Waters Of Princeton, The

Based on observation, interview, and record review, the facility failed to ensure there was not an emergency call light in 6 of 6 public restrooms that could be utiized by residents in 2 of 2 observations. (Back Hallway, East Hallway) Findings Include: On 1/14/26 at 2:30 P.M., the woman's public restroom in the back hallway was observed to have no key or emergency call system. On 1/15/26 at 8:3 A.M., the public restrooms on back hall and east hall public were observed to have no key or emergency call bell systems. During an interview on 1/16/26 at 10:38 A.M., the administrator was not aware of the need to have an emergency call light or key for a public bathroom if could be accessed. She had been told different things. On 1/16/26 at 1:45 P.M., a policy for the call system was asked for and not received. 3.1-19(u)(2)

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and an account of all drugs were maintained for 2 of 2 nursing units reviewed. The narcotic drug count was not accurate. (East Unit, [NAME] Unit) Finding includes: On 8/27/25 at 10:51 a.m., RN 2 was observed to do a narcotic drug count on the East unit medication cart. The following was observed:hydrocodone- acetaminophen oral tablet 5-325 mg (milligram) -the narcotic count log indicated 23 available, RN 2 indicated 22 were in the drug pack.hydrocodone- acetaminophen Tablet 5-325 mg- the narcotic count log indicated 30 available, RN 2 indicated 29 were in the drug pack. RN 2 indicated she must have been in a hurry and forgot to sign the medications out after giving them, she typically signs the narcotic log as she gives them. On 8/27/25 at 11:04 a.m., QMA 2 was observed to do a narcotic drug count on the [NAME] unit medication cart. The following was observed:clonazepam oral tablet 0.5 mg - the narcotic count log indicated 17 available, QMA 2 indicated 16 were in the drug…

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 physician orders were followed for 1 of 3 residents reviewed for wounds. Wound treatments were not signed as completed on the Electronic Medical Administration Record (EMAR). Resident B Finding includes: On 6/9/25 8:47 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral infarction due to thrombosis of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, type 2 diabetes mellitus, dysphagia, aphasia following cerebral infarction, altered mental status, acquired absence of other right toe, unspecified protein-calorie malnutrition, hyperlipidemia, hypertension, peripheral vascular disease, occlusion and stenosis of carotid artery. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was severely impaired, impairment one side upper and lower, toileting partial/moderate assist,( helper…

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 notify the physician and resident representative of a change in condition for 1 of 3 residents reviewed for skin/wounds. A treatment order was not obtained for a pressure injury, a resident representative was not notified of a pressure wound or facial bruising. (Resident B) Findings include: On 1/10/25 at 8:56 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, personality disorder, diabetes mellitus, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, muscle weakness, unsteadiness on feet. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was severely impaired. Care plans included, but were not limited to: Wound is present - L (left) buttock, stage 2, date initiated 1/10/25. Interventions included, but were not limited to: Tx (treatment) as ordered, date initiate 1/10/25. January 2025 physician orders…

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 administered according to physician's orders and professional standard for 4 of 4 residents observed during medication pass. (Resident 10, Resident 39, Resident 42, Resident 30) Five medication errors were observed during 31 opportunities for error in medication administration. This resulted in a 16.13 error rate. Findings include: 1. During a medication administration on 10/18/24 at 8:02 A.M., RN 6 prepared the following medications for Resident 10: one tablet of certirizine 10 mg, one tablet of desvenlafaxine 100 mg, one tablet of famotidine 10 mg, one tablet of furosemide 40 mg, one tablet of meloxicam 7.5 mg, one tablet of Nuedexta 20-10mg, one tablet of vitamin D3 5000 units, one tablet of asenapine 5mg, and mixed a packet of polyethylene glycol in 8oz of water. RN 6 took the medications to Resident 10; Resident 10 took all of the medications orally and drank the polyethylene gylcol mixed in water. RN 6 then went to the EDK and removed a tablet of metoprolol 25mg, placed the pill…

