Legacy On 10th Avenue

The facility identified a census of 54 residents. The sample included 14 residents with two residents reviewed for falls. Based on interviews, observation, and record review the facility failed to ensure fall interventions were implemented as care planned for Resident (R) 6 when staff failed to ensure his call light was within reach.Findings included:- R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), dementia (a progressive mental disorder characterized by failing memory and confusion), and cerebrovascular accident (CVA-stroke- 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).The Quarterly Minimum Data Set (MDS) dated 01/15/25 documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R6 had one non-injury fall during the observation period. R6's Falls Care Area Assessment (CAA), dated 10/27/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 54 residents. The sample included 14 residents with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 26 and R8. The facility also failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections), pneumococcal (type of bacterial infection) for R8.Findings included:- 1. On 03/30/26, R26's clinical record revealed he was admitted on [DATE]. The EMR under the Immunization tab lacked documentation the influenza vaccination was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. The facility was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 53 residents. The sample included five residents reviewed for accidents and falls. Based on observation, record review, and interview, the facility failed to ensure that staff placed and secured Resident (R) 1's wheelchair and the safety belt properly used in the facility's transportation van prior to engaging the vehicle to drive. This resulted in R1's wheelchair overturning, and R1 fell from his wheelchair. This placed R1 at risk of injury and likely harm.Findings included:- R1's Electronic Medical Record (EMR) recorded diagnoses of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), sensorineural hearing loss (hearing loss caused by damage to the inner ear or the nerve from the ear to the brain), muscle wasting and atrophy (the decrease in muscle mass 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.

The facility identified a census of 55 residents. The sample included 15 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This placed all residents in the facility at risk for unidentified care needs and inadequate care. Findings Included: - On 10/08/24 at 08:00 AM an inspection of the Facility Assessment dated 08/06/24 provided by the facility revealed the following: The assessment lacked information stating the specific staffing needed for each unit including nights and weekends and lacked the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit. The assessment lacked an informed contingency plan for events that did not require activation of the facility's emergency plan but had the potential to impact resident care. The assessment lacked a plan to maximize recruitment and retention of direct care…

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 identified a census of 55 residents. The facility identified 29 residents with facility-managed trust accounts. Based on observation, record review, and interviews, the facility failed to ensure residents had same-day access to their funds for amounts less than $100.00. This deficient practice placed 29 residents at risk for decreased psychosocial well-being and impaired rights. Findings Included: - A review of the facility's Resident Funds accounts revealed 29 residents had active trust accounts with the facility. On 10/07/24 at 07:05 AM an inspection of the central hallway door revealed a sign that read Bank open 3pm to 5pm on Monday through Fridays. On 10/07/24 at 02:20 PM Resident (R)31 sat outside the business office. R31 reported he was waiting for the bank to open so he could get some money out of his account. He stated he could only access the money from 03:00 PM through 05:00 PM. He stated he could not access money on weekends or after hours. On 10/08/24 at 01:30 PM, Resident Council members R10, R29, and R15 reported the facility's bank was only open on…

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

The facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings Included: - On 10/07/24 at 07:00 AM upon entrance to the facility a strong urine odor was evident in the west and central hallways. On 10/07/24 at 07:03 AM an inspection of the dining hall area revealed multiple food trays with the previous evening's partially eaten taco and sloppy joe meals on a kitchen transport cart. Several flies were observed landing on the food. An inspection of the dining hall revealed flies in the area of the exposed food and trays. On 10/08/24 at 07:05 AM an inspection of the dining hall revealed old food and dirty plates left out from the previous evening's dinner across from the vending machine. Flies were present in the dining room and vending machine area. On 10/08/24 at 09:54 AM an inspection of the dining…

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 identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and unresolved grievances and concerns. Findings Included- - On 10/07/24 at 08:10 AM an inspection of the facility revealed no designated grievance drop boxes or system available in the areas accessible to the residents and visitors of the facility. On 10/08/24 at 01:21 PM, the Resident Council members reported they were not aware that the facility provided a way to complete anonymous grievances. The council reported they must take the grievance to a staff member. The Resident Council stated the staff does help the residents fill out grievances, and the staff would slide the grievance under the door of the administrator's office, or just give the grievance to the administrator. On 10/09/24 at 12:14 PM, Licensed Nurse (LN) G stated 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.

