Parkview Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 13 residents, with one reviewed for restraints. Based on observation, record review, and interview, the facility failed to provide a physician's order and assessment for a Lap Buddy (a cushioned pad that fits across the resident lap, placed in a wheelchair to remind residents to remain seated and to alert caregivers when a resident attempts to rise and prevents falls by discouraging independent movement) used to restrain Resident (R) 29 while in his wheelchair, placing the resident at risk for complications related to physical restraints. Findings included:- R29's Electronic Medical Record (EMR) documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), and traumatic subdural hematoma (SDH- serious condition, typically caused by head injury, where blood collects between the skull…

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.

The facility had a census of 44 residents. Based on observation, record review and interview the facility failed to provide a background check for Housekeeping Supervisor (HS) U, who had been employed with the facility since 1979, left, and came back in 1991. This placed the residents at risk for abuse.Findings included:- Review of background checks revealed the facility lacked a background check on HS U.On 08/19/25 at 01:50 PM, observation revealed HS U pushed a housekeeping cart down the west side of the facility.On 08/18/25 at 02:00 PM, Administrative Staff A stated the facility lacked documentation a background check was conducted on HS U, because she had been employed with the facility since 1991.On 08/19/25 at 12:57 PM, HS U stated she was employed with the facility in 1979 or 1980, left, then was rehired in 1991.The facility failed to provide a policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 13 residents. Based on record review and interview, the facility staff failed to identify an unwitnessed fall which resulted in serious injury as a potential allegation of neglect or abuse and report immediately to the State Survey Agency (SA), when Resident (R) 2, a cognitively impaired resident, had an unwitnessed fall with a fracture, and R8, a cognitively impaired resident, had a bruise of unknown origin. This placed the resident at risk for further injury and unidentified abuse or neglect. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), and a fracture neck of the left femur (thigh bone).R2's Significant Change (MDS), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Resident (R) 7 and R52 and notify the Office of the Long-Term Care Ombudsman (LTCO public official who works to resolve resident issues in nursing facilities) of the discharge for R7, R52, and R50 discharge from the facility. This placed the residents, and/or their representatives, at risk for uninformed care choices and impairs rights.Findings included:- R7’s Electronic Medical Record (EMR) included diagnoses of heart failure, generalized osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), pain, tremors, Parkinson’s disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), aftercare following joint replacement surgery, muscle weakness, and a history of falls. R7’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 The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include Resident (R) 21's ongoing use of prophylactic (preventative in nature) antibiotics (class of medication to treat infections) related to a history of urinary tract infections (UTI- an infection in any part of the urinary system). This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 21's long-term use of prophylactic (preventative in nature) antibiotic (medications used to treat infections). This placed R21 at risk for inappropriate use of medications.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness, agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues).R21's Quarterly Minimum Data Set (MDS) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure the need for continued antibiotic (a class of medications used to treat infections) use for Resident (R) 21, which placed the resident at risk of receiving unnecessary medication.Findings included:- R21's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dehydration, hypertension (elevated blood pressure), restlessness and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), dementia (a progressive mental disorder characterized by failing memory and confusion), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues).R21's Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had moderately impaired cognition, used…

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 The facility had a census of 44 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 3, who was admitted to hospice on 06/19/25, which included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care.Findings included: - R3's Electronic Health Record (EHR) revealed a diagnosis of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of the breast and bones.R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview of Mental Status (BIMS) score of six, which indicated severe cognitive impairment. The MDS document R25 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.

