Camelot Leisure Living

Based on interview and record review the facility failed to ensure prompt resolution of an allegation of not providing proper Ileostomy care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to initiate a grievance for Resident #1.Findings: Review of the Facility's Policy titled Filing/Grievances/Complaints with a revision date of 01/22/2025 revealed in part.Policy Statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made.Policy Interpretation and Implementation:3. Grievances and/or complaints may be submitted orally or in writing.5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegation and submit a written report of such findings to the administrator within 24 hours of receiving the grievance and/or complaint.7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct…

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

Based on interview and record review, the facility failed to develop a person-centered care plan for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to develop a care plan related to feeding assistance for Resident #2.On 07/16/2025 at 10:39 a.m., review of facility policy titled, Care Plans, Comprehensive Person- Centered, with revision date of 01/15/25, revealed in part. A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A comprehensive, person-centered care plan will. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 07/16/2025 at 10:40 a.m., review of facility policy titled, Activities of Daily Living (ADLs), Supporting, with revision date of 01/15/25, revealed in part. Appropriate care and services will be provided to residents who are unable to carry out ADLs independently, 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.

Based on Observation, interview and record review the facility failed to ensure that a resident who required Ileostomy services received such care consistent with professional standards of practice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to change Resident #1's ileostomy bag as needed.Findings: Review of the Facility's Policy titled Colostomy/Ileostomy Care with a review date of 01/25/2025 revealed in part.Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter.Documentation: The following information should be recorded in the resident's medical record:1. The date and time the colostomy/ileostomy care was provided.2. The name and title of the individual (s) who provided the colostomy/ileostomy care.6. The signature and title of the person recording the data.Reporting: Report other information in accordance with facility's policy and professional standards of practice.Review of Resident #1's medical record revealed an admit date of 04/20/2022…

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

Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 3 (Resident #10, Resident #17 and Resident #273) of 35 residents reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings: Review of a Facility Policy titled Oxygen Administration with a revision date of 12/02/2024, revealed in part . All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and PRN. All tubing and bottles are to be labeled each week when changed. When the tubing I not being used, it should be stored properly in a zip lock bag. Humidifiers are not required but are permitted with oxygen flow of 1-2 LPM. Resident #273 Review of Resident #273's medical record revealed an admit date of 02/06/2025 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Type 2…

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

Based on observation, interview, and record review the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by: 1. Failing to ensure an insulin vial was labeled with the date it was opened; 2. Failing to maintain accurate and complete documentation for medications in the emergency kit; 3. Having a loose pill in 1 (Cart A) of 1 medication cart checked for safe and secure storage; 4. Failing to ensure expired medications were not available for use; 5. Failing to document administration of controlled substances; 6. Failing to ensure a narcotic record included the strength of the medication; and 7. Failing to discard a controlled substance when it was discontinued. Findings: Review of the facility's policy entitled Insulin Administration dated 01/15/2025 revealed, in part .if opening a new vial, record the expiration date and time on the vial, and follow the manufacturer's recommendations for expiration after opening. Lantus insulin vials expire 28 days after opening. Review of the facility's undated policy entitled Emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services. The facility failed to ensure meals were served timely according to the meal times posted. This deficient practice had the potential to affect the 62 residents that received meals from the facility kitchen. Findings: Review of the facility's Meal Times revealed the following in part: Dining Room: Breakfast 07:30 a.m., Lunch 11:30 a.m., and Supper 4:30p.m. Hall Trays (Cart): Breakfast 7:45 a.m., Lunch 12:00 p.m , and Supper 5:00p.m. Review of the facility's policy titled Frequency of Meals dated 06/2003 read in part . 1. At least three meals or their equivalent are served daily, at regular times. Observation on 02/17/2025 at 12:35 p.m. revealed kitchen staff began to serve lunch to residents in the dining room. Observation revealed the lunch meal service began 1 hour and 5 minutes past the posted lunch meal service time.…

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

Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 11 (#6, #7, #10, #12, #15, #26, #30, #45, #55, #61, and #224) of 11 Residents who were ordered and served pureed diets. Findings: Record Review of the facility's current, undated policy titled Standardized Recipes read in part . Standardized recipes shall be developed and used in preparation of foods. Record Review of the facility's current, undated Cook Job Description read in part . Responsibilities: Follows menu and recipes to prepare food. Record Review of the facility's approved 2024 Fall/Winter Lunch Menu revealed the facility was on Week: 3, Day: Monday: Red beans and Sausage, Steamed Rice, Club Spinach, Cornbread, Caramel Sour Cream Cake for Dessert, and Beverage/Water. Alternate Menu item: Beef Patty (hamburger steak). Record Review of the facility's approved recipe for Pureed steamed rice read in part . Ingredients: Serving size 15: 11.25 ½ cups Seamed Rice, 1 cup and 1 tablespoon of Whole Milk, and ½ cup and 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. failing to ensure staff decontaminated reusable medical equipment between residents, 2. failing to ensure staff washed their hands or applied an alcohol-based hand rub before and after direct contact with residents, 3. failing to ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #9) of 1 resident sampled for Dialysis, 4. failing to ensure oxygen was properly stored in a sanitary manner that prevented the transmission of infection. Findings: Review of the facility's policy entitled Cleaning and Disinfection of Resident-Care Items and Equipment dated 01/13/2025 revealed, in part .Reusable resident care equipment will be decontaminated between residents. Review of the facility's undated policy entitled Infection Control…

