Orchard Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents, with six residents observed for accidents and hazards. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards when multiple residents had lighters in their rooms. Additionally, R45 had unsecured medications and R52 had an unsecured 1.75-liter bottle of vodka along with firecrackers and a two-inch pocketknife. Additionally, the facility failed to store chemicals in a secure safe manner. These failures placed the affected residents at risk for preventable accidents and related injuries. Findings included: - During an observation on 03/26/25 at 11:42 AM across from room [ROOM NUMBER] there was a workstation with a sink and an unlocked cupboard under the sink that had a spring-loaded mouse trap, a full gallon bottle of drain cleaner, a gallon bottle of disinfectant cleaner with approximately 200 ml of clear liquid in the bottle, and a one-quart spray bottle 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 reported a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to ensure staff utilized acceptable infection control practices to mitigate the spread of infections when staff failed to cover clean clothes left in the folding area, and under areas with noted debris and insulation. The facility staff failed to utilize enhanced barrier precautions (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing a dressing change for Resident (R) 52 and additionally failed to use EBP for R39 when staff administered a tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). The facility further failed to use proper hand hygiene and standard infection control practices for R14 and R18 when staff failed to complete proper hand hygiene and cleansing during peri-care. This deficient practice had the potential to spread possible infections to the residents 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.

The facility reported a census of 66 residents which included a sample of three residents identified by the facility with Medicare Part A stay termination of benefits before exhaustion of Medicare Part A 100-day benefit period. Based on interviews and record review, the facility failed to provide two residents with the Centers for Medicare and Medicaid Services (CMS) form CMS- 10055 Skilled Nursing Facility Advanced Beneficiary Notice [ABN], which provides the recipient with the information related to the right to choose continued services and associated charges for continued skilled services after termination of Medicare Part A services for Resident (R) 13 and R121. This placed the residents at risk for uninformed decisions and unanticipated costs regarding skilled services. Findings included: - A review of R13's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, revealed the resident started Medicare Part A services on 12/08/24. He was discharged from Medicare A services on 01/03/25 and remained in the facility. The facility did not provide the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 66 residents. The sample included 18 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to two residents, Resident (R) 28, and R69, and/or their representative at the time of the residents' transfers to the hospital. This placed the residents at risk for impaired ability to return to the facility in the same room. Findings included: - R28's Electronic Health Record (EHR) docuemnted R28 was admitted to the hospital on [DATE]. R28's EMR lacked evidence the facility provided a bed hold notice for the transfer/discharge to the hospital. R69's EHR documented that R69 was admitted to the hospital on [DATE]. R69's EMR lacked evidence the facility provided a bed hold notice for the transfer/discharge to the hospital. During an interview on 03/31/25 at 05:36 AM, Licensed Nurse (LN) O reported that she would not complete a bed hold form when a resident was transferred to the hospital.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 66 with 18 in the sample, which included Resident (R)2 reviewed for Preadmission Screening and Resident Review (PASARR). Based on observation, interviews, and record review the facility failed to obtain a PASARR Level 2 for R2. This placed R2 at risk for unidentified care needs and impaired quality of care. Findings include: - The Electronic Health Records (EHR) for R2 included diagnoses of suicidal ideations (the thoughts, fantasies, or contemplations about ending one's own life), auditory hallucinations (sensory experiences of hearing sounds that are not present in the external environment), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), generalized anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry about a wide range of events or activities), schizoaffective disorder (a mental health…

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 reported a census of 66 residents. The sample included 18 residents reviewed for comprehensive care plans. Based on observation, interview, and record review the facility failed to review and revise comprehensive care plans for Residents (R)43 related to bathing. This placed the resident at risk for poor hygiene due to uncommunicated care needs. Findings Included: - R43's Electronic Health Records (EHR) Physician Orders (POS), dated 01/07/25 documented diagnoses which included disorientation (confusion), dementia (condition that causes a decline in memory, thinking, and other cognitive abilities making it harder to perform everyday tasks) with behavioral disturbances, generalized anxiety disorder (mental health disorder characterized by feelings of left artificial knee joint replacement, atrial fibrillation (irregular heartbeat), insomnia, (inability to sleep), and psychotic disorder (a mental disorder characterized by disconnection from reality) with hallucinations (a perception of having seen,…