The facility identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for the residents. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, isolation, and boredom. Findings Included: - An inspection of the September 2024 activity calendar indicated the residents were to have four scheduled staff-led activities throughout the day for each day. The calendar indicated staff-led activities would be held on or around 08:00 AM-0900 AM, 10:00 AM-11:00 AM, 01:00-02:00 PM, and 06:00-0700 PM with varied events like coffee chat, crafts, social hours, Bingo, and trivia. Observation on 10/08/24 from 07:00 AM through 05:00 PM revealed no staff-led morning or afternoon activities were observed for the residents. Observation on 10/07/24 at 07:00 AM a walkthrough of the facility revealed September 2024 activity calendars still posted through the facility. Observation on 10/08/24 from 07:00 AM through 05:00 PM revealed no staff-led…

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 identified a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional to direct the activities program in the facility. This deficient practice placed the affected residents at risk for impaired quality of life. (refer to F679) Findings Included: - An inspection of the September 2024 activity calendar indicated the residents were to have four scheduled staff-led activities throughout the day for each day. The calendar indicated staff-led activities would be held on or around 08:00 AM-0900 AM, 10:00 AM-11:00 AM, 01:00-02:00 PM, and 06:00-0700 PM with varied events like coffee chat, crafts, social hours, Bingo, and trivia. The facility was unable to provide evidence for an activity coordinator as requested on 10/07/24. Observation on 10/08/24 from 07:00 AM through 05:00 PM revealed no staff-led morning or afternoon activities were observed for the residents. Observation on 10/07/24 at 07:00 AM a walkthrough of the facility revealed September 2024 activity…

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 identified a census of 55 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, record review, and interview the facility failed to secure potentially hazardous equipment, oxygen tanks, and chemicals in a safe, locked area, and out of reach of eleven cognitively impaired independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 10/07/24 at 07:05 AM a walkthrough of the facility was completed and revealed the following: An unsecured oxygen storage room contained 40 pressurized supplemental oxygen cylinders in the storage rack. The central and west hallways revealed unsecured furnace closets. The west hallway also had multiple bottles of bleach wipes stored in a storage room (room [ROOM NUMBER]) with the door propped open. The bottle contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. The central hallway…

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 identified a census of 55 residents. The facility failed to ensure staff performed adequate hand hygiene, ensure respiratory equipment was stored in a sanitary manner, and further failed to ensure linens were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - An initial walkthrough of the facility was completed on 10/07/24 at 07:34 AM. R30's nebulizer mask laid directly on his bedside table. The mask was not in a sanitary container. On 10/07/24 at 07:54 AM during the initial tour, a high-back wheelchair in the south hallway revealed unbagged oxygen tubing coiled around the back arm of the wheelchair. On 10/07/24 at 01:34 PM, an inspection of the west hall revealed a storage room with clean linen next to a soiled linen bin. The clean linen cover was left open next to the soiled bin. On 10/08/24 at 09:16 AM Certified Nurse's Aide (CNA) M and CNA O donned gloves, without performing hand hygiene first. CNA M pushed R50 into his room, and the CNAs used a Hoyer (total body mechanical lift) to place…

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 identified a census of 55 residents. The sample included 15 residents. Based on record reviews, interviews, and observations, the facility failed to provide effective pest control to ensure the facility was free from pests. This placed the residents at increased risk for impaired comfort and disease. Findings Included: - A review of the facility's pest control Service Inspection Report revealed an inspection was completed on 10/07/24 at 09:00 AM and indicated Dietary Staff BB reported no pest concerns. The report noted fly bait traps were placed around the dining and vending machine areas. Observation on 10/07/24 at 07:00 AM of the dining hall area revealed multiple food trays with the previous evening's exposed and partially eaten taco and sloppy joe meals on a kitchen transport cart. There were several flies observed landing on the food. Further observation of the dining hall revealed flies in the area of the exposed food and trays. Observation on 10/08/24 at 07:05 AM of the dining hall revealed old food and dirty plates left out from the previous evening's dinner…

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 55 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 50's representative in the development and planning of the resident's care plan, which placed R50 at risk of impaired care and decreased autonomy. Findings Included: - R50's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty) following cerebral infarction (stroke - 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), kidney disease (a condition in which 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 identified a census of 55 residents. The sample included 15 residents. One resident was sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)50's call light was within his reach. This deficient practice left R50 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings Included: - R50's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of s diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty) following cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by…

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 identified a census of 55 residents. The sample included 15 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)50's representative of changes related to falls. This deficient practice placed R50 at risk for uninformed treatment or care decisions. Findings included: - R50's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of s diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty) following cerebral infarction (stroke - 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…