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

Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#32 and #19) of 2 Residents reviewed for dignity. The facility failed to ensure: 1. Resident #32, who was seated at a table with another Resident, was served his meal at the same time; and 2. Resident #19 was free from facial hair. Findings: Review of the facility's policy titled Quality of Life- Dignity dated 01/15/2025 read in part . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individually. 1. Residents shall be treated with dignity and respect at all times. 3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Resident #32 Observation on 02/18/2025 at 11:58 a.m. revealed all residents seated in the dining room with the exception of Resident #32 had been served their lunch meal tray. Interview on 02/18/2025 at 11:58 a.m. with S15 CNA revealed…

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

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for 1 (#72) of 3 (#49, #71, and #72) closed records reviewed. Findings: Record Review on 02/20/2025 of the facility's policy dated 01/15/2025 titled Change in Resident's Condition or Status read in part Policy statement: Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.) Policy: 1.The nurse will notify the resident's Physician or physician on call when they there has been a (an): a. Accident or incident involving the resident d. Significant change in resident's physical/emotional/mental condition. Review of Resident #72's medical record revealed an admit date of 12/06/2024 with diagnoses that included: Heart Failure, Coronary Angioplasty Implant and Graft, Essential Hypertension, Type 2 Diabetes Mellitus, and Dementia. Review 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.

Based on observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records. Findings: On 02/20/2025, review of the facility's policy entitled Electronic Medical Records dated 12/23/2024 revealed, in part .computer screens with resident's information will be placed in privacy mode or covered when the employee is not present. Observation on 02/19/2025 at 9:02 a.m. revealed Cart A in Hall A with the electronic medical record (EMR) screen open and visible. There was no employee present. The surveyor remained with Cart A until a staff member approached Cart A. The staff member identified herself as S7LPN. An interview on 02/19/2025 at 9:15 a.m. with S7LPN confirmed she was currently using Cart A to provide medications to residents on Hall A. S7LPN confirmed the computer screen with resident's information was not closed when she was away from the medication cart, but should have been. An interview 02/19/2025 at 9:40 a.m. with S6ADON confirmed computer screens with resident information should be closed and not visible when staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon discharge for 1 (Resident #28) of 1 resident sampled for Resident Assessment. Findings: Record review revealed Resident #28 was admitted on [DATE] and discharged on 12/14/2024. Review of Resident #28's MDS record revealed no Discharge MDS assessment. An interview on 02/19/2025 at 1:00 p.m. with S6ADON confirmed she was responsible for completion of MDS assessments. S6ADON confirmed she did not complete a Discharge MDS assessment when Resident #28 was discharged , but should have. An interview on 02/19/2025 at 2:52 p.m. with S6ADON revealed she had submitted a Discharge MDS assessment for Resident #28. She provided a CMS Submission Report dated 02/19/2025 at 3:46 p.m. which revealed, in part .Target date of 12/14/2024 .assessment completed late, more than 14 days after the Assessment Reference Date (ARD).

Based on record review and interview the facility failed to complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 1 (#7) of 35 sampled resident's. Findings: Record Review of the facility's current policy titled MDS dated 01/15/2025 read in part . Our facility will complete, conduct, and submit resident assessments in accordance with current federal and state submission timeframes. Record Review of Resident #7's medical record revealed an admission date of 03/25/2019. Resident #7 had diagnoses that included in part . Parkinson's Disease, Unspecified Psychosis, and Depression. Record Review of a MDS State Optional Assessment with ARD of 12/17/2024 revealed Resident #7's BIMS was not assessed, due to being rarely understood. Resident #7 was dependent on staff with 2 person physical assistance required for Bed Mobility, Transfers, and Toileting, and 1 person physical assistance required for Eating. Record Review of Resident #7's paper chart revealed a written order dated 02/03/2025: Admit resident to hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality. The facility failed to revise the care plan interventions to prevent development of a wound for 1 (Resident #43) of 3 residents (Resident #10, Resident #43, and Resident #223) sampled for skin conditions. Findings: Review of the facility's policy entitled Care Plans, Comprehensive Person-Centered dated 01/15/2025 revealed, in part, the Interdisciplinary Team (IDT) develops and implements a comprehensive, person-centered care plan for each resident. The care plan will describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review revealed Resident #43 was admitted on [DATE] with diagnoses including, in part, Hemiplegia and Hemiparesis following a…