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 reported a census of 66 residents. The sample included 18 residents with seven dependent residents reviewed for activities of daily living (ADLs). Based on observation, interview, and record review the facility failed to provide necessary services in accordance with their preferences and in keeping with their plan of care for Resident (R)43, R51, and R28. This placed the affected residents at risk for decreased quality of care. Findings Included: - R43's Electronic Health Records (EHR) Physician Orders (POS), dated 01/07/25 documented diagnoses which included disorientation (confusion), dementia (condition that causes a decline in memory, thinking, and other cognitive abilities making it harder to perform everyday tasks) with behavioral disturbances, generalized anxiety disorder (mental health disorder characterized by feelings of left artificial knee joint replacement, atrial fibrillation (irregular heartbeat), insomnia, (inability to sleep), and psychotic disorder (a mental disorder characterized…

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 reported a census of 66 residents which included 18 residents sampled, which included two residents reviewed for functional equipment. Based on interview, observation, and record review, the facility failed to ensure Resident (R)29 and R2's bed was in safe and operable condition. This deficient practice placed the residents at risk for discomfort and decreased safety. Findings include: - Observation on 03/26/25 at 02:49 PM revealed that R2's bed frame appeared to be broken, and the bed would not sit level. The bed was a crank style. Observation on 03/27/25 at 10:40 AM revealed that the remote R29's bed was under it and stuck in the frame. The sheathing was stripped from the wires the wires were unraveled. The bed rested almost completely on the ground. During an interview on 03/27/25 at 10:40 AM, R29 reported that the bed would go up and down but the head of the bed would not work to be raised or lowered. During an interview on 04/02/25 at 4:00 PM, Maintenance/Housekeeping EE said the remote to R29's bed should have been unplugged for safety and replaced. During 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 reported a census of 66 residents with one resident sampled for sexual abuse. Based on observation, interview and record review, the facility failed to report an allegation of abuse by one Resident (R)1, when he made an allegation of sexual abuse. Findings included: - Review of Resident (R)1's electronic medical record (EMR) revealed a diagnosis of schizoaffective disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations [the apparent perception of something not present] or delusions [a false belief or judgment about external reality], and mood disorder symptoms, such as depression or mania). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He had no delirium or psychosis and had rejection of care and wandering one to three days of the assessment period. He took antipsychotics (medication used to treat psychosis)…

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 reported a census of 60 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - During an initial tour of the kitchen on 09/07/23 at 09:47 AM, the following areas of concern were noted: 1. The inside of the microwave had several areas of dried on food. 2. The dish cart, which held clean plates, had dried on food substances. 3. The shelf above the steam table had dried food debris. 4. A large plastic container of brown sugar had food debris on top of the lid. 5. The reach-in refrigerator had food debris on the bottom. 6. Two wire shelves in the reach-in refrigerator had the protective coating peeling off, making the area unsanitizable. 7. A metal container which held sliced tomatoes and onions in a reach-in refrigerator was not covered. 8. A kitchen drawer containing specialized eating utensils had food debris. 9. A kitchen drawer containing menus had food debris. 10. Five containers 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 reported a census of 60 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline. Findings included: - The PBJ reported by the Centers for Medicare & Medicaid services (CMS) for Fiscal Year (FY) 2023 quarter one (October to December) showed the facility had no licensed nurses in the facility for the entire three-month period from 10/01/22 to 12/31/22. On 09/10/23 at 07:00 PM review of the staff clock in sheets and schedules for the PBJ for the FY quarter one 2023 (Oct to Dec) revealed adequate nurses for 8-hour RN coverage and 24-hour nurses listed every day. The clock in's verified there was no concerns noted with scheduling. On 09/07/23 at 09:17 AM interview with Consultant GG reported when reviewing the PBJ for the FY quarter 1 2023 (Oct to Dec) the report showed they had no licensed nurses in the building for the entire 3-month…

