Majestic Care Of Newburgh

Based on observation, interview, and record review, the facility failed to ensure food was stored, and served in a sanitary manner for 2 of 2 kitchen observations. The kitchen floors had debris build up, and equipment was soiled. ( Kitchen) Findings include: On 7/15/24 at 8:55 a.m., the kitchen was observed to have the following: 1. Floor debris build up, including along the edges of the the walls, under storage racks and tables, behind the stove, and warmers, under the dish machine, three compartment sink, under the steam table. The dry pantry floor had debris build up on floors, under racks, condiment packets observed on the floor and under the food racks. 2. Debris build up on the sides of the stove, the shelf above the stove, shelves on the stainless steel table the steamer was sitting on, top of steamer. The same was observed on 7/16/24 at 11:40 a.m. On 7/16/24 at 2:00 p.m., kitchen cleaning schedules were reviewed and included, but were not limited to: AM cook: 3 compartment sink- please clean outside and the floor underneath. AM cook : stove top & stove- clean stove top,…

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

Based on observation, interview, and record review, the facility failed to ensure that food was served at an appetizing temperature for 1 of 1 trays tested for temperature. (Resident 21, Resident 246, Resident 74, Resident 73, Resident 87, Resident 4, Resident 24, Resident 55, Resident 25) Finding includes: On 4/30/24 at 9:33 A.M., Resident 21 indicated the food was cold. On 4/30/24 at 9:59 A.M., Resident 246 indicated the food was cold. On 4/30/24 at 10:10 A.M., Resident 74 indicated the food was tough, overcooked, and cold. On 4/30/24 at 10:44 A.M., Resident 73 indicated the food was cold. On 4/30/24 at 12:40 P.M., Resident 87 indicated the food tasted cold. On 4/30/24 at 12:58 P.M., Resident 4 indicated the food was hard and cold. On 4/30/24 at 1:23 P.M., Resident 24 indicated the food was warm or cold. On 5/1/24 at 8:35 A.M., Resident 55 indicated the food was always cold. On 5/1/24 at 8:46 A.M., Resident 25 indicated the food was burnt and cold. On 5/2/24 at 1:06 P.M., a test tray was obtained. Food temperatures for that meal were: - Baked chicken 100 degrees F (Fahrenheit) -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 4 of 4 kitchen observations and 1 of 1 nutrition pantry observation. Food was not labeled, left open to air, and expired food was not disposed of from the refrigerator, hair nets were not worn, and hand hygiene was not completed. (Kitchen, 100 hall nutrition pantry, Dietary Aide 3, Dietary Aide 21, Dietary Manager) Findings include: 1. On 4/29/24 at 8:29 A.M., during the full kitchen tour with Dietary Aide 3 the following was: - Dirt, food debris, a rag, and an ice scoop were on the floor under the dishwasher. Food debris was on the clean side of the dishwasher. - Liquid was on the floor by the juice cart. - In the freezer, Marzetti frozen pasta and beef patties were open to air. - In the walk-in refrigerator, the following items were observed: shredded mozzarella cheese - no label/date small cup white liquid - no label/date bologna - no label/date yogurt - lid not closed and 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.

Based on interview and record review, the facility failed to immediately notify the resident's family of a resident to resident altercation for 1 of 1 residents reviewed for notification of changes. (Resident 35) Finding includes: On 5/2/24 at 9:30 A.M., a family member indicated a previous roommate attacked Resident 35 with a walker and a drawer in February, and the facility did not contact her until 11:00 A.M. the next morning. On 5/3/24 at 8:44 A.M., Resident 35's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and major depressive disorder. The most recent Annual Minimum Data Set (MDS) assessment, dated 4/23/24, indicated Resident 35 had severe cognitive impairment and had no behaviors during the assessment period. A late entry Social Services Note, dated 2/27/24 at 11:01 A.M., indicated that on the previous evening (2/26/24), Resident 35 was asleep in his bed when his roommate threw a walker and drawer from the nightstand at him resulting in bruising to Resident 35's hand. An Incident Note, dated 2/27/24 at 11:07 A.M., 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 and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 3 of 19 residents reviewed. Antipsychotic medications, dental status, and significant weight loss were coded inaccurately. (Resident 25, Resident 246, Resident 55) Findings include: 1. On 5/1/24 at 10:00 A.M., Resident 25's clinical record was reviewed. The diagnoses included, were not limited to, Parkinson's Disease, major depressive disorder, and anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment, dated 3/4/24, indicated Resident 25 was cognitively intact and did not receive an antipsychotic medication during the seven day look back period. The current Physician Orders included but were not limited to: Aripiprazole (antipsychotic medication) 2 mg (Milligrams), give 2 mg by mouth at bedtime related to unspecified mood disorder, dated 12/6/23. On 5/3/24 at 2:58 P.M., the Social Worker indicated there was a mistake on the MDS assessment. Resident 25 was on an antipsychotic for seven days during the assessment and was coded as not taking…

