Resident 16) Finding includes: A clinical record review was completed, on 1/9/2023 at 3:18 P.M. Resident 16 diagnoses included, but were no limited to: hypertension, hemiplegia, anxiety, depression, diabetes and seizures. A Quarterly MDS Assessment, dated 12/12/2022, indicated the residents' BIMS (Brief Interview for Mental Status) score was 15, cognition intact. Required extensive assist of 2 staff for bed mobility, dressing, toilet use, total assist of 2 staff for transfers and bathing and limited assist for eating During an interview, on 1/9/2023 at 4:06 P.M., Resident 16 indicated a staff member came to the room and asked what! The resident indicated she needed to pee and needed the bedpan, the resident stated the aide stomped in the room and got the bed pan and stated you didn't have to wait until right before you needed to go. During an interview, on 1/10/2023 at 10:07 A.M., the Administrator indicated she had reported the allegation to the state and had…

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 report the follow-up to a reportable timely for 1 of 3 residents whose reportable's were reviewed. ( Resident 18) Finding includes: On 1/17/2023 at 3:03 P.M., a facility reportable was reviewed for Resident 18. The reportable, dated 3/18/2022, indicated the resident had reported she had missing money of $80.00. An investigation was initiated, but unable to determine who took the resident's money. A follow-up report was sent to the State Department of Health on 3/29/2022, 11 days after the initial incident had been reported. During an interview, on 1/17/2023 at 3:09 P.M., the Administrator indicated she was unsure of why the follow-up report had been sent in late. On 1/9/2023 at 12:11 P.M., the Administrator provided the policy titled, Abuse Prevention Program, dated March 2022, and indicated the policy was the one currently used by the facility. The policy indicated . The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification…

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 complete an activity comprehensive assessment for 1 of 3 residents reviewed for activities comprehensive assessments. (Resident 280) During an initial interview on 1/10/2023 at 11:51 A.M., Resident 280 indicated she stayed in her room all day, including meals, and would like to participate in activities. Finding includes: On 1/11/2023 at 11:39 A.M., Resident 280 was observed lying in bed in a facility gown watching the television. An observation and interview on 1/12/2023 at 1:42 P.M., Resident 280 was observed lying in bed with a facility gown on. She indicated during an interview, she enjoys horseback riding, crocheting, listening to music and coloring. Independent activities were not observed in the room. During observations on 1/13/2023 at 11:12 A.M. and 2:58 P.M., Resident 280 was observed lying in bed with a facility gown on and the television playing. A clinical record review was completed on 1/18/2023 at 10:20 A.M. Diagnoses included, but were not limited to: displaced trimalleolar fracture of left…

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 activities of choice for 1 of 3 residents reviewed for activities. (Resident 280) Finding includes: During an initial interview on 1/10/2023 at 11:51 A.M., Resident 280 indicated, she stays in her room all day, including meals, and would like to participate in activities. On 1/11/2023 at 11:39 A.M., Resident 280 was observed lying in bed in a facility gown watching the television. An observation and interview on 1/12/2023 at 1:42 P.M., Resident 280 was observed lying in bed with a facility gown on. She indicated during an interview, she enjoys horseback riding, crocheting, listening to music and coloring. No independent activities were observed in the room. During observations on 1/13/2023 at 11:12 A.M. and 2:58 P.M., Resident 280 was observed lying in bed with a facility gown on and the television playing. A clinical record review was completed on 1/18/2023 at 10:20 A.M. Diagnoses included, but were not limited to: displaced trimalleolar fracture of left lower leg, hemiplegia and hemiparesis…

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 collaborate with hospice regarding the development of a comprehensive hospice care plan related to communication of resident changes i.e.: pain, nutrition, skin and end of life for 1 of 3 residents reviewed for hospice. (Resident 180) Findings include: A clinical record review was completed on, 1/13/2023 at 9:57 A.M., and indicated Resident 180's diagnoses included, but were not limited to: necrotic bowel secondary to small obstruction, metabolic encephalopathy, anemia, neuromuscular dysfunction of the bladder, altered mental status, intestinal obstruction, dysphonia, hypertension and hypothyroidism. An admission MDS (Minimum Data Set) assessment, dated 12/29/2022, indicated Resident 180 had a BIMS (Brief Interview for Mental Status) score of 15, cognition intact. Current physician orders, dated January 2023, indicated Resident 180 was receiving Hospice Care with a local hospice. A current care plan, dated 12/23/2023, indicated Resident 180 is receiving hospice services and indicated the facility would work…

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 catheter care was completed appropriately for 2 of 3 residents reviewed for catheter care. (Resident 28 and Resident L) Findings include: 1. During and observation, on 1/17/2023 at 1:55 P.M., CNA 12 was observed to provide catheter care to Resident 28. The CNA washed her hands and applied gloves. A basin of water, one with soapy water and wash cloths and towels were on the bed side table. The CNA removed the tape from the sides of the resident's brief and then with a soapy wash cloth, washed the penis from the abdomen towards the meatus (opening of the penis). She then washed the catheter, by using different parts of the wash cloth washing the tube away from the penis opening. she then washed the groin area and removed her gloves. The CNA applied new gloves and used a wet wash cloth to rinse the penis and groin area by moving towards the penis tip. Without washing her hands, she applied new gloves and then turned the resident to wash his buttocks. She removed the brief, washed the buttocks and then…