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 properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 2 of 2 medication carts observed. (100 hall west medication cart and 200 hall east medication cart) Findings include: 1. During an observation on 10/16/24 at 9:03 A.M., the 200 hall east medication cart contained the following items: Humalog insulin pen - opened; lacked opened on or expiration date Lantus insulin pen- opened; lacked opened on or expiration date, pen needle attached and not capped Latanoprost eye drops- expiration date 10/13/24 Lantus insulin pen - expiration date 9/23/24 Humalog insulin pen- lacked identification tag or resident name - expiration date 10/14/24 insulin aspart pen- name rubbed off of identification tag two insulin lispro pens - seal is unopened, tag on insulin states refrigerate until opening opened bottle of Pro-Stat (liquid protein)- lacked label or opened date 2. During an observation on 10/16/24 at 9:25 A.M., the 100 hall…

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

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (200-hall) Finding includes: On 10/16/24 at 10:13 A.M., Resident 52 indicated the food was cold. On 10/16/24 at 10:38 A.M., Resident 31 indicated the food was cold. On 10/16/24 at 12:14 P.M., Resident 15 indicated the food tasted bad and was cold. On 10/17/24 at 10:45 A.M., Resident 42 indicated the food tasted bad and was cold. On 10/21/24 at 12:22 P.M., a test tray was obtained. Food temperatures for that meal were: BBQ chicken 102.9 F (Fahrenheit) Roasted potatoes 109.7 F Yellow squash 107.9 F At that time, the food tasted cold. On 10/21/24 at 12:31 P.M., the Dietary Manager expected food to be about 148 F when served. He indicated he was aware cold food was an issue and hoped to get new insulated holders and carts to help. On 10/22/24 at 10:05 A.M., the Dietary Manager provided an undated current Food Temperatures policy that indicated Best efforts will be made to present hot foods hot and cold foods cold 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.

Based on observation, interview, and record review, the facility failed to ensure food was correctly prepared for 4 of 4 residents who received puree altered diets. Finding includes: On 10/17/24 at 10:01 A.M., [NAME] 5 was observed preparing 4 servings of pureed beef and cheddar sandwiches. [NAME] 5 added the following ingredients to the blender and blended in between each item: 8 slices of pre-cooked roast beef 1-ounce (oz) scoop of mayonnaise 1-oz scoop of mayonnaise 1-oz scoop of mayonnaise 4 hamburger buns torn up 2 1-oz scoops of mayonnaise 2 1-oz scoops of mayonnaise 4 slices of cheese torn up 2 1-oz scoops of mayonnaise At that time, [NAME] 5 indicated the food did not look right and it would probably taste like straight mayonnaise. She indicated she usually would add broth to help with the consistency, but the recipe did not call for it. That was a new recipe and she had never made it before. Cook 5 added 4 more 1-oz scoops of mayonnaise. (Total mayonnaise added was 13-oz.) Cook 5 went to the reach-in refrigerator and obtained milk. The best by date on the milk was 10/16/24.…

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 prepared under sanitary conditions during 3 of 3 kitchen observations and 1 of 1 dining observations. Staff did not wear hairnets, and gloves were not changed before touching food items. (Dietary Manager, [NAME] 5, [NAME] 14, Activities Department Staff) Findings include: 1. During a lunchtime dining observation on 10/16/24 at 12:00 P.M., Activities Department staff were observed assembling and serving hot dogs for lunch in the dining room. Residents placed orders and staff assembled buns, hot dogs, condiments, and chili in the dining room. Staff did not change gloves in between touching the hot dog buns and touching condiment bottles. Staff were not wearing hairnets while assembling food. 2. On 10/16/24 at 9:12 A.M., the Dietary Manager was observed in the kitchen without a beard net. [NAME] 5 and [NAME] 14 were observed in the kitchen wearing a hairnet that did not cover all of their hair. 3. On 10/17/24 at 10:01 A.M., the Dietary Manager was observed in the kitchen without a beard net.…