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 care plan interventions were implemented for 1 of 2 residents reviewed for falls. The call light was not within reach. (Resident 26) Findings include On 5/1/24 at 8:50 A.M., Resident 26 was observed sitting in a chair with the call light wrapped around the call light monitor and not within reach of the resident. On 5/6/24 at 10:05 A.M., Resident 26 was observed sitting in a recliner with the call light lying across the bed not within reach of the resident. On 5/6/24 at 9:00 A.M., Resident 26's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's Disease with late onset, dementia, and generalized anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment, dated 3/6/24, indicated Resident 26 was moderately cognitively impaired, needed substantial to maximum assistance for mobility, transfer, and eating, and was a fall risk. Care plan interventions for fall risk included but were not limited to call light and personal items within reach, assisting 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.

Based on observation, record review, and interview the facility, failed to ensure that documentation of interventions were not revised for 1 of 2 residents reviewed for falls. (Resident 56) Findings include: On 4/29/24 at 11:05 A.M., Resident 56 was observed wearing a cast on her left arm. On 5/3/24 at 1:55 P.M., Resident 56's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia, aphasia following cerebral infarction, unspecified fracture of the lower end of right radius, and nondisplaced fracture of right ulna styloid process. The most current Quarterly MDS assessment, dated 4/17/24, indicated Resident 56 had moderate cognitive impairment, was independent in sit to stand transfers and toileting, did not use any mobility devices, and had 1 fall with major injury since the prior assessment on 2/16/24. A current falls care plan, revised 2/4/23, indicated Resident 56 was at risk for falls or fall related injury due to a history of CVA (cerebrovascular accident), diabetes, decreased vision, and neuropathy. An Event Note, dated 4/12/24 at 11:25…

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

Based on interview and record review, the facility failed to ensure medication was given according to physician orders for 1 of 5 residents reviewed for unnecessary medications. A blood pressure medication was given outside of parameters and glucagon was administered without an order. (Resident 246) Finding includes: On 5/2/24 at 9:35 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, hypotension, type 1 diabetes mellitus, and disease of the pancreas. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/29/24, indicated Resident 246 was cognitively intact, required setup assistance for eating, and received a hypoglycemic medication during the 7-day look back period. Physician orders included, but were not limited to: Midodrine (a medication to treat low pressure) HCl Oral Tablet 5 MG (milligrams) - Give 3 tablets by mouth three times a day for hypotension hold if SBP (systolic blood pressure) more than 110, dated 4/24/24. Baqsimi (a medication used to treat low blood sugar) One Pack 3 MG/DOSE (milligrams per dose) Powder -…

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 nutritional care and services including the failure to obtain weekly weights, failure to provide assistance with meals and alternative food/supplement choices, and failure to notify the physician and address the resident's refusal of nutritional supplements and poor intakes resulting in a significant weight loss of 18.37% in less than 30 days 1 of 3 residents reviewed for significant weight loss and ensure a resident was receiving adequate fluids resulting in dehydration and a urinary tract infection 1 of 1 residents reviewed for dehydration. (Resident 55 and Resident 75) Findings include: 1. During an interview on 5/1/24 at 8:25 A.M., a family member expressed concern Resident 55 was not receiving all of her meals, that staff would sometimes bring Resident 55's tray in to her room and place it on her bedside table and come back and collect the tray without assisting her to eat, and that family would travel from hours away to come sit with her multiple days in a row each week to ensure 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.

