Chateau Living Center

Based on observations and interviews the facility failed to maintain an effective pest control management program for 7 (Resident #16, Resident #24, Resident #67, Resident #72, Resident #95, Resident #139, Resident #148) of 7 (Resident #16, Resident #24, Resident #67, Resident #72, Resident #95, Resident #139, Resident #148) sampled resident rooms observed for pests, 1 (Hall C ) of 3 (Hall C, Hall D, Hall E) sampled halls reviewed for environment, and for 2 (Dining Room A, Dining Room B) of 2 (Dining Room A, Dining Room B) sampled dining rooms observed during dining observations. Findings:Observation on 07/21/2025 at 10:30AM revealed a brown flying insect in Resident #148's room.In an interview on 07/21/2025 at 10:47AM, Resident #24 indicated it bothered her that there were flying insects in her room. Observation on 07/21/2025 at 10:48AM revealed brown flying insects in Resident #24's room. Observation on 07/21/2025 at 11:14AM revealed a brown flying insect in Resident #95's room. Observation on 07/21/2025 at 11:26AM revealed two brown flying insects on Resident #67's blanket while…

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 interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by a resident for 1 (Resident #110) of 1 (Resident #110) sampled residents identified to have physically abused residents during a mood and behavior investigation. Findings: Review of the facility's policy and procedure titled, Abuse - Prevention and Prohibition, and dated 03/25/2023 revealed in part, physical abuse included hitting, slapping, pinching, biting, shoving, and kicking. Further review revealed each resident has the right to be free from abuse. Review of Resident #110's incident report dated 07/02/2025 revealed, in part, Resident #110 hit Resident #62 and punched Resident #180 in the chest. Review of S1Administrator's documentation dated 07/02/2025 revealed, in part, Resident #110 slapped Resident #62 on the foot and punched Resident #180 in the upper chest. In an interview on 07/23/2025 at 8:50AM, Resident #62 indicated Resident #110 entered her room and hit her legs several times with a closed fist. Resident #62 further indicated Resident #110…

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 interviews and record reviews, the facility failed to ensure:1. The skilled nurse documented adequate indication for use of an anti-psychotic (medication used to treat psychosis) medication used on an as needed (PRN) basis (Resident #3); and,2. The physician re-evaluated the use of an anti-psychotic used on a PRN basis and documented the rational and duration for an as needed (PRN) anti-psychotic drug (Resident #3). This deficient practice was identified for 1 (Resident #3) of 5 (Resident #3, Resident #16, Resident #98, Resident #110 Resident #119) sampled residents investigated for unnecessary medications. Findings:Review of Resident #3's record revealed diagnoses of, in part, unspecified dementia (condition which caused atrophy of the brain with loss of cognitive function), delusional disorder (condition which caused altered reality), major depressive disorder (condition which caused prolonged episodes of sadness), and psychosis (condition which caused altered reality). Review of Resident #3's July 2025 Physician Order revealed, in part, Haldol 1mg give one tablet by…

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

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's fingernails were maintained for 1 (Resident #174) of 2 (Resident #119, Resident #174) sampled residents investigated for activities of daily living (ADL). Findings:Review of Resident #174's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/21/2025, revealed Resident #174 required substantial/maximal assistance with personal hygiene.Review of Resident #174's Care Plan revealed Resident #174 required staff assistance with ADL care with an initiation date of 10/11/2024. Observation on 07/21/2025 at 10:29AM revealed the fingernails on Resident #174's right and left hands extended past the end of the tip of Resident #174's fingers. Further observation revealed the fingernails on Resident #174's right 3rd finger (middle finger) and 5th finger (the smallest finger or the finger furthest from the thumb) were approximately one-fourth of an inch past Resident #174's fingertips. Observation on 07/22/2025 at 8:24AM revealed the fingernails on Resident #174 right and left hands extended…