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 2. On 10/17/24 at 12:08 P.M., Resident 16's clinical record was reviewed. Resident 16 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/19/24, indicated Resident 16 was cognitively intact, required partial assistance from staff for toileting and bathing, and was completely dependent on staff for transfers. Current physician orders included, but were not limited to: Basaglar (insulin medication) Inject 10 unit subcutaneously every morning and at bedtime for diabetes, Start date 4/9/24 On the following dates subcutaneous insulin administration was documented by QMA 10 on the electronic medication administration record during the last 30 day period: 9/20/24 8:00 A.M. 9/27/24 8:00 A.M. 10/2/24 8:00 A.M. 10/3/24 8:00 A.M. 10/16/24 8:00 A.M. 10/17/24 8:00 A.M. 10/21/24 8:00 A.M. On 10/22/24 at 9:58 A.M., the Director of Nursing provided a document titled Qualified…

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 physician consultation was provided before treatment alterations occurred to modify medications prior to administration for 1 of 1 residents reviewed for crushed medications received. (Resident 47) Finding includes: On 10/18/24 at 10:23 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, major depressive disorder, and anxiety. The most recent Significant change MDS (Minimum Data Set) assessment, dated 9/13/24, indicated Resident 47 was severely cognitively impaired, required partial assistance from staff for eating, toileting, and bathing, and was completely dependent on staff for transfers. A progress note, dated 10/17/24 at 12:32 P.M., indicated Resident 47 had been given her medications in a crushed form. The clinical record, including physician orders, progress notes, care plan, and assessments, lacked an order for medications to be crushed…

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 residents' MDS (Minimum Data Set) Assessment's were completed within 14 days of admission for 1 resident reviewed for accidents and 1 resident reviewed for advanced directives. (Resident 259 and Resident 261) Findings included: 1. On 10/17/24 at 1:43 P.M., Resident 261's clinical record was reviewed. The resident's admission MDS dated [DATE] indicated it was in progress and was not complete. Resident 261 was admitted on [DATE]. 2. On 10/21/24 at 10:00 A.M., Resident 259's clinical record was reviewed. The resident's admission MDS dated [DATE], indicated it was in progress and was not complete. On 10/22/24 at 9:45 A.M., the DON (Director of Nursing) indicated it was expected that an admission MDS be completed within 14 days after admission to facility, and the facility followed the RAI (Resident Assessment Instrument) manual guidelines for comprehensive assessments. 3.1-31(d)(1)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the MDS (Minimum Data Set) Assessments were completed accurately for 1 of 2 residents reviewed for falls, 1 of 2 residents for nutrition, 1 of 5 residents reviewed for unnecessary medications. (Resident 50, Resident 30) Findings include 1. On 10/16/24 at 11:44 A.M., Resident 50 was observed sitting in a chair in the activities room with a chair alarm attached to the resident's clothing. On 10/18/24 at 1:25 P.M., Resident 50 was observed sitting in a chair in the activities room with a chair alarm. On 10/21/24 at 9:55 P.M., Resident 50 was observed sitting in a chair in the activities without a chair alarm. On 10/18/24 at 9:53 A.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, weakness, osteoarthritis, and dementia. The current Quarterly MDS assessment dated [DATE], indicated Resident 50 was moderately cognitively impaired. The resident needed supervision for toileting, dressing, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop care plans for 1 of 1 residents reviewed for communication. A care plan was not developed for residents with English as a second language. (Resident 50) Findings include: 1. On 10/17/24 at 9:01 A.M., during a random observation in Resident 50's room there was no Spanish communication board available in room to meet the resident's needs if asked. On 10/18/24 at 9:53 A.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, weakness, osteoarthritis, and dementia. The current Quarterly MDS assessment dated [DATE], indicated Resident 50 was moderately cognitively impaired. The resident needed supervision for toileting, dressing, and mobility. The resident was not coded this assessment for a chair alarm or significant weight loss. The clinical record lacked an order for the use of communication devices. The clinical record lacked a care plan to concerning the resident's communication needs. On 10/21/24 at 10:04…