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was labeled and oxygen administration signs were in place for 3 of 3 residents reviewed for oxygen administration. (Resident 24, Resident 73, Resident 88) Findings include: 1. On 4/30/24 at 9:05 A.M., Resident 24's was observed wearing O2 (oxygen) via a cannula in bed alongside of a CPAP (Continuous Positive Airway Pressure) machine at the bedside with tubing that lacked a date and initials when changed. There were no oxygen administration warning signs on the outside door frame. On 5/3/24 at 1:28 P.M., Resident 24 was observed wearing O2 via cannula while sitting in a chair and the CPAP machine sitting on a bedside table, the tubing lacked a date and initials when changed. There were no oxygen administration warning signs on the outside door frame. On 5/3/24 at 12:08 P.M., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), heart failure, and anxiety. The current admission MDS (Minimum Data Set)…

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

Based on observation, interview, and record review, the facility failed to provide pain assessments and provide pain management in accordance with the resident's comprehensive care plan for 1 of 1 residents reviewed pain. (Resident 55) Findings include: During an observation on 4/30/24 at 3:50 P.M., Resident 55 was observed in bed and appeared to be restless, moaning, and crying out in pain. On 5/1/24 at 8:34 A.M., Resident 55's clinical record was reviewed. Resident 55's diagnoses included, but were not limited to, Alzheimer's disease, Parkinson's disease, and low back pain. Resident 55's most recent Quarterly MDS (Minimum Data Set) assessment, dated 3/7/24, indicated severe cognitive impairment and was not experiencing pain during the pain assessment. Current physician orders included, but were not limited to: Tylenol (acetaminophen pain relief) extra strength oral tablet 500 MG (milligrams). Give two tablet by mouth, two times a day for pain, start date 12/29/23 Celecoxib (anti-inflammatory medication) oral capsule 200 MG. Give one capsule by mouth one time a day for pain, start…

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 ensure CNA's had a current and valid certificate to work in the facility for 1 of 27 CNA's reviewed. (CNA 2) Finding includes: On [DATE] at 2:09 P.M., the employee records were reviewed. CNA 2's CNA certificate expired on [DATE]. On [DATE] at 3:25 P.M., the Administrator indicated Human Resources (HR) was responsible for making sure licenses stayed current and that they were working to get CNA 2's certificate renewed. On [DATE] at 12:23 P.M., the dates CNA 2 worked as a CNA were provided by the Infection Preventionist (IP). CNA 2 worked as a CNA on 10 shifts from [DATE] to [DATE]. On [DATE] at 11:07 A.M., the IP provided a current Licensed Health Professional Check policy, revised [DATE], that indicated If an existing Care Member's license is not renewed prior to the expiration date, the licensed Care Team Member will be placed in a non-certified position or removed from the schedule until the license has been renewed and the Human Resources Director…

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

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 2 of 26 opportunities observed to administer medications, resulting in an error rate of 7.7%. (Residents 7, Resident 15) Findings include: 1. During a medication administration observation on 5/2/24 at 7:09 A.M., QMA 9 prepared medications for Resident 15. QMA 9 measured 17g (Grams) of Miralax powder and mixed it in water, and prepared the following oral medications: Furosemide (high blood pressure medication) 40mg (milligrams) Potassium chloride (potassium supplement) 10 mEq (milliequivelant) Sodium chloride (sodium supplement) 1gm (Gram) Thiamine (Vitamin) 100 mg Galantimine (dementia medication) 8 mg Senna (constipation medication) 8.6-50 mg Carbidopa-Levodopa (Parkinson's Medication) 25-100 mg Depakote (Seizure Medication) Sprinkles 125 mg capsules Levetiracetam (Seizure medication) 5 ml (milliliter) solution into a separate medication cup. QMA 9 then crushed all pills together, opened four Depakote capsules and emptied the sprinkles…