The facility had a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that had the required membership in attendance. This placed the resident with a lack of quality care.Findings included:- Upon review of the facility's QA&A committee attendance signed roster for the monthly meetings held 10/08/24 to 07/29/25, the roster of attendance lacked the signature of the Medical Director on one of the quarterly meetings (03/11/25).On 08/20/25 at 02:00 PM, Administrative Nurse D stated the medical director had been in attendance on the 03/11/25 quarterly meeting but failed to sign the signature sheet.Upon request, the facility failed to provide a QA&A policy.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full time certified dietary manager for the 49 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/13/23 at 8:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 12/13/23 at 09:10 AM, Dietary Staff BB verified she was not a certified Dietary Manager. Dietary Staff BB stated the facility had four residents who required a pureed texture diet. On 12/13/23 at 2:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The Facility's Director of Food and Nutrition Services dated 2021 documented the director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, cost management, and meeting nutritional need of the residents served. The director of food…

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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs. Findings included: - On 12/13/23 at 11:30AM, observation of the lunch meal revealed the kitchen served lasagna and strawberry short cake for dessert. On 12/13/23 at 11:40AM, review of the menu for the meal to be served at lunch stated, Resident Choice Meal, lasagna, garlic bread and a vegetable to be served. On 12/13/23 at 11:50AM, Dietary Staff (DS) CC verified he did not prepare a vegetable or garlic bread to serve with the meal. On 12/14/23 at 12:30PM, DS BB verified the menu for the lunch meal on 12/13/23 was to include a vegetable and garlic bread. The facility's Meal Service policy dated 12/21, documented a menu is to be approved each month by a registered dietician. The facility failed to serve the menu items, placing the residents at risk for unmet nutritional needs.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety when staff failed to check temperatures of food items prior to serving, failed to ensure clean and sanitary refrigerators and food preparation areas, failed to check sanitation for the dishwasher, and failed to keep food items off the floor in the food storage room. This placed the residents at risk for foodborne illness. Findings included: - On 12/13/23 at 08:30AM, observation of the kitchen revealed #8 freezer had food particles of yellow and orange chunks smeared on freezer surface, an open and uncovered three-gallon tub of vanilla ice cream with ice particles on top. The large upright refrigerator had a four-quart clear plastic container with white substance and brown particles in container, not labeled or dated, and a four-quart clear plastic container of shredded cheese, not labeled or dated. On 12/13/23 at 08:40AM, observation revealed a 12-quart…

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.

The facility had a census of 50 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 1, 2,3 and 4 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. (Quarter 1: 36 dates, Quarter 2: 27 dates, Quarter 3: 20 dates, Quarter 4: 17 dates) Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 12/13/23 at 08:30AM, observation revealed a registered nurse on duty in the facility. On 12/14/23 at 01:00PM, Administrative Staff A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Reporting Payroll Based Data…

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.

The facility had a census of 50 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training and possessed the required certification in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 12/13/23 at 11:00 AM, Administrative Nurse D stated she was responsible for the Infection Prevention and Control Program and verified she lacked certification as an Infection Preventionist. Administrative Nurse D stated she had not completed the training modules and had not taken the test for certification. The facility's Infection Preventionist policy, dated August 15, 2022, documented the Infection Control Preventionist is responsible for implementing the infection prevention and control program. The facility would designate a qualified individual as Infection Preventionist (IP) whose primary role is 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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label and store drugs and biological medications appropriately. This deficient practice placed the affatced residents at risk to receive ineffective or inappropriate medication. Findings included: - On 12/13/23 at 08:55 AM, observation in the East Hall medication room revealed the medication refrigerator temperature logs were not assessed and recorded daily. The medication refrigerator had a vial of Levemir insulin (hormone that lowers the level of glucose in the blood) without an open or expiration date. The vial of Levemir was used and contained less than half. On 12/13/23 at 08:55 AM, Licensed Nurse (LN) H verified the insulin was not dated and had not been used since the resident had gone to the hospital a couple of months ago and should have been disposed of. She verified the temperature log was not completed daily and said it should have been. The facility's Medication Storage policy, dated 01/01/20, stated medication requiring…

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.