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 reported a census of 60 residents with 18 selected for review. Based on observations, interviews, and record review the facility failed to sanitize a multi-resident use glucometer (a device that measures the amount of sugar in the blood) in an appropriate manner, failed to provide sanitary catheter care of two Residents (R)28 and R15, failed to provide sanitary dressing changes for R53, R64, and R15, failed to maintain oxygen tubing in a sanitary manner for R21, and failed to store personal protective equipment in a sanitary manner. Findings included: - Observation on 09/07/23 at 11:09 AM revealed Licensed Nurse (LN) I obtained blood glucose level from Resident (R) 50 with a glucometer. LN I then obtained an alcohol swab to clean the glucometer. Interview at that time revealed seven residents on the unit required blood glucose levels with the glucometer. LN I stated she did not know of any other method to clean the glucometer. Observation on 09/07/23 at 11:15 AM, revealed LN G was about to obtain a blood glucose level from an unsampled resident. LN G stated that she…

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 reported a census of 60 residents. Based on observation, record review, and interview, the facility failed to provide necessary maintenance services for the kitchen floor and floors on the resident 400 halls and one resident room on 400 hall to provide a safe, functional, and sanitary environment. Findings included: - During an initial tour of the kitchen on 09/07/23 at 09:47 AM, revealed the kitchen floor had multiple areas of broken, cracked, and missing tiles. On 09/12/23 at 10:16 AM, Dietary staff BB confirmed the kitchen floor was in poor condition and needed to be replaced. The facility lacked a policy regarding upkeep of the kitchen floor. The facility failed to provide necessary maintenance services for the kitchen floor to provide a safe, functional, and sanitary environment. - Observation on 09/06/23 at 02:30 PM through 09/12/23 revealed the floors on the resident 400 hall contained multiple areas of discolorations, black streaks, dirt, and accumulation of grime in the corners of doorway thresholds. The floor in a resident room contained six tiles 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 reported a census of 60 residents. Based on interview and record review the facility failed to ensure residents had opportunities for COVID boosters. Findings included: - Review of Resident (R) 15's medical record, immunization tab, revealed the resident received two doses of the COVID vaccine with the last dose received on 04/01/21. The resident signed a COVID declination on 06/21/23 with no other indication that the facility offered the vaccine booster until 06/21/23. Review of R38's immunization medical record revealed the resident received two doses of COVID vaccine with the last dose received 01/29/21. The resident signed a COVID declination on 06/21/23 with no other indication that the facility offered the vaccine booster until 06/21/23. Review of R 24's immunization medical record revealed the resident received two doses of the COVID vaccine with the last dose 01/29/21. The resident signed a COVID declination on 06/21/23 with no other indication that the facility offered the vaccine booster…

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 reported a census of 60 residents with 18 selected for review, which included two residents reviewed for personal property. Based on observation, interview, and record review, the facility failed to ensure a completed inventory for one Resident (R)119. Findings included: - Review of Resident (R)119's Physician Order Sheet, dated 12/02/22, revealed diagnoses included paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) mood disorder, and post-traumatic stress disorder,(PTSD- a psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with 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 reported a census of 60 residents with 18 residents sampled. Based on interview and record review, the facility failed to complete a comprehensive assessment for one Resident (R)50, by the failure to complete triggered Care Area Assessments (CAA). Findings included: - The Physician Order Sheet (POS), dated 08/29/23, for Resident (R)50, included the following diagnoses: major depressive disorder with severe psychotic symptoms (MDD-major mood disorder characterized by a gross impairment in reality), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. He had rejection of care one to three days and received an antipsychotic (drugs used to treat psychosis-related conditions and symptoms) 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 census totaled 60 residents with 18 included in the sample. Based on interview and record review the facility failed to complete discharge tracking assessments when two residents were discharged from the facility. Resident (R) 17, R25. Findings included: - Review of the Electronic Medical Record (EMR) for R17 revealed the resident discharged from the facility on 04/27/23. No Discharge Tracking Minimum Data Set (MDS) was completed for the resident. Review of the EMR for R25 revealed the resident discharged from the facility on 04/24/23. No Discharge MDS was completed for the resident. Interview on 09/11/23 at 2:30 PM Administrative Nurse E reported she did not complete MDS discharge assessments for these residents. Review of the Resident Assessment Instrument User Manual dated 10/19 revealed a Discharge Tracking Assessment is a federally mandated assessment to be completed no later than 14 days following discharge from the facility. The facility failed to complete discharge tracking assessments when two residents were discharged from the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 60 residents with 18 included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for two Residents (R)45 regarding pain and R65 for the lack of communication between the facility and the dialysis center. Findings included: - Resident (R)45's Signed Physician Orders dated 07/01/23 revealed the following diagnoses: osteoporosis with current pathological fracture of right ankle and foot (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), alcohol abuse and dependence, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized…