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 that documentation of interventions were not revised for 1 of 2 residents reviewed for falls and revise a residents care plan after they returned to facility from a hospital admission with a urinary tract infection and sepsis for 1 of 1 resident reviewed for urinary tract infections. (Resident 36, Resident 50). Findings include: 1. On 10/18/24 at 9:53 A.M., Resident 50's clinical record was reviewed. Diagnoses included, but were not limited to, weakness, osteoarthritis, and dementia. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident 50 was moderately cognitively impaired. The resident needed supervision for toileting, dressing, and mobility. The resident was not coded in assessment for a chair alarm or significant weight loss. There were no orders for chair alarms or Dycem devices. The current fall risk care plan lacked interventions for a chair alarm and a Dycem device. During an interview on 10/21/24 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 interview and record review, the facility failed to ensure practitioner's diagnostic practices met professional standard of care for 1 of 1 resident diagnosed with scizoaffective disorder and bipolar disorder after admission. (Resident 47) Finding includes: On 10/18/24 at 10:23 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, major depressive disorder, and anxiety. The most recent Significant change MDS (Minimum Data Set) assessment, dated 9/13/24, indicated Resident 47 was severely cognitively impaired, required partial assistance from staff for eating, toileting, and bathing, was completely dependent on staff for transfers, and received antipsychotic, antianxiety, and antidepressant medications during the 7-day lookback period. Current physician orders included, but were not limited to: Depakote sprinkles (antiepileptic medication) oral capsule delayed release 125 MG, Give one capsule by mouth three times 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 clinical record review and interview, the facility failed to ensure care consistent with professional standards of practice were received to prevent pressure ulcers from progressing by administering treatments as physician ordered and treatments were administered by qualified personnel for 1 of 2 residents reviewed for wounds. (Resident 16) Finding includes: On 10/17/24 at 12:08 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/19/24, indicated Resident 16 was cognitively intact, required partial assistance from staff for toileting and bathing, and was completely dependent on staff for transfers. Current physician orders included, but were not limited to: Sacral wound: Cleanse and pat dry, apply skin prep, and cover with bordered gauze every day shift, Start date 10/12/24. Left heel: cleanse with wound cleanser, apply skin prep to peri wound, apply collagen to wound bed, and cover with silver alginate.…

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 diet recommendations were followed in 1 of 3 residents reviewed for nutrition. (Resident 34) Findings include: On 10/17/24 at 1:11 P.M., Resident 34's clinical record was reviewed. Diagnoses included, but were not limited to, gastro-esophageal reflux disease, schizoaffective disorder, and dementia. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 50 was moderated cognitively impaired. The resident needed partial assistance to for toileting and dressing. The resident was noted for significant weight loss during the assessment period. Physician orders included, but were not limited, General diet, regular texture, and thin liquid consistency dated 4/12/24. Weekly weight records as follows: 10/2/2024 1:06 P.M. 124.5 Lbs. (Pounds) 9/25/2024 10:35 A.M. 126.5 Lbs. 9/16/2024 9:25 A.M. 121.5 Lbs. 9/9/2024 10:49 A.M. 122.0 Lbs. 9/2/2024 9:34 A.M. 128.0 Lbs. 8/23/2024 7:22 A.M. 124.5 Lbs. 8/1/2024 10:12 A.M. 128.5…

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 a pharmacy recommendation was followed for 1 of 5 residents reviewed for unnecessary medications (Resident 47). Finding includes: On 10/18/24 at 10:23 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and cognitive communication deficit. The most recent Significant Change MDS (Minimum Data Set) assessment, dated 9/13/24, indicated Resident 47 was severely cognitively impaired, required partial assistance from staff for eating, toileting, and bathing, and was completely dependent on staff for transfers. Physician orders included, but were not limited to: Omeprazole (proton pump inhibitor (PPI) medication) 40 MG capsule delayed release, give one capsule by mouth one time a day. Start date 6/8/24 The clinical record lacked a care plan related to the use of a proton pump inhibitor (PPI) medication. A pharmacy recommendation, dated 9/14/24, indicated a pharmacy…

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 implement infection prevention measures by following physician orders for enhanced barrier precautions for 1 of 1 residents observed for wound care. (Resident 6) Finding includes: On 10/17/24 at 10:40 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, seizures and bipolar disorder. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/16/24, indicated Resident 6 was severely cognitively impaired and required partial assistance from staff for eating, bathing, toileting, and transfers. Current physician orders included, but were not limited to: Enhanced Barrier Precautions, start date 9/16/24 Left calf abrasion: Cleanse with wound cleanser, apply collagen and secure with rolled gauze due to fragile skin. No tape on skin every day shift, Start date 9/28/24. During an observation of wound care on 10/21/24 at 9:11 A.M., LPN (Licensed Practical Nurse)12 entered Resident 6's room. Resident 6's door had a sign that indicated enhanced barrier precautions. LPN…