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 identified a census of 55 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the Consulting Pharmacist (CP) identified and reported the inappropriate indication or lack of diagnosis for Resident (R)4's Risperdal (antipsychotic medication used to treat major mental conditions that cause a break from reality). This deficient practice placed R4 at risk for unnecessary medications and side effects. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of altered mental status, epilepsy (brain disorder characterized by repeated seizures), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), cerebral infarction (stroke - 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), and heart failure. R4's Significant Change Minimum Data Set (MDS) completed 09/12/24 noted a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 55 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to obtain the physician-ordered test to monitor for side effects related to the use of psychotropic (alters mood or thought) medication for Resident (R) 21. The facility also failed to ensure R4 had a Center for Medicare and Medicaid Services (CMS) approved indication or appropriate diagnosis for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality). These deficient practices placed the residents at risk for adverse medication effects and unnecessary medications. Findings Included: - R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling 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 identified a census of 55 residents. The sample included 15 residents with three residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a collaborated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)51. This deficient practice created a risk for missed or delayed services and impaired care for R51. Findings Included: - R51's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), atrial fibrillation (rapid, irregular heartbeat), cirrhosis (chronic degenerative disease of the liver), chronic obstructive pulmonary…

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 identified a census of 53 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 1 or his representative. This deficient practice had the risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services. Findings included: - R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses for dementia (progressive mental disorder characterized by failing memory, confusion) and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated 05/23/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. R1 had no behaviors in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 53 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 1 or his representative when he was transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R1. Findings included: - R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses for dementia (progressive mental disorder characterized by failing memory, confusion) and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The admission Minimum Data Set (MDS) dated 05/23/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. R1 had no behaviors in the assessment period.…

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 identified a census of 54 residents. Based on observation, record review and interview the facility failed to ensure an accurate and consistent reconciliation of all controlled substances on the medication carts. This placed the residents at risk for misappropriation and ineffective medication regimens. Findings included: - A review of the facility's Licensed Nurse: As Needed (PRN) Narcotic Count Sheet dated April 2024 revealed that 17 out of 88 opportunities the narcotic reconciliation was not performed on Medication Cart A and 52 out of 88 opportunities the reconciliation was not completed on Medication Cart B. A review of the facility's Scheduled Narcot [sic] Count Sheet dated April 2024 revealed 34 opportunities out of 132 opportunities the narcotic reconciliation was not completed on Medication Cart C, and 22 opportunities out of 132 opportunities a reconciliation was not completed on Medication Cart D. Review of the facility's Shift to Shift Sheet Med Count East/West Station two pages, ranging in dates from 04/08/24 through 04/23/24, had the following dates…

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 identified a census of 52 residents. The sample included three residents reviewed for urinary catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to ensure Resident (R)1, who had an indwelling catheter, had a physician order for the catheter which included the diagnosis or indication for the indwelling catheter. This placed the resident at risk for catheter related complications. Findings included: - R1's Electronic Medical Record (EMR) under the Diagnosis tab documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), neuromuscular dysfunction of bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), and weakness. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which…

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 identified a census of 52 residents. The sample included three residents reviewed for urinary catheter (flexible tubing inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care. Based on record review, interview, and observation, the facility failed to ensure Resident (R)2 received appropriate treatment and services related to her nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion) catheter. This placed R2 at risk for complications related to her nephrostomy catheter. Findings included: - R2's Electronic Medical Record (EMR) under the Diagnosis tab documented diagnoses of displacement of nephrostomy catheter, and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated intact cognition. R2 required set or clean-up assistance with the shower, toileting hygiene, upper and lower body dressing. R2…

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 identified a census of 55 residents. The sample included three residents with one reviewed for transfer and discharge. Based on record review and interview, the facility failed to provide written notice of discharge for Resident (R)1's immediate involuntary discharge. This placed the resident at risk for impaired rights. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of schizoaffective disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual MDS dated 08/13/23 documented a BIMS score of 14 which indicated intact cognition. R1 required no supervision or physical help with all activities of daily living (ADL) but required set up help for personal hygiene. The MDS recorded R1 had no…

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

The facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 54 residents who resided in the facility and received their meals from the kitchen. Findings included: - On 04/10/23 at 09:40 AM, observation revealed two dietary staff in the kitchen preparing the lunch meal. On 04/10/23 at 09:45 AM, Dietary Staff BB verified she worked at the facility for a few months. She said she was enrolled in the dietary manager course. Dietary Staff BB stated one resident received a pureed (foods with soft, pudding like consistency) diet. On 04/18/23 at 09:45 AM, Administrative Nurse D verified Dietary Staff BB was not certified and was currently enrolled in the dietary manager online course. The facility' Dietician policy, dated 10/2021 documented a qualified, competent, and skilled Dietician would help oversee the food and nutrition services in the facility. The policy documented if the dietician was not employed full time (35 or more…