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 - Resident (R) 21's signed Physician Orders dated 07/01/23 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), morbid obesity (the state or condition of being very fat or overweight), and chronic resp failure (lungs are unable to provide the body with enough oxygen). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required total assistance of two to three staff for all daily cares. The resident had shortness of breath with all activities. The resident required oxygen (O2) and continuous positive airway pressure (CPAP). The Care Area Assessment (CAA) dated 05/14/23 for Activities of daily living (ADL) revealed the resident required…

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 reported a census of 60 residents with 18 residents sampled, including three residents reviewed for Activities of Daily Living (ADL's). Based on observation, interview, and record review, the facility failed to provide appropriate ADL assistance to one dependent Resident (R)28, regarding facial shaving and nail care. Findings included: - The Physician Order Sheet (POS), dated 08/29/23, documented Resident (R)28 had a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He required total assistance of two staff for personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), documented the resident had impaired ADL function related 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 reported a census of 60 residents with 18 selected for review, which included three residents reviewed for urinary tract infection/urinary catheter. Based on observation, interview, and record review, the facility failed to provide sanitary catheter care as ordered by the physician for one Resident (R)15. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/29/23, revealed diagnoses included hemiplegia (weakness on one side of the body), and hemiparesis (paralysis on one side of the body), chronic pain syndrome, cerebral infarction (stroke), heart valve replacement and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was dependent on staff for toileting and had an indwelling catheter. The resident had weakness on one side of his body…

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 census totaled 60 residents with 18 included in the sample, and one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure that Resident (R) 21's oxygen (O2) tubing was maintained and documented, and the resident received the ordered O2 therapy. Findings included: - Resident (R) 21's signed physician orders dated 07/01/23 revealed the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), morbid obesity (the state or condition of being very fat or overweight), chronic respiratory failure (lungs are unable to provide the body with enough oxygen). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.…

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 reported a census of 60 residents with 18 residents sampled, including one resident reviewed for dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney). Based on observation, record review, and interview the facility failed to ensure coordination of care between the dialysis center and the facility, for one Resident (R) 65, regarding a lack of regular dialysis communication sheets, with the facility. Findings included: - Review of Resident (R)65's Electronic Medical Record (EMR), revealed a diagnosis of end stage renal disease (a condition in which the kidneys do not function normally and requires external support to meet the daily requirements of life). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He received dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney)…