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

Based on interview and record review, the facility failed to develop care plans for 1 of 3 residents reviewed for wounds. A care plan was not developed after a resident returned from the hospital with a new diagnosis and new medication order. (Resident M) Finding includes: On 7/2/24 at 10:19 A.M., Resident M's clinical record was reviewed. Diagnosis included, but was not limited to, cellulitis of the right lower limb, dated 5/22/24. The most current admission MDS (Minimum Data Set) Assessment, dated 4/24/24, indicated Resident M had moderate cognitive impairment, required partial to moderate assistance (staff does less than half) for sit to stand transfers and toileting, was at risk for pressure ulcers, and had no ulcers, wounds, or skin issues. The facility census indicated Resident M was discharged to the hospital on 5/20/24 and returned to the facility on 5/22/24. Hospital discharge papers, dated 5/22/24, indicated Resident M was discharged to the facility with a new diagnosis of cellulitis of right lower extremity and had new orders for clindamycin (an antibiotic) 300 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed for medications. A resident's blood pressure parameters were not followed for giving a medication. (Resident B) Finding includes: On [DATE] at 9:26 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, intellectual disabilities, generalized epilepsy, hypotension. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE] indicated Resident B's cognition was moderately impaired. Resident B expired in the facility on [DATE]. Care plans were reviewed and no care plan related to hypotension was developed. Physicians orders for March and [DATE] included, but were not limited to: [DATE]: Midodrine HCI (hydrochloride) (antihypotensive agent ) oral tablet 5 mg (milligram) give 1 tablet by mouth every 8 hours for bp (blood pressure) hold if bp above 100/50, order date [DATE]. [DATE]: Midodrine HCI oral tablet 5 mg give 1 tablet by mouth every 8 hours 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, interviews and record review the facility failed to store, prepare and serve food in accordance with professional standards for food service for 1 of 2 kitchen observations. Food was served on dishes that were not thoroughly sanitized, emergency use of paper goods was delayed for 55 of 55 residents served meals in the facility. The facility failed to ensure that the temperature of unit refrigerators were with acceptable range in 3 of 3 refrigerators observed. ( Kitchen, East Hall Nourishment Pantry) Findings include: 1. During the initial kitchen tour on 8/21/23 starting at 8:58 A.M., the Dietary Manager indicated that the temperature gauge on the dishwasher was not functioning properly and he had been using a digital thermometer to record temperatures. At that time, a load of dishes including, but not limited to, trays and plate covers was being ran through the dishwasher. The Dietary Manager used his digital thermometer to take the temperature of the wash water. The thermometer read 112 degrees Fahrenheit (F). At that time, the Dietary Manager indicated that…

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 schedule care plan conferences and revise care plans for 12 of 12 residents reviewed. (Resident 14, Resident 16, Resident 20, Resident 22, Resident 24, Resident 25, Resident 30, Resident 36, Resident 38, Resident 39, Resident 43, and Resident 47). Findings include 1. On 8/23/23 at 9:20 A.M., Resident 14's clinical record was reviewed. Diagnoses included but were not limited to, Chronic Obstructive Pulmonary Disease and anxiety. The most recent MDS (Minimum Data Set) assessment dated [DATE] indicated that the resident was cognitively intact. The progress notes lacked documentation of a care plan conference being conducted. The MDS care plan binder lacked documentation of care plan conference. During an interview on 8/21/23 at 3:51 P.M., Resident 14 indicated she had never been asked to come to a care plan conference 2. On 8/23/23 at 1:47 P.M., Resident 24's clinical record was reviewed. Diagnoses included but were not limited to atrial fibrillation 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, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored under proper temperature controls for 1 of 2 medication storage refrigerators reviewed during the survey, and that medications refused by a resident were disposed of properly (Resident 16, [NAME] hall, East Hall). Findings include: 1. During observation of the medication cart on the east hall on 8/23/23 at 11:00 A.M., loose pills were observed in the drawers of the medication cart. These included: 2 small white pills, 3 oblong white pills, 1 large yellow round pill, and 1 small yellow round pill. The pills were removed by QMA 5, who indicated they are supposed to dispose of them in the sharps container attached to the cart. 2. During observation of the medication cart on the west hall on 8/23/23 at 11:20 A.M., loose pills were observed in the drawers of the medication cart. These included: 1 oblong white pill, 2 medium yellow pills, one gold gel pill, 1 large white triangular pill, 3 small pink pills, 4 small white oblong pills, 5 white…