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 change PICC (peripherally inserted central catheter) line dressings for 1 of 1 resident reviewed for intravenous antibiotic therapy ( Resident 101) During an observation on 1/10/2023 at 2:26 P.M., Resident 101's PICC line dressing had a PICC line kit dated tape adhered to the clear Tegaderm with the date of 12/4/2022. The Tegaderm was observed to be rolled on the edges and not adhered around the PICC lines. A clinical record review of Resident 101 was completed on 1/13/2023 at 9:13 A.M. Diagnoses included, but were not limited to: congestive heart failure, atrial fibrillation, chronic kidney disease, and osteomyelitis. A Significant Change MDS (Minimum Data Assessment) Assessment on 12/15/2022 indicated Resident 101 was cognitively intact. He received intravenous therapy with antibiotics for 7 of 7 days of the assessment period. There was no documented rejection of care. A Care Plan on 10/4/2022 indicated Resident 101 required intravenous…

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 maintain oxygen equipment and non-invasive respiratory mechanical devices in a sanitary manner for 2 of 4 residents reviewed for oxygen use. (Resident 44 and 279) Findings include; 1. During an observation, on 1/10/2023 at 10:17 A.M., Resident 44's oxygen tubing was undated, hanging over the trash can and on the floor. During an observation, on 1/11/2023 at 9:21 A.M., Resident 44's oxygen tubing was undated, and under a pile of dirty clothes. A clinical record review was completed on 1/11/2023 at 2:40 P.M., and indicated Resident 44's diagnoses included, but were not limited to: chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, hypoxemia, heart failure, obstructive sleep apnea, chronic atrial pulmonary edema, pleural effusion, chronic pulmonary edema, chronic atrial fibrillation, polyosteoarthritis, insomina, visual hallucinations, benign prostatic hyperplasia, major depressive disorder, adjustment…

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

Based on record review and interview, the facility failed to ensure a resident did not receive unnecessary antibiotics for 1 of 6 residents reviewed for urinary tract infections. (Resident 279) Finding includes: During an initial interview on 1/10/2023 at 10:22 A.M., Resident 279 indicated she had a urinary tract infection. A clinical record review was completed on 1/12/2023 at 11:39 A.M. Diagnoses included, but were not limited to: urinary tract infection, chronic respiratory failure, congestive heart failure, obstructive sleep apnea, and history of MRSA (Methicillin-resistant Staphylococcus aureus) infection. An admission MDS Assessment on 1/6/2023, indicated Resident 279 was frequently incontinent of bladder and always incontinent of bowel. She was dependent with two or more staff members for toileting. A Nurse's Note on 1/8/2023 at 6:07 P.M., indicated, .Resident has had mild confusion for two days; primarily in the morning. Urine dipstick positive for blood, leukocytes, {and} nitrite. NP [Nurse Practitioner] notified. Urine sent to [hospital name] lab for UA with C&S…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a gradual dose reduction for a resident receiving psychotopic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 46) Finding includes: A clinical record review was completed on, 1/11/2023 at 10:53 A.M. Resident 46's diagnoses included, but were not limited to: chronic respiratory failure, Parkinson's disease, diabetes, obesity, Schizoaffective disorder, Bipolar, anxiety, depression and dementia. A Quarterly MDS (Minimum Data Set) Assessment, dated 7/23/2022, indicated Resident received antipsychotic, antianxiety, and antidepressant medications routinely. No GDR was documented. A Quarterly MDS, dated [DATE], indicated the resident had received the same medications. No GDR was completed due clinically contraindicated, dated 8/22/22. A Quarterly MDS, dated [DATE], indicated Resident 46 had a BIMS (Brief Interview for Mental Status) score of 15, cognition intact. Received antipsychotic, antianxiety, and antidepressant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications/treatments were kept in locked carts when unattended, failed to ensure medication storage areas were free from loose medications; failed to have medications labeled; failed to date medications when opened; and failed to destroy medications that were discontinued /refused or the resident had been discharged and no longer being used during medication storage reviews for 1 of 2 medication rooms observed and 3 of 5 medication carts observed. (Dogwood Medication carts, Birch Medication carts and med room, and Cedar treatment cart.) Findings include: 1. During a random observation, on [DATE] at 4:50 A.M., 3 of 3 medication carts on the Dogwood hall were unlocked and unattended. During an interview, on [DATE] at 4:55 A.M., LPN (Licensed Practical Nurse) 13 indicated the medications carts should have been locked. 2. During a medication observation, on [DATE] at 5:01 A.M., LPN 14 left the medication cart on Birch hall unlocked when going into 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.