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 reported a census of 60 residents with 18 selected for review and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed up on the pharmacy recommendation to complete the Abnormal Involuntary Movement Scale (AIMS) for three Residents (R) 15, R28 and R50 to ensure the residents did not experience adverse effects from psychoactive (medications used to treat severe mental disorders) medications. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/29/23, revealed diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), hemiplegia (weakness on one side of the body), hemiparesis (paralysis on one side of the body), and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (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 reported a census of 60 residents with 18 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor three Residents (R)15, R 28 and R 50 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms). Findings included: - The Physician Order Sheet (POS), dated 08/29/23, for Resident (R)28, documented a diagnosis of major depressive disorder (MDD-major mood disorder). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He received an antipsychotic (drugs used to treat psychosis-related conditions and symptoms) seven of the seven days of the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 06/23/23, documented the resident took medications with a black box warning (BBW--a warning required certain 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 reported a census of 65 residents who all received their meals from one main kitchen. Based on observation, interview and record review the facility failed to prepare and serve food in a sanitary manner by the observation of roaches in the food prep area, on steam table and on plates used for the noon meal. This had the potential to affect all residents in the facility. Findings included: - Observation on 11/18/21 at approximately 08:00 AM revealed a small live cockroach crawling off a tray of water and coffee dietary staff brought to the conference room. Observation on 11/22/21 at approximately 09:30 to 09:45 AM revealed three small, live cock cockroaches crawling in the hallway outside of the kitchen. During tour of the kitchen on 11/22/21 at 11:30 AM Dietary Staff C pureed salisbury steak and vegetables for four residents. During the process of pureeing the vegetables a live cockroach crawled across the cutting board where the utensils used by the staff and soiled dishes sat. DS C removed the cockroach using a napkin after carrying the cutting board to the sink.…

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 reported a census of 65 residents. Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure the facility was free of live cockroaches. Findings included: - Observation on 11/18/21 at approximately 08:00 AM revealed a small live cockroach crawling off a tray of water and coffee dietary staff brought to the conference room. Observation on 11/22/21 at approximately 09:30 - 09:45 AM revealed three small, live cock cockroaches crawling in the hallway outside of the kitchen and near the east nurses' station. Observation during tour of the kitchen on 11/22/21 at 11:30 AM while dietary staff C pureed Salisbury steak and vegetables for four residents, a live cockroach crawled across a cutting board including utensils being used by the staff. Another cockroach crawled on the floor and was killed by the surveyor. During meal service, two cockroaches crawled across and in between the plates, another large cockroach crawled across the steam table in front of the food, another cockroach was on the side of 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 census totaled 65 residents with 11 residents reviewed for Minimum Data Set assessments later than 120 days, with no assessment completed. Based on interview and record review the facility failed to complete Quarterly MDS assessments as required by State and Federal regulations not less frequently than once every three months for 10 residents who had quarterly assessments due and not completed. Resident (R) 7, R9, R8, R3, R6, R5, R2, R14 and R4. Findings included: - On 11/22/21 at 10:46 AM the Electronic Medical Record revealed the following Quarterly MDS assessments no completed for the following residents and dates due: R3's quarterly MDS due on 10/05/21, not completed. R2's quarterly MDS due on 10/05/21, not completed. R4's quarterly MDS due on 10/07/21, not completed. R5's quarterly MDS due on 10/07/21, not completed. R6's quarterly MDS due on 10/08/21, not completed. R7's quarterly MDS due on 10/14/21, not completed. R14's quarterly MDS due on 10/14/21, not completed. R9's quarterly MDS due on 10/15/21, not completed. R8's quarterly MDS due on 10/15/21, not…

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 reported a census of 65 residents with 16 included in the sample. Based on observation, interview, and record review the facility failed to include the resident in the development and planning of the resident's care plan and failed to have regular care plan meetings for Resident (R) 49. Findings included: - Resident (R) 49's signed Physician Orders dated 10/14/21 revealed the following diagnoses: diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), low vision both eyes (unable to see because of injury, disease, or a congenital condition). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had no behaviors. The resident required supervision and limited assistance 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 census totaled 65 residents with 11 reviewed for Minimum Data Set assessments later than 120 days with no assessment completed. Based on interview and record review the facility failed to complete a comprehensive MDS assessment by the due date of 10/19/21 for Resident (R)10. Findings included: - Review of R10's Electronic Medical Record revealed the resident had a Quarterly Minimum Data Set (MDS) completed on 07/19/21. The resident had an annual MDS started on 10/19/21, however the assessment was not completed, as required. Interview on 11/22/21 at 11:00 AM Administrative Staff A reported the facility had no MDS coordinator but hired one who will start that position on 12/11/21. She thought another facility was helping part time to do the MDS assessments and would have to contact the corporate office to let them know assessments were not being done. Review of the July 2017 facility policy named MDS Completion and Submission Time Frame revealed the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes.…