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 54 residents. Based on observation, interview, and record review the facility failed to provide thorough infection control measures to prevent the spread or development of infection for the 54 residents of the facility when the facility failed to disinfect shared equipment between residents and failed to have a water management plan for Legionaires ( a serious type of pneumonia caused by legionella bacteria), and failed to ensure laundry temperatures were hot enough to kill bacteria. This deficient practice placed the 54 residents of the facility at risk for infection. Findings included: - The facility's Infection Control and Influenza policies were reviewed October 2021. The Influenza policy, dated as reviewed October 2021, and the Pneumococcal policy was dated August 2016. On 04/17/23 at 03:19 PM, observation in the facility laundry revealed Maintenance Staff U tested the laundry water temperature from the water line to the machines. He held the thermometer to the rubber hose and obtained a temperature of 158 degrees Fahrenheit (F). The facility 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 census of 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean comfortable and homelike environment in one of three halls in the facility and failed to provide hot water temperatures at an appropriate, comfortable temperature. This placed the residents at risk for an unsanitary, non-homelike, and uncomfortable environment. Findings included: - On [DATE] at 11:00 AM, observation revealed Resident (R)11's room floor was sticky with blackish grime. On [DATE] at 02:40 PM, observation revealed the following findings: R4's bathroom mopboard had black discoloration and there was a open package of incontinent briefs on the floor. R50's bathroom had an open package of incontinent briefs on the floor and a small hole in the wall with crumbles of the inner wall on the floor. R4's room had dried, red liquid on the floor by the wall on the other side of his room by the B bed where his former roommate, now deceased ,…

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 54 residents. The sample included 21 residents, with seven reviewed for side rails. Based on observation, record review, and interview the facility failed to educate and obtain consent for the use of a side rail and/or assessment for the safe use of side rails for for Resident (R) 7, R15, R23, R2, R16, R51 and R27. This placed the residents at risk for side rail related injuries. Findings included: - R7's Electronic Medical Record (EMR) documented the resident had diagnoses of age-related physical debility, muscle wasting, muscle weakness, lack of coordination, and cerebral infarction (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). R7's Quarterly Minimum Data Set (MDS) dated [DATE], documented R7 had short and long term memory problems and moderately impaired cognition. The MDS documented R7 required extensive staff assistance with bed mobility and transfers. The MDS lacked documentation…

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 54 residents. Based on observation, interview, and record review the facility failed to label and date (when opened) two insulin (medications used to treat high blood glucose levels) pens and assess and document the medication refrigerator temperatures daily. This deficient practice placed two residents who received insulin at risk to receive ineffective insulin and placed residents who received refrigerated medications at risk for ineffective medication results. Findings included: - On 04/10/23 at 09:39 AM, observation of the west hall nurse medication cart revealed an undated Levemir (long-acting insulin) insulin pen for Resident (R)30 and an undated Humalog (fast acting insulin) insulin pen for R33. The west hall medication refrigerator temperature was 39 Fahrenheit (F), but the temperature log lacked several days of temperatures. On 04/10/23 at 10:49 AM, observation in the east hall medication room revealed the medication refrigerator was 43 F and the log lacked temperatures for two days in April. On 04/10/23 at 09:39 AM, Licensed Nurse (LN) G…

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 54 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to maintain an effective pest control program so that the facility would be free of pests and rodents. This placed the 54 residents at risk for diseases and impaired comfort. Findings included: - The Pesticide Service Sheets revealed a pest control company came to the facility on the following dates to provide pest control for mice and other pests: 10/12/22, and 10/26/22 11/09/22, and 11/23/22 12/16/22 and 12/30/22 01/11/23 and 01/25/23 02/17/23 and 02/20/23 03/02/23 and 03/16/2304/03/23. The 04/03/23 Pesticide Service Sheet documented Maintenance Staff U reported no pest concerns 04/10/23 01:28 PM, Resident (R)29 stated staff never cleaned underneath his bed. R29 reported mice crawled on him at night while he was sleeping in his bedR29's representative was in the room and stated she purchased mice glue traps all the time to place around R29's room because he always had mice. R29's representative stated she brought containers in (pointed…