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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 6 resident rooms, 1 of 2 medication storage rooms, 1 of 1 pantries, and 4 of 4 units reviewed for environment. Floors were sticky and dirty, there were holes in the walls, sticky substances were on surfaces, drawers were missing, dressers were in disrepair, and clutter was present (2 east halls, 1 west hall, 1 locked unit, west medication room, east pantry, and room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). Findings include: 1. During observation on 8/21/23 at 10:00 A.M., the floor in the hallway next to the kitchen was observed to be dirty, with a 10x 6 chunk out of the tile in front of the kitchen door. On 8/22/23 at 8:00 A.M. the same was observed. On 8/23/23 at 8:02 A.M. the same was observed. On 8/24/23 at 8:03 A.M. the same was observed. 2. During observation of the main dining area and the two east halls on 8/21/23 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.

Based on interview and record review, the facility failed to attempt to obtain labs, indicate clinical signs of a UTI (urinary tract infection), or ensure the proper antibiotic was prescribed prior to administering an antibiotic for behaviors for 1 of 1 residents reviewed for current antibiotic use. (Resident 47) Findings include: During an interview on 8/22/23 at 1:07 P.M., LPN (licensed practical nurse) 19 indicated that resident 47 had been prescribed an antibiotic by hospice, due to agitated behaviors, without attempting to obtain a urine specimen for lab review of a possible urinary tract infection. On 8/23/23 at 1:07 P.M. Resident 47's clinical record was reviewed. Diagnoses included, but were not limited to, severe dementia with mood disturbances and major depressive disorder with severe psychotic symptoms. A quarterly MDS (Minimum Data Set) Assessment, dated 6/14/23, indicated resident 47 was severely cognitively impaired and required assistance for mobility, transfers, toileting, and bathing. A progress note, dated 8/18/23 at 12:30 P.M. indicated hospice had given an order…

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 a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 1 residents reviewed for respiratory care (Resident 38). Findings include: During an observation on 8/21/23 at 2:05 P.M., Resident 38's oxygen was observed to be on at 2.5 liters per minute (lpm) per nasal cannula (nc), without humidification. During an interview with the resident at the same time, she indicated the oxygen dries her nose out bad. The top of the oxygen concentrator was covered with a white powdery substance, the external filter had small amount of white powdery substance, inside filter had a larger amount of white powdery substance. Tubing was dated 8/20/23. On 8/24/23 at 11:41 A.M., the resident was observed asleep with oxygen on at 2+ lpm per nc, without humidification. The concentrator was covered with white powdery substance, external filter has small amount of white powdery substance, inside filter has more white powdery substance. Tubing dated 8/20/23.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that staff received sufficient training to ensure resident safety and reduce the number of adverse events or other resident complications for 1 of 1 residents reviewed who use the mechanical lift. (Resident 37) Findings include: During an interview with Resident 37 on 8/21/23 at 3:55 P.M., the resident indicated that the day before yesterday the mechanical lift had tipped over with her in it. During an interview with the Director of Nursing (DON) on 8/25/23 at 2:20 P.M., she indicated she was not at work that day but was aware of the incident. She indicated there were no injuries. During an interview with the Assistant Director of Nursing (ADON) on 8/28/23 at 8:43 A.M., she indicated she was aware of the incident and there was no injury. She indicated that on 8/11/23 at 12:12 P.M., Certified Nursing Assistant (CNA) 10 and CNA 14 were re-educated on making sure the legs on the mechanical lift were fully spread before using it. She indicated they…

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.