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 reported a census of 65 residents with 16 sampled which included two for respiratory care. Based on observation, interview, and record review the facility failed to provide safe and sanitary care for oxygen tubing to help prevent the development and transmission of diseases and infections for both Resident (R) 64, and R69. Findings Included: - R64's Electronic Health Record (EHR) documented the diagnosis of chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 02/08/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental status (BIMS) of 15, indicating intact cognition. The 02/02/21 Care Plan documented R64 had COPD. Staff were to monitor R64 for signs or symptoms of acute respiratory insufficiency and respiratory infection. R64 had oxygen (O2) therapy, as needed (PRN). The EHR documented on 02/01/21 R64 had an order for O2 therapy, O2 tubing care, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility census totaled 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide pharmaceutical services by the failue of staff to administer insulin (a hormone which regulates blood sugar) according to the physician orders to Resident (R)51. Findings Included: - The Physician Orders in the Electronic Health Record (EHR) documented R51 with a diagnosis of type 2 diabetes (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R51 received insulin daily. The Quarterly MDS dated 09/24/21 documented a BIMS score of six, which indicated severely impaired cognition. R51 received insulin daily. The 03/19/2021 Care Plan documented R51 had diabetes mellitus. Interventions…

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 reported a census of 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified and reported missing documentation concerning the lack of administration of Tresiba (very long acting insulin) insulin (a hormone which regulates blood sugar) for R51 and missing blood sugar documentation for R11. Findings included: - The Physician Orders in the Electronic Health Record (EHR) documented R51 with a diagnosis of type 2 diabetes (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R51 received insulin daily. The Quarterly MDS dated 09/24/21 documented a BIMS score of six, which indicated severely impaired cognition. R51 received insulin daily.…

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 census totaled 65 residents, with 16 included in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the adequate monitoring of insulin, when staff did not obtain physician ordered blood glucose (blood sugar) levels for three diabetic residents: Resident (R)11, R29 and R49. The facility also failed to ensure adequate monitoring of antihypertensive medication when staff did not obtain pulses prior to administration of Carvedilol for R29. Findings included: - The signed November 2020 Physician Order Summary (POS) for R11 revealed a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin.) The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and R11 received insulin daily in the seven-day review period. The Quarterly 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 reported a census of 65 residents. Based on observation, record review, and interview the facility failed to properly date an opened tuberculin vial (a purified protein derivative used in a skin test to help diagnose tuberculosis infection in persons at increased risk of developing active disease). The facility further failed to remove a package of two promethazine (used to treat allergy symptoms, nausea and vomiting, or used a sedative to help with sleep) suppositories (medication that is inserted into the rectum to be broken down and absorbed by the body) with an expiration date of [DATE]. Findings included: - An observation of the facility's east and west medication rooms on [DATE] at 09:25 AM revealed a tuberculin test vial opened with no date on the box or vial in the east medication room and a package of two promethazine suppositories with an expiration date of [DATE] in the west medication room. On [DATE] at 01:36 PM Administrative Nurse B stated she expected opened vials of medication to be…

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 reported a census of 65 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff use Personal Protective Equipment (PPE) appropriately to reduce the risk of spread of infectious diseases. Findings Included: - On 11/18/21 at 08:11 AM, observation revealed Licensed Nurse (LN) E entered R64's room with just a mask on. R64 was on Transmission Based Precautions (TBP, the second tier of basic infection control and are to be used in addition to Standard Precautions) from her recent hospital stay. LN E entered the room and talked to the resident, put R64's O2 mask on and adjusted it. LN E then left the room and used hand sanitizer from the hall dispenser. There was a sign instructing the staff to don PPE and a PPE supply cart located outsideof R64's room. There were 2 bins in R64's room for trash and linens. With the TBP sign still posted outside of R64's room, on 11/22/21 at 09:30 AM, observation revealed CNA F entered R64's room without donning the proper PPE (gown and gloves). When the CNA F exited the room, she reported she…

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.