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 reviews, the facility failed to ensure chemicals in the beauty shop room were secured and not accessible to wandering residents. Findings:Review of the facility's Wandering Residents List revealed, in part, 11 residents were identified by the facility as at risk for wandering. Observation on 07/21/2025 at 1:05PM revealed the facility's beauty shop room was unlocked, open, and unmonitored. Further observation revealed a container of blue solution labeled Barbicide on the counter not secured. Review of the Barbicide Safety Data Sheet provided by the facility, dated 06/14/2018, revealed, in part, the chemical was irritating to skin and eyes and harmful if swallowed and poison control should be called immediately if ingested. Further review revealed safety glasses and googles should be worn when handling the chemical. In an interview on 07/23/2025 at 12:00PM, S6Housekeeping Supervisor (HS) confirmed the beauty room should be closed and locked when unmonitored or unsupervised. S6HS further confirmed the Barbicide chemical was in the beauty…

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 observations, interviews, and record reviews, the facility failed to have evidence a resident's oxygen tubing was changed weekly for 1 (Resident #74) of 2 (Resident #74, Resident #187) residents reviewed for respiratory care. Findings: Review of the facility's Oxygen Administration Policy and Procedure dated 11/16/2014 revealed, in part, at regular intervals, the facility staff were responsible to check and clean oxygen equipment, masks, tubing and cannula. Review of Resident #74's electronic health record revealed diagnoses of chronic obstructive pulmonary disease with an acute exacerbation (lung disease that blocks air flow) and acute chronic respiratory failure with hypoxia (absence of oxygen in body tissue).Review of Resident #74's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 15 (score of 08-15) which indicated Resident #74 was cognitively intact. Further review revealed Resident #74 required oxygen. Review of Resident #74's physician orders dated 08/13/2024 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 observations and interviews, the facility failed to ensure food was stored in a sanitary manner. Findings:Observation on 07/21/2025 at 8:45AM revealed an employee's frozen drink was present in the facility's freezer. In an interview on 07/21/2025 at 8:46AM, S8Dietary Manager indicated the employee's frozen drink should not have been stored in the facility's freezer. In an interview on 07/21/2025 at 1:20PM, S1Administrator confirmed the employee should not have stored her frozen drink in the facility's freezer. Observation on 07/22/2025 at 12:21PM revealed a bottle of clear liquid labeled with S21Dietary Aide's name and date stored in the facility's freezer. In an interview on 07/22/2025 at 12:22PM, S21Dietary Aide confirmed she had placed her water bottle in the facility's freezer. S21Dietary Aide further indicated she should not have put her bottle of water in the facility's freezer. In an interview on 07/22/2025 at 12:23PM, S8Dietary Manager confirmed S21Dietary Aide should not have put her water in the facility's freezer.

Based on observation and interviews, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #R9) of 1 (Resident #R9) residents reviewed for catheters. Findings: Observation on 04/07/2025 at 8:02AM revealed Resident #R9 was ambulating in her wheelchair on Hall c. Further observation revealed Resident #R9's catheter drainage bag was attached under her wheelchair seat and her yellow urine was visible in the catheter drainage bag. Further observation revealed Resident #R9 called out to S4LPN, and asked for a privacy cover for her catheter drainage bag. Further observation revealed S4LPN responded back to Resident #R9 that she would get her a privacy cover for her catheter drainage bag. S4LPN further indicated to Resident #R9 that she was aware Resident #R9 had requested the privacy cover last week. In an interview on 04/07/2025 at 8:03AM, Resident #R9 indicated she had asked for a privacy cover for her catheter drainage bag last week but had not received one. In an interview on 04/07/2025 at 9:25AM, S4LPN confirmed Resident #R9 had asked for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for resident use for 2 (Medication Cart a, Medication Cart b) of 2 (Medication Cart a, Medication Cart b) medication carts reviewed for medication storage. Findings: Review of the United States Food and Drug Administration's Information Regarding Insulin Storage and Switching Between Products in an Emergency, located on the website https://www.fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency, and current as of 09/19/2017 revealed, in part, open and unopened insulin products contained in vials or cartridges may be left unrefrigerated up to 28 days and continue to work. Review of the Lantus SoloStar Step-by-Step Guide dated 2022, revealed, in part, an opened Lantus pen should be discarded after 28 days. Observation of Medication Cart b on 04/07/2025 at 6:11AM revealed Resident #R11's Insulin Lispro (a medication used 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 observation, interviews, and record reviews, the facility failed to ensure medications were not left unattended at a resident's bedside for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #12) sampled residents investigated for medication storage. Findings: Review of the facility's Medication Pass Guidelines policy and procedure dated 12/04/2017 revealed, in part, nurses should not leave residents with medications in a medication cup. Observation on 04/07/2025 at 2:25AM revealed a medication cup containing 2 unidentified white/round pills were present on Resident #2's bedside table. In an interview on 04/07/2025 at 2:25AM, Resident #2 indicated the two pills on her bedside table were her sleeping pills that were given to her by the nurse last night; however, she did not want the medication at the time so she left them on the side. In an interview on 04/07/2025 at 9:32AM, S2Assistant Director of Nursing (ADON) indicated Resident #2's medication should not have been left in a medication cup on Resident #2's bedside table.