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 54 residents. The sample included 21 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff administered insulin (a medication used to regulate blood sugar levels) to Resident (R)30 at the [NAME] medication cart, in the hallway, with other residents in full view of the procedure. Findings included: - On 04/10/23 at 10:50 AM, observation revealed R30 pulled his shirt up and Licensed Nurse (LN) G injected an insulin injection subcutaneous (applied under the skin) into R30's abdomen while other residents were in the hallway in full view of the insulin injection. On 04/18/23 at 09:40 AM, Administrative Nurse D stated she expected the nurse to take the resident to the medication room or the resident's room or another private area to administer their insulin. The facility's Quality of Life-Dignity policy, dated October 2021, documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being, level 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.

The facility had a census of 54 residents. The sample included 21 residents. Based on record review and interview, the facility failed to provide Resident (R)20 , or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and the completed Notice of Medicare Non-Coverage Form (NOMNC) Centers for Medicare and Medicare Services (CMS) form 10123, and failed to provide R7's legal guardian the 10055 and the 10123 form to sign until two days after the services ended. This placed the resident, or their representatives at risk to make uninformed decisions about their skilled services and at risk to incur charges if exercising their right to appeal. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal 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 54 residents. The sample included 21 residents, with seven reviewed for side rails. Based on observation, record review, and interview the facility failed to update Resident (R)27's care plan for the safe use of a side rail, placing him at risk for accident or injury. Findings included: - R27's diagnoses included cerebral vascular accident (CVA-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), hemiplegia ( paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and dementia (progressive mental disorder characterized by failing memory, confusion). R27's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented R27 required extensive assistance of one staff with bed mobility and transfers. The MDS lacked documentation 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 54 residents. The sample included 21 residents, with five reviewed for nutrition. Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance for Resident (R) 28 who had problems with swallowing and staff were to monitor while eating due to risk of aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident). This deficient practice placed R28 at risk for serious health issues such as pneumonia or malnutrition. Findings included: - R28's Electronic Medical Record documented diagnoses of dementia (group of thinking and social symptoms that interferes with daily functioning), cerebral infarction (stroke), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body), and pneumonia (lung inflammation caused by bacterial or viral infection). The admission Minimum Data Set (MDS), dated [DATE], documented R28 had short- 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.

The facility had a census of 54 residents. The sample included 21 residents. Based on observation, interview and record review, the facility failed to provide a licensed nurse with adequate competency and skills to safely administer medications. This placed Resident (R)39 at risk for medications errors. Findings included: - On 04/10/23 at 10:55 AM, observation revealed a plastic medication cup on R39's bedside table with numerous pills in the cup. Continued observation revealed R39 was out of the room, however R35, his roommate, was sitting up on the edge of the bed. Surveyor proceeded to find Licensed Nurse (LN) G, the charge nurse, and asked him about the medications in R39's room. LN G stated he would have to ask Certified Medication Aide (CMA) R who administered the medications to the residents that morning. CMA R went to R39's room, looked at the cup of pills and stated she had administered the resident his morning medications and observed him take all of the medications. She said she was unsure what medications were in the cup on the bedside table. CMA R took the medication…

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 54 residents. The sample included 21 residents, with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to ensure blood pressures were monitored for Resident (R) 28 who received four medications which included instructions when to hold (not administer) the medication. This deficient practice placed R28 at risk for unnecessary medications and adverse effects. Findings included: - R28's Electronic Medical Record documented diagnoses of congestive heart failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should), dementia (group of thinking and social symptoms that interferes with daily functioning), cardiomyopathy (disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body), cerebral infarction (stroke), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body), coronary atherosclerosis (build-up 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.

The facility had a census of 54 residents. The sample included 21 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for Resident (R)28. This placed the resident at risk for inadequate nutrition. Findings included: - On 04/11/22 at 11:35 AM, observation revealed Dietary Staff (DS) BB prepared one pureed diet. Dietary Staff BB placed one serving of turkey in a food blender with an unmeasured amount of turkey juice. DS BB stated the juice was approximately two ounces. She then blended to the pureed texture and emptied the pureed turkey onto a plate. DS BB placed one serving of corn bread dressing, which she said was about half a cup, in a food blender, added an unmeasured amount of turkey broth to the pureed texture, then emptied the cornbread dressing onto a plate. Dietary Staff BB placed one serving of green bean casserole in a food blender, added an unmeasured amount of turkey broth, identified by DS BB as approximately two ounces, then blended to a pureed texture. DS BB placed one serving of hominy with 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.