The facility had a census of 50 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This placed the residents at risk for impaired nutrition. Findings included: - On 12/14/23 at 11:15 AM, Dietary Staff (DS) CC stated the facility had four residents with pureed diets. DS CC placed four pieces of roast beef into the blender container with one cup beef broth. DS CC placed it in a metal pan, covered, and placed on the steam table. Further observation revealed DS CC placed four scoops of au gratin potatoes into the blender then poured milk from the gallon jug into the blender, DS CC then placed four scoops of carrots into the blender and poured milk from the gallon jug into the blender, without following a recipe. On 12/14/23 at 11:30AM, DS CC verified he had not followed a recipe and stated he was unsure if there was a pureed recipe. On 12/14/23 at 12:30PM, DS BB…

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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide ice water in a sanitary manner. The facility further failed to ensure appropriate infection control principles related to the use of an indwelling catheter (tube inserted directly in the bladder to drain urine) for Resident (R) 14. These deficient practices placed the residents at risk for infection. Findings included: - On 12/13/23 at 11:30AM, observation revealed Dietary Staff (DS) DD with a cart by the facility ice machine in the dining room. Further observation revealed the cart contained clear water glasses. Observation revealed DS DD used her bare hands to grab ice out of the ice machine and place in the glasses. On 12/13 23 at 11:40AM, DS DD verified she should use an ice scoop to place ice in the glasses but said the scoop holder was broken on the side of the ice machine and she did not know where the scoop was. On 12/13/23 at 11:42AM, per request, DS DD emptied the glasses and obtained new water glasses to fill 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 The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to report Resident (R) 43's allegation of physical and verbal abuse to the State Agency (SA). This placed the resident at risk for unidentified and/or ongoing abuse. Findings included: - R43's Electronic Medical Record (EMR) documented R43 had diagnoses of acute and chronic respiratory failure, hemiplegia/hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke/CVA- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting left non-dominant side, heart failure, chronic kidney disease, unspecific complication of kidney transplant, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (major mood disorder which causes persistent…

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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to apply compression hose to Resident (R) 4, as ordered by the physician. This placed the resident at risk for ongoing complications related to edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Findings included: - R4's Electronic Medical Record (EMR) documented R4 had diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear disorder, chronic bronchitis (inflammation of the tubes that let air in and out of lungs), major depressive disorder (major mood disorder which causes persistent feelings of sadness), polyneuropathy (malfunction of nerves throughout the body), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) with acute exacerbation, heart failure, atrial fibrillation (rapid, irregular heart beat), abnormal…

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 The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment for the three cognitively impaired independently mobile residents who resided on the [NAME] and the West/East halls. The facility further failed to ensure an environment free from accident hazards for Resident (R)2. This placed the affected resident at risk for injury. Findings included: - On 12/13/23 at 08:40 AM, observation during initial facility tour revealed an unlocked soiled utility room door on the West/East Hall. Further observation revealed the door contained a keypad to open the door that was unlocked. The soiled utility room contained the following: 1- one-quart Bio-Enzymatic Spotter spray-with the warning keep out of reach of children, may cause serious eye irritation, if swallowed call a poison control center. 1- 32-ounce (oz) spray bottle of Clorox clean-up disinfectant spray with the warning keep out of reach 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 The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement the Registered Dietician (RD) recommendation for Resident (R) 4's weight loss which placed R4 at risk for further weight loss. The facility further failed to monitor R14 and R43's physician ordered fluid restriction which placed R13 and R43 at risk of complication related to hydration status. Findings included: - R4's Electronic Medical Record (EMR) documented R4 had diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear disorder, chronic bronchitis (inflammation of the tubes that let air in and out of lungs), major depressive disorder (major mood disorder which causes persistent feelings of sadness), polyneuropathy (malfunction of nerves throughout the body), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity…