Based on observations and interviews, the facility failed to serve residents' food at an acceptable temperature as required. Findings: In an interview on 04/08/2025 at 8:40AM, Resident #3 indicated the facility's food was always cold. In an interview on 04/08/2025 at 10:14AM, Resident #2 indicated the facility's food was cold when it was served to her in her room. In an interview on 04/08/2025 at 10:17AM, Resident #1 indicated the facility served cold food. Observation on 04/08/2025 at 12:11PM revealed Resident #R14's lunch tray was placed on top of an insulated tray cart (a cart used to help food retain it's temperature as it is transported,) instead of inside the insulated tray cart, as S5Certified Nursing Assistant (CNA) pulled the insulated tray cart down Hall c. On 04/08/2025 at 12:15PM, surveyor collected Resident #R14's tray to be used as a test tray. Upon sampling the food on Resident #14's tray, the chicken, rice, and peas were found to be lukewarm/room temperature. In an interview on 04/08/2025 at 12:20PM, Resident #4 indicated the food at the facility was always cold.…

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 a functional call bell was available for 2 (Resident #2, Resident #R6) of 15 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #R5, Resident #R6, Resident #R7, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #12, Resident #R13, Resident #R14, Resident #R15) residents investigated for functional call bells. Findings: Observation on 04/07/2025 at 2:20AM revealed the door/call light was illuminated above the door to Resident #2 and Resident #R6's room. In an interview on 04/07/2025 at 2:20AM, S5Certified Nursing Assistant (CNA) indicated Resident #2 and Resident #R6's call bell was illuminated above their door because it was broken. In an interview on 04/07/2025 at 2:25AM, Resident #2 indicated her call bell had been broken since Friday, 04/04/2025. Observation on 04/07/2025 at 5:21AM revealed the door/call light was illuminated above the door to Resident #2 and Resident #R6's room. In an interview on 04/08/2025 at 10:11AM, Resident #R6 indicated the call bell had been broken since Friday,…

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 observations and interviews, the facility failed to ensure 1. facility's halls were free of strong unpleasant odors for Hall A and Hall B; and, 2. debris and trash were removed from Resident #1's floor; and 3. a damaged wedge pillow used to reposition Resident #1 was replaced. This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for environment. Findings: Observation on 03/11/2025 at 5:09AM, revealed Hall A had very strong unpleasant odor of urine throughout. Observation on 03/11/2025 at 5:12AM, Hall B had a strong unpleasant odor of trash and urine. Observation on 03/11/2025 at 5:20AM, of Resident #1's room revealed a container, napkins, mints, two plastic bags and chipped paint, wall debris on the floor near Resident #1's bed. Observation on 03/11/2025 at 5:33AM, revealed Resident #1's wedge pillow had pieces of foam missing from it. In an interview on 03/13/2025 at 2:05PM, S1Administrator indicated that Resident #1 floor had trash on it. S1Administrator further indicated Resident #1's room…