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

Based on observation, interviews and record review the facility failed to ensure the resident's environment remained as free of accidents/ hazards as possible for 1 (#13) resident reviewed for accidents. The facility failed to repair a crack in the parking lot's concrete which resulted in a fall for Resident #13. Total sample size was 35. Findings: Review of Resident #13's medical record revealed an admit date of 09/29/2023 with diagnoses which included in part .Chronic Systolic (Congestive) Heart Failure, Pain Unspecified, Cognitive Communication Deficit, Unspecified Lack of Coordination, and Muscle Weakness. Review of Resident #13's Quarterly MDS with ARD of 12/29/2024 revealed Resident #13 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #13 required supervision or touching assistance for walking 10 feet and partial/moderate assistance for walking 150 feet. The MDS indicated Resident #13's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor) should not be attempted due to a medical condition or safety concerns. Review of Resident #13's…

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

Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 64. Findings: Observation on 02/17/2025 at 12:30 p.m. revealed a form for Daily Nursing Census dated 02/17/2025 was posted on a bulletin board near the nurse's station. Daily staffing hours required, and daily staffing hours provided were not posted on the form. Observation on 02/18/2025 at 9:51 a.m. revealed a form for Daily Nursing Census dated 02/18/2025 was posted on a bulletin board near the nurse's station. Daily staffing hours required, and daily staffing hours provided were not posted on the form. Observation on 02/18/2025 at 12:49 p.m. revealed forms for Daily Nursing Census dated 02/10/2025- 02/18/2025 did not have daily staffing hours required and daily staffing hours provided documented on the forms. Interview on 02/18/2025 at 12:55 p.m. with S2 DON to review 02/10/2025- 02/18/2025 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.

Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 64 residents who resided in the facility. Findings: Review of a facility policy on 02/17/2025 at 2:32 p.m. titled, Garbage and Rubbish Disposal with an unknown original date and a revised date of 06/2023 revealed in part .Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters .5. Garbage and rubbish containing food wastes shall be stored so as to be inaccessible to vermin .8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area . Observation on 02/17/2025 at 8:50 a.m. of the facility dumpster area accompanied by S4 Maintenance Supervisor revealed there were two facility dumpsters. Both dumpster's top lids were opened and both dumpster's side door was opened. Observed several bags of trash piled in both dumpsters. One dumpster's top lid was unable to close properly due to being broken completely off. Observed…

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

Based on record review and interview the facility failed to ensure an allegation of sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the sexual abuse was reported for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility also failed to report a fracture of unknown origin for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents. Findings: Review of the facility's undated policy titled Abuse Investigation and Reporting revealed in part . Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Resident #1 Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included in part . Pain…

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

Based on interview and record review the facility failed to thoroughly investigate and allegation of sexual abuse for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 sampled residents. Findings: Review of the facility's undated policy titled Abuse Investigation and Reporting revealed in part . Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included: Pain Unspecified, Anxiety Disorder Unspecified, Depression Unspecified, Bipolar Disorder Unspecified, and Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Review of Resident #1's admission MDS with an ARD of 11/11/2024 revealed Resident #2 had a BIMS…

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

Based on record review and interview, the facility failed to develop a comprehensive care plan with appropriate interventions after a fall for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents. Findings: Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included in part . Pain Unspecified, Anxiety Disorder Unspecified, Depression Unspecified, Bipolar Disorder Unspecified, and Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Review of Resident #1's admission MDS with an ARD of 11/11/2024 revealed Resident #1 had a BIMS score of 13 indicating intact cognition. The MDS revealed Resident #1 required limited assistance with bed mobility and eating, and extensive assistance with transfers and toilet use. Review of Resident #1's Care Plan with a review date of 02/12/2025 revealed in part .11/12/2024 Fall Actual from wheelchair with interventions that included: Refer to inpatient Behavioral Unit, Return to facility from Emergency Room-not a danger to self at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were maintained in a safe operating condition. The facility failed to ensure the walk-in freezer was functioning properly. The deficient practice had the potential to affect the 52 residents that received meals prepared in the kitchen. Findings: Review of the Facility's policy titled Dietary Equipment read in part . All Kitchen equipment (ovens, refrigerator/freezers, compartment sink, dishwasher, etc.) will be maintained and operated per manufacturer specifications. An observation on 01/08/2023 at 8:50 a.m. accompanied by S9 Dietary Manager revealed a large amount of frost and ice noted on floor on the outside of the walk in freezer entrance door. Inside the freezer a thick layer of frost covered all crates and food boxes. Ice [NAME] were observed hanging from the 2 fans inside the freezer. Upon exiting the freezer, the door did not appear to seal, leaving a small gap, after attempting 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.

Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records regarding code status consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate). The total sample size was 32. Findings: Review of the facility's policy titled Advance Directives read in part . The Director of Nursing Services or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident # 38's Electronic Medical Record revealed an admit date of 01/11/2023 with diagnoses that included: Chronic Kidney Disease, Type 1 Diabetes Mellitus, Atrial Fibrillation, End Stage Renal Disease, and Congestive Heart Failure. Review of Resident #38's Face Sheet revealed the code status as Full Code. Review of Resident #38's 01/2024 Physician's…

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

Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner to residents or his or her responsible parties for 2 (Resident #164 and Resident #165) of 3 (Resident #2, Resident #164 and Resident #165) residents reviewed for Beneficiary Notification. The facility failed to issue NOMNC at least two days prior to the end of Medicare Part A coverage to allow the right to appeal the discharge. Findings: #164 Review of Resident #164's Beneficiary Notification Review revealed in part .Resident #164's Medicare covered Part A services started on 12/04/2023 and his last Medicare Part A covered day was 12/06/2023. Review of Resident #164's NOMNC revealed Resident #164's last covered day of Medicare Part A service was 12/06/2023. Review revealed Resident #164's representative signed the NOMNC on 12/05/2023 to acknowledge she received and understood the notice. #165 Review of Resident #165's Beneficiary Notification Review revealed in part .Resident #165's Medicare covered Part A services started on 06/02/2023 and her last Medicare…

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

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #53) of 1 sampled residents with MDS record over 120 days old. Findings: Review of an MDS transcription report revealed an entry assessment for Resident #53 with an ARD of 04/06/2023 and a discharge assessment with an ARD of 10/24/2023 had been transmitted on 01/09/2023. Interview on 01/10/2024 at 9:19 a.m. with S2 ADON revealed she was responsible for transmitting MDS Assessments. S2 ADON confirmed Resident #53's MDS Assessments had not been transmitted timely and should have been.

Based on observations, record review and interviews the facility failed to implement a comprehensive person-centered care plan for 1 (#33) of 32 sampled residents. The facility failed to ensure Resident #33 was provided a hand roll as directed in the plan of care. Findings: Review of Resident #33's medical records revealed an admit date of 02/28/2020 with diagnoses that included: Essential HTN, Unspecified Dementia, Anxiety Disorders, Dysphagia, Primary Osteoarthritis, and Hyperlipidemia. Review of Resident #33's annual MDS with an ARD of 12/26/2023 revealed a BIMS score of 0, indicating severe cognitive impairment. Resident #33 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, and bathing. Review of Resident #33's Care Plan with a review date of 03/26/2024 revealed in part .Resident requires assistance with hand roll to right hand contracture. Assist with the correct application of braces/splints, assist with the application according to scheduled wearing time, and monitor skin under the devices for irritation or breakdown. An observation 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.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 2 (Resident #40 and Resident #33) of 4 (Resident #2, Resident #29, Resident #33, and Resident #40) residents sampled for ADLs. Findings: Review of the facility policy titled: Fingernail/Toenail Care, revealed in part .Nail care includes daily cleaning and regular trimming. #40 Review of Resident #40's Comprehensive Plan of Care revealed in part . Requires staff assistance with ADL's. Clean/trim fingernails/toenails daily & prn. Review of Resident #40's Physician's Orders revealed in part . 05/01/2023 Nurse to ensure nail care is performed daily. Review of Resident #40's December 2023 MAR revealed in part .Nurse to ensure nail care is performed daily. Observation on 01/08/2024 at 9:50 a.m. revealed contractures to Resident #40's bilateral lower extremities and foot drop to both feet. Resident #40's toe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a winged mattress to his bed was followed for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 63. Findings: Review of Resident #1's clinical record revealed an admit date [DATE] with diagnoses which included: Unspecified Dementia, Seizures, Depressive episodes, Anxiety disorders, Type 1 Diabetes Mellitus, History of Falling and Fracture of the Skull and Facial Bones left side. Review of Resident #1's Quarterly MDS with an ARD of 08/01/2023 revealed a BIMS score of 10 (indicating moderately impaired cognition), and required extensive assistance of one person with transfers and toilet use. Resident #1 had no impairment of ROM to his upper or lower extremities. Review of Resident #1's care plan with a review date of 08/02/2023 revealed he had a fall from his bed on 07/25/2023 with interventions that included a winged mattress to his bed.…

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