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 The facility had a census of 50 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R)2. This placed the affected resident at risk for injury. Findings included: - R2's diagnoses included diabetes mellitus (when the body cannot use glucose), morbid obesity (being 100 pounds or more above ideal body weight), dementia (progressive mental disorder characterized by failing memory, confusion), and tremors. R2's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R2 was independent with bed mobility and transfers. The MDS lacked documentation the resident had siderails. R2's medical record recorded a Device Assessment was completed on 11/30/23 for assist rails used by the resident as an enabling devise to provide the opportunity…

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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility's pharmacy services failed to provide medication in the specific dosage prescribed when they packaged the pills for the facility. This deficient practice placed Resident (R) 3 at risk for an incorrect dose of medication. Findings included: - On 12/19/23 at 08:19 AM, observation revealed Certified Medication Aide (CMA) R administered a 25 milligram (mg) metoprolol (medication that lowers blood pressure and heart rate) pill to R3. The pills in the medication bubble card were not cut in half and the card stated 25 mg, give one-half tab. On 12/19/23 at 08:36 AM, Licensed Nurse (LN) H verified the order and stated the pills should have been cut in half. LN H stated the pharmacy failed to cut the pills when packaging the morning dose, however, the evening dose was correctly packaged. The facility's Provider Pharmacy Requirements policy, dated April 2020, stated the provider pharmacy would dispense prescriptions based on the authorized prescriber…

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.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to prevent a significant medication error for Resident (R)3. This placed the resident at risk for adverse medication effects. Findings included: - On 12/19/23 at 08:19 AM, observation revealed Certified Medication Aide (CMA) R administered a 25 milligram (mg) metoprolol (medication that lowers blood pressure and heart rate) pill to R3. The pills in the medication bubble card were not cut in half and the card stated 25 mg, give one-half tab (12.5 mg) On 12/19/23 at 08:36 AM, Licensed Nurse (LN) H verified the order and said R3 should only have received 12.5 mg and stated the pill should have been cut in half to give the correct dose. The facility's Medication Administration policy, dated 2022, directed staff to compare the medication source (bubble pack) with the order, check expiration date, and administer the medication as ordered. The facility's Medication Errors policy, dated 01/01/20, stated the facility would ensure medications…

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.

The facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 51 residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness. Findings included: -On 05/09/22 at 09:37 AM, during initial tour of the kitchen observations revealed the following: Up right freezers labeled #11, 12, and 13, lacked inside thermometers and temperature logs for the month of May 2022. A chest freezer had an open package of chicken patties without readable date when opened or expired. The floor had boxed cases of banana pudding, crispy onions, pancake mix, waffle syrup, Hershey chocolate syrup, cornbread mix, and half a case of raw potatoes. Observation in the kitchen revealed: Unfinished cement floor with cracks and divots. The lower legs and base of all equipment were soiled with dark grey/black matter and dried food. Two roaster pans and a crock pot stored on shelf below the prep tables 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.

The facility had a census of 52 residents. The sample included 13 residents with six reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) R12,R16, R32, R23 and with dignity when staff stood over the residents when assisting them to eat, and when staff curled R16, R35, R36, R23, and R32's hair at the dining room table during meal service and dining and when staff gave (R) 41 medicated ointment to put in his nose while he was seated at the dining table with other residents. This placed the residents at risk for an undignified dining experience. Findings included: - On 05/09/22 at 11:31 AM, observation revealed Temporary Nurse Aide (TNA) M stood over R 12, R16, R32, and R23, while assisting them to eat their noon meal, taking turns giving them bites of their food items. On 05/12/22 at 08:29 AM, observation revealed TNA M stood over R 23, R 15, and R 32, while assisting them to eat their breakfast meal, taking turns giving them bites of their food items. On 05/12/22 at 08:32 AM, Licensed Nurse (LN) G verified the above…

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.