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 a Certified Nursing Assistant (CNA) notified the nurse that wound dressings were removed from Resident #1's sacral wound; right gluteal wound; and right ischium ; and, a Licensed Practical Nurse (LPN) ensured Resident #1's heel protector was applied to her left heel. The deficient practice was identified for 1 (Resident #1) of 2 (Resident #1, Resident #3) residents observed for wound care. Findings: Review of the facility's Wound Care policy and procedure, dated 11/26/2024, revealed in part; after observation of the affected skin area, implement standing orders. Further review revealed, in part, Nursing Interventions: Cleansing and dressing as ordered and appropriate; and heel protectors. Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Further review revealed Resident #1 had diagnoses, in part, morbid obesity,…

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 a resident diagnosed with peripheral vascular disease had an appointment for toenail trimming for 1 (Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for foot care. Findings: Review of Resident #3's clinical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnoses , in part, of peripheral vascular disease ( a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Observation on 03/12/2025 at 9:42 AM, revealed Resident #3's left Great toe toenail was unusually long, thick, and curled backwards away from the nail bed. In an interview on 03/12/2025 at 9:42 AM, Resident #3 stated she requested toenail care when she was admitted to the facility. In an interview on 03/12/2025 at 11:56 AM, S11Assistant Director of Nursing (ADON) stated both of Resident #3's great toes toenails were long and thick and needed to be trimmed. In 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 Based on observation, record reviews, and interviews, the facility failed to ensure Certified Nursing Assistants (CNAs) demonstrated competencies for hand hygiene; use of Enhanced Barrier Precautions; proper showering; and and, a Licensed Practical Nurse (LPN) demonstrated competency applying a heel protector when providing care to residents. This deficient practice was identified for 2 (Resident #1, Resident#2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated. Findings: Resident #1 Review of Resident #1's record revealed, in part, an initial admit date of 03/25/2019 with a readmission date of 11/23/2024. Review of Resident #1's March 2025 physician orders revealed, in part, an order dated 08/01/2024, for heel protectors to protect left lateral ankle while in bed, monitor every shift. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2025 revealed, in part, Resident #1 had four stage three pressure injuries and an indwelling…

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 reviews facility failed to maintain an infection prevention and control program for 2 (Resident #1, Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. Findings: Resident #1 Review of Resident #1's physician orders dated March 2024 revealed, in part, Oxygen-Clean Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BIPAP/CPAP) mask (respiratory face mask used for machines that treat sleep apnea) and tubing change every week and in the evening every 24 hours as needed. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2025 revealed, in part, Resident #1 had four stage three pressure injuries and an indwelling urinary catheter. Further review revealed Resident #1 was always incontinent of bowel and bladder. Further review revealed Resident #1 was dependent on staff for toileting hygiene. Review of Resident #1's Care Plan with a target date of 05/03/2025 revealed, in part,…

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, interviews, and record reviews, the facility failed to provide good personal hygiene for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for Activities of Daily Living (ADL) care. Findings: Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, in part, dementia, neuroleptic-induced parkinsonism, and hypertension. Review of Resident #2's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/2025, revealed Resident #2 had Brief Interview for Mental Status (BIMS) Score of 10 which indicated moderate cognitive impairment; required substantial/maximal assistance with shower/bathing and personal hygiene; and was incontinent of bladder and bowel. Observation on 03/11/2025 at 9:11AM, revealed S7Certified Nursing Assistant (CNA) transferred Resident #2 to the shower chair, and rinsed the front of Resident #2's body. S7CNA then gave Resident #2 a soapy rag to wash his own…

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 interviews and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA) was competent in the facility's procedure for elopement risk residents for 1 (S7CNA) of 21 (S3CNA, S6CNA, S7CNA, S11Ward Clerk, S12CNA, S13Licensed Practical Nurse [LPN], S14CNA, S15LPN, S16Restorative Aide, S17CNA, S18CNA, S19LPN, S20LPN, S21LPN, S22CNA, S23LPN, S24CNA, S25CNA, S26CNA, S27LPN, and S28CNA facility employees interviewed for competency as it related to residents at risk for elopement. Findings: Review of the facility's policy with an effective date of 07/31/2019 and titled, Elopement, Resident