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

Based on observation and interview, the facility failed to ensure deteriorated medications were discarded for 1 of 3 medication carts observed. (100 Hall Cart 1) Findings include: During a medication storage observation, of the 100 Hall Cart 1 on 5/8/24 at 9:05 A.M., the following loose and unlabeled medications were observed: one tan round pill with no imprints one light blue round pill with imprints SG 45 three white round pills with imprints C 73 two white oval pills with imprints ZF 41 one pink round pill with imprints lupin 10 one half semi-round white pill with no imprints one white round pill with imprints SC one pink round pill with imprints 201 LS one green round pill with imprints HH 974 one clear capsule filled with tan powder one red round pill with no imprints one white oval pill with imprints 11 A one white round pill with imprints GG 26 During an interview on 5/8/24 at 9:12 A.M., LPN 8 stated loose pills in the medication cart should be disposed of, then disposed of all 16 medications into the sharps container on the side of the medication cart. On 5/9/24 at 9:56 A.M.…

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

Based on observation, interview, and record review, the facility failed to provide food to accommodate a resident's food allergy for 1 of 7 residents reviewed for nutrition. Milk was given with a meal to a resident who had a lactose allergy. (Resident 246) Finding includes: On 4/20/24 at 9:59 A.M., a family member indicated Resident 246 got milk on his meal trays and he was lactose intolerant. At that time, milk in an unopened carton was observed on the resident's breakfast tray. On 5/2/24 at 9:35 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, intestinal malabsorption and gastroparesis. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/29/24, indicated Resident 246 was cognitively intact and required setup assistance for eating. An allergy list included lactose intolerance (gastrointestinal issues), dated 10/5/23. An admission Nutrition Assessment, dated 9/19/23, indicated Resident 246 had a food allergy to milk and cheese which resulted in an upset stomach. A nutrition care plan, initiated 9/5/23, included an…

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

Based observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 1 of 5 residents reviewed for unnecessary medications, 1 of 3 residents observed for medication administration, and 1 of 2 residents reviewed falls. (Resident 246, Resident 15, Resident 26) Finding includes: 1. On 4/30/24 at 10:00 A.M., a family member indicated Resident 246 received insulin. On 5/2/24 at 9:35 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, type 1 diabetes mellitus, intestinal malabsorption, and generalized anxiety disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/29/24, indicated Resident 246 was cognitively intact and received insulin 7 days during the 7-day lookback period. Physician orders included, but were not limited to: Insulin Lispro Injection Solution (a fast-acting hypoglycemic medication) 100 UNIT/ML (units per milliliter) - Inject as per sliding scale: if 0 - 150 = 0 units; 210 - 265 = 1 units; 266 - 320 = 2 units; 321 - 375 = 3 units; 376 - 430 = 4…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for 2 of 2 residents observed for wound care. Hand hygiene and glove changes were not completed. (Resident 12, Resident 11, LPN 8, CNA 7, RN 7, Nurse Practitioner 19) Findings include: 1. On 5/3/24 at 9:19 A.M., wound care was observed on Resident 12 by LPN 8 and CNA 7. During wound care the resident was observed to have a bowel movement. LPN 8 had gloves on, turned the resident on left side, cleaned buttocks with wipes, and proceeded to touch the resident without changing gloves or performing hand hygiene. The resident was then turned to the right side by gloved CNA 7, soiled dressing removed, peri care completed, and dirty linen was removed. CNA removed gloves but did not perform hand hygiene before placing new gloves on. The resident again turned to the left side so that LPN 7 could complete wound care to the sacral wound. LPN 7 proceeded to touch clean linen with the same gloved hands without changing gloves or performing hand hygiene. 2. On 5/2/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents fall interventions were in place to prevent a fall for 1 of 3 resident reviewed for falls. ( Resident E) Finding includes: On 2/2/24 at 9:05 a.m., Resident E was observed in his room in bed eating breakfast. Resident E indicated he had no concerns with his care except sometimes when he wants up for the day it takes staff awhile to come help him. Resident E indicated he feels he is independent and tried to get up and fell recently. Resident E's electric wheelchair was observed in his room in the vicinity of his bed. On 2/2/24 at 9:13 a.m., Resident E's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified sequel of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction. A Quarterly MDS (Minimum Data Set) dated 11/23/23 indicated Resident E's cognition was intact, limited range of motion impairment upper and lower one side, mobility device electric wheelchair, bed…

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 food was stored, and served in a sanitary manner for 2 of 2 kitchen observations. The kitchen floors had debris build up, equipment was soiled, and food was open to air and undated. ( Kitchen) Finding includes: On 2/1/24 at 8:19 a.m., the kitchen was observed to have the following: 1. Floor debris build up, including along the edges of the the walls, under storage racks, behind the stove, and warmers, under the dish machine, the area where cleaning supplies and mops were stored. 2. In the walk in cooler a partially used open log of ground hamburger wrapped in foil, a plastic bag with part of a cucumber, plastic bag with sliced tomatoes, were observed with no dates. 3. In the walk in freezer a bag of chicken tenders, bag of hashbrowns, bag of ravioli, were open to air and undated. A bag of hamburger patties were undated. 4. The top of ovens soiled. On 2/1/24 at 11:37 a.m., the same was observed except the bag of hamburger patties were gone. On 2/2/24 at 11:45 a.m., the Dietary Manager 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed. The correct dose of a resident's pain medication was not given. (Resident B) Finding includes: On [DATE] at 9:54 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, cluster headache syndrome, unspecified, intractable, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, epilepsy intractable, without status epilepticus. An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, pain frequency almost constantly, effects sleep and activities, pain 8 on scale. Resident B admitted to the facility on [DATE] and expired at the facility on [DATE]. Care plans were reviewed and included, but were not limited to: [name] is at risk for pain due to encephalopathy, left hemiplegia, epilepsy, chronic headaches. Interventions included, but were not limited to: Administer…

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 appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures at meals and distasteful food during meals. (100 Hall, Resident B, Resident J) Finding includes: 1. During a review of facility grievances on 12/1/23 at 10:00 A.M., a concern was reported to the facility, dated 8/3/23, by Resident B that all food was distasteful. During a review of Resident Council minutes on 12/1/23 at 10:15 A.M., Resident Council concerns from meeting notes dated 9/26/23, included but were not limited to, potatoes of all kinds are never done all the way and that the bread was soggy. During an interview on 12/1/23 at 1:00 P.M., Resident J indicated that the food was not good and that it was delivered hot only some of the time. Resident J indicated that he ate both in his room and in the dining room. 2. During an observation on 12/4/23 at 12:05 P.M., staff were passing trays to the 100 Hall. A sample tray was removed from the hall cart and tempted at 12:10 P.M.…

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

Based on interview and record review, the facility failed to ensure quarterly care conferences for the Minimum Data Set Assessment were completed for 2 of 4 residents reviewed for care conferences. (Resident B, Resident E) Finding includes: On 8/16/23 at 10:22 a.m., Resident B indicated it had been months since they or their representative had been invited or attended a care conference. On 8/18/23 at 12:53 p.m., Resident E indicated they thought they had been invited to a care conference before, but not sure when. On 8/17/23 at 10:11 a.m., the Social Services Director indicated it looked like the last care conference for Resident B was on 3/30/23, the next one due had been missed. On 8/18/23 at 12:49 p.m., the Social Service Director indicated Resident E had a care conference on 10/11/23, 5/18/23, and 7/28/23, Resident E had a hospital stay in November and December 2022. The Social Service Director indicated the next care conference due after the October 2022 conference would have been in March of 2023, it had been missed, care conferences were done by the MDS (Minimum Data Set)…

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

Based on observation, record review, and interview, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 breakfast trays sampled. Finding included: During the survey from 8/3/22 to 8/11/22 the following random resident interviews were completed: The food is not good. The food is cold. The food is cold and too salty. On 8/5/22 at 7:40 A.M., a breakfast tray was obtained with the following temperatures and tastes: sausage 108 degrees Fahrenheit, taste was cold, sausage was pink in the middle. waffle 110 degrees Fahrenheit, taste was cold. oatmeal 153 degrees Fahrenheit, taste was bland. On 8/11/22 at 8:35 A.M., a current Food Production policy, dated March 2019, was obtained and indicated the sausage should be 155 degrees Fahrenheit for .sausage . This Federal tag relates to Complaint IN00387611. 3.1-21(a)(1) 3.1-21(a)(2)

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 for 4 of 6 residents during observation of perineal care, medication administration, placement for Foley catheter bag and 1 of 1 resident receiving a Covid 19 test. Gloves were not changed between dirty and clean tasks during peri care, staff was observed not wearing a mask with a resident present, a medication was picked up from the top of a medication cart with bare hands and given to a resident, and Foley catheter bag and tubing was touching the floor. (Resident 156, Resident 221, Resident 226, Resident 122, Resident 229, Resident 2) Findings include: 1. On 8/9/22 at 10:04 A.M., CNA (certified nurse aide) 25 was observed performing incontinence care for Resident 156. Prior to beginning, CNA 25 put on a pair of gloves. After removing the visibly soiled brief, CNA 25 cleaned the resident with several wipes, and placed all dirty items in a trash bag. CNA 25 then put a clean incontinence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to meet medical needs that are identified in the comprehensive assessment. Staff did not implement care plan interventions, or follow MD orders for 3 of 5 residents reviewed for implementation of the care plan intervention for respiratory care, urinary care, and weight management while on enteral feedings. (Resident G, Resident 10, Resident 44) Findings include: 1. On 8/8/22 at 9:03 A.M., Resident G's clinical record was reviewed. Diagnosis included, but were not limited to, COPD (chronic obstructive pulmonary disease). The most recent quarterly MDS (minimum data set) Assessment, dated 7/22/22, indicated Resident G had a significant cognitive impairment, and required extensive assistance of 2 (two) staff for bed mobility, transfers, and toileting. Current physical orders included, but were not limited to: Elevate head of bed to alleviate shortness of breath…

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 adequate supervision and prevent falls for 2 of 4 residents reviewed for accidents. Fall interventions were not in place for residents with multiple falls. (Resident 25, Resident 9) Findings include: 1. On 8/8/22 at 8:46 A.M., Resident 25's clinical record was reviewed. Diagnosis included, but were not limited to, epilepsy, anxiety disorder, history of falling, and Alzheimer's disease. The most recent significant change MDS (minimum data set) Assessment, dated 5/12/22, indicated Resident 25 had a severe cognitive impairment, and required extensive assistance of 2 (two) staff with bed mobility, transfers, and toileting, extensive assistance of 1 (one) staff with eating, and was totally dependent on 1 (one) staff for bathing. Resident 25's care plan included, but were not limited to, [Resident] at risk for falls r/t [related to] History of falls, Poor safety awareness, Incontinence, dated 3/21/17 and revised 4/21/22. Interventions included, but were not limited to, Placed sign in room to Call for…

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

Based on observation, interview and record review, the facility failed to ensure a resident who experienced weight loss had new interventions instituted and that the registered dietitian and the physician were notified of a significant weight loss for 1 of 3 reviewed for nutrition. (Resident G) Findings include: On 8/4/22 at 8:55 A.M., Resident G was observed lying asleep in bed. A tray with a full plate of food including scrambled eggs and juice was observed sitting on a bedside table in front of her, untouched. The tray lacked a supplemental drink. On 8/4/22 at 9:28 A.M., CNA (certified nurse aide) 5 was observed to enter Resident G's room, walked past Resident G, and handed the roommate a cup of water. CNA 5 then exited the room without addressing Resident G. At that time, the plate in front of Resident G was still untouched, and Resident G was still asleep. During an interview on 8/4/22 at 9:36 A.M., CNA 3 indicated the breakfast trays had been passed that morning between 7:30 and 8:00 A.M. At that time, Resident G's plate was still untouched. On 8/8/22 at 9:03 A.M., Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 5 residents reviewed for unnecessary medications. A GDR (gradual dose reduction) was not completed to reduce a psychotropic medication. A resident's as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 32, Resident 55) Finding includes: 1. On 8/8/22 at 10:41 A.M., Resident 55's clinical record was reviewed. Diagnosis included, but were not limited to, Non-Alzheimer's dementia, anxiety disorder, and depression. The most recent significant change MDS (Minimum Data Set) Assessment, dated 7/2/22, indicated Resident 55's cognition was moderately impaired and was currently on hospice. Current physician orders included, but were not limited to, Ativan Tablet 0.5MG (LORazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety related to ANXIETY DISORDER, UNSPECIFIED dated 5/30/22. Resident 55's clinical record lacked any physician assessments for lorazepam…

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.