The facility had a census of 52 residents. The sample included 13 residents. Based on record review and interview the facility failed to provide five of five residents or their representatives a current Center of Disease Control (CDC) Vaccination Information Statement (VIS), dated 08/06/21, when staff obtained consent for the Influenza vaccination administered on 09/29/21 and 10/01/21. This deficient practice placed residents at risk to make uninformed decisions about their immunizations. Findings included: - Resident (R) 34's 2021 Influenza vaccination consent form included the 08/15/19 vaccination information. R23's 2021 Influenza vaccination consent form included the 08/15/19 vaccination information. R10's 2021 Influenza vaccination consent form included the 08/15/19 vaccination information. R41's 2021 Influenza vaccination consent form included the 08/15/19 vaccination information. R42's 2021 Influenza vaccination consent form included the 08/15/19 vaccination information. On 05/11/22 at 03:05 PM, Administrative Nurse F stated she noted the VIS was outdated after the resident or…

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 The facility had a census of 52 residents. The sample included 13 residents with one reviewed for physical restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) use. Based on observation, interview, and record review the facility failed to assess Resident (R) 23 for the use of physical restraints, failed to obtain consent from the resident or resident's representative, and periodically re-assess for the continued use. This deficient practice placed R23 at risk for unnecessary physical restraint. Findings included: - R23's Physician Order Sheet (POS), dated 03/22/22, documented diagnoses of delusions with hallucinations (hallucinations revolve around senses and delusions center on beliefs), macular degeneration (causes loss in the center of the field of vision), and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various…

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 The facility had a census of 52 residents. The sample included 13 residents. Based on observations, record review, and interview, the facility failed to review and revise Resident (R) 3 plan of care with resident centered interventions aimed to prevent falls which placed the resident at increased risk of falls and injury. -R3's Physician Order Sheet (POS), dated 05/04/22, included diagnoses of low back pain, urinary tract infection, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertensive (elevated blood pressure), heart disease, dizziness and giddiness, and repeated falls. The admission Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition, required limited assistance of one staff for transfers and walking, was not steady, and only able to stabilize with human assistance during transition and walking. The MDS further recorded R3 had falls prior to admission. The Fall Care Area Assessment (CAA), dated 02/09/22, documented R3…

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 The facility had a census of 52 residents. The sample included 13 residents with five reviewed for accidents. Based on observation, record review and interview the facility failed to ensure Resident (R) 24's motion alarm was turned on at all times as directed in her plan of care and failed to identify causative factors and implement interventions on R3's care plan to prevent further falls. This placed the resident at increased risk for falls and fall related injury. Findings included: - R24's Electronic Medical Record (EMR) documented she had diagnoses dementia (progressive mental disorder characterized by failing memory, confusion) , osteitis deformans (a chronic bone disorder that typically results in enlarged, deformed bones due to excessive breakdown and formation of bone tissue that can cause bones to weaken and may result in bone pain, arthritis, bony deformities and fractures of bone), difficulty in walking, and history of falling. R24's Quarterly Minimum Data Set (MDS), dated [DATE], documented 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 The facility had a census of 52 residents. The sample included 13 residents with three reviewed for urinary catheter (tube inserted into the bladder to drain urine) or urinary tract infection (UTI). Based on observation, record review and interview, the facility staff failed to change gloves when providing Resident (R) 3 and R24 incontinent cares and continued to provide care with the same soiled gloves. This placed the residents at risk for infection. Findings included: - R3's Electronic Medical Record (EMR) documented the resident had diagnoses urinary tract infection (UTI-an infection in any part of the urinary system ), dementia (progressive mental disorder characterized by failing memory, confusion), and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had short- and long-term memory problems and severely impaired cognition. The MDS documented the resident requireed total staff…

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.

The facility had a census of 52 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to store oxygen cannula and tubing in sanitary condition for one of one resident reviewed for respiratory care, Resident (R) 42. This placed the resident at risk for respiratory infections. Findings included: - R42's Physician Order Sheet (POS), dated 05/04/22, documented diagnoses of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing ), COVID-19 (contagious disease caused by severe acute respiratory syndrome), chronic bronchitis (large air passages of the lungs which are inflamed), hypertensive (high blood pressure) heart disease, and atrial fibrillation (rapid, irregular heart beat). The Annual Minimum Data Sheet, dated 04/12/22, documented R42 required extensive assistance of one staff for activities of daily living (ADL's ), used a wheelchair, and experienced shortness of breath with exertion, when sitting at rest 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 The facility had a census of 52 resident. The sample included 13 resident with eight reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported inappropriate diagnoses for four of Resident (R) 12's physician ordered medications, and the facility failed to follow up with the CP recommendation for a stop date for R12's Lorazapam. Findings included: - R12's Electronic Health Record (EMR) documented R12 had diagnoses anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder(any major mental disorder characterized by a gross impairment in reality testing), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure) and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness 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 The facility had a census of 52 residents. The sample included 13 residents with eight review for unnecessary medication. Based on observation, interview, and record review the facility failed to identify appropriate medication diagnoses for R12.This deficient practice placed R12 at risk for unecessary medication therapy. Findings included: - R12's Electronic Health Record (EMR) documented R12 had diagnoses anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder(any major mental disorder characterized by a gross impairment in reality testing), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure) and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). R12's Quarterly Minimum Data Set(MDS), dated [DATE], documented R12 had short and long term memory problems 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 The facility had a census of 52 residents. The sample included 13 residents with eight reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to document appropriate indications for administration and failed to place a stop date on as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R)12. This placed the resident at risk for unnecessary medications and related complications. Findings included: - R12's Electronic Health Record (EMR) documented R12 had diagnoses anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), psychotic disorder(any major mental disorder characterized by a gross impairment in reality testing), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure) and major depressive disorder (abnormal emotional state characterized by exaggerated feelings 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 The facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review , and interview the facility failed to store drugs and biologicals for one of three medication carts placing the residents at risk for missing medications and unsafe access to medications. Findings included: -On 05/10/22 at 08:10 AM upon entering the south east hallway, a medication cart had been parked outside room [ROOM NUMBER] unattended and unlocked. A box of Advair (an inhalation medication) sat on top of the cart, visible and accessible to residents, staff, and visitors. At 05/10/22 at 08:12 AM Licensed Nurse (LN) [NAME] Marshall RN exited room [ROOM NUMBER] and returned to the unlocked medication cart. LN [NAME] stated she had left the cart quickly to attend to the resident in room [ROOM NUMBER]. She verified the cart was unlocked, and Advair had been left on top of the cart, unsecured. She further verified the cart should have been locked, and no medications left unattended. The facility'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.

The facility had a census of 52 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserved nutritive value, flavor, and appearance for two residents who received pureed diets placing the residents at risk for inadequate nutrition. Findings included: -On 05/11/22 at 11:45 AM, observation revealed Dietary Staff (DS) DD prepared pureed diets for two residents. DS DD placed one half pound of Swedish meatballs into a blender. DS DD added half a teaspoon of beef base, one cup of hot water (the recipe called for six tablespoons and one teaspoon of water), then DS DD had to add dried infant rice cereal to obtain correct consistence. On 05/11/22 at 11:55 AM, DS BB reported she had prepared the heated water for DS DD to use in the pureed diet process. Both DS BB and DD had not referred to the recipe's water amount. The facility failed to provide a pureed recipe policy upon request. The facility failed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 52 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to provide adequate infection control during wound care for Resident (R)34 when the nurse placed the unwrapped dressings and scissors directly on a visibly soiled bedside table and failed to clean the wound prior to applying the dressing. This deficient practice placed R34 at increased risk for a wound infection. Findings included: - The Physician Order Sheet (POS), dated 04/11/22, documented a diagnosis of open wound of right buttock. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired decision making. The MDS documented R34 was independent with eating, required extensive one staff assistance for bed mobility, locomotion, dressing, hygiene, and two staff total assistance for transfers and toileting. The MDS documented R34 had impaired range of motion in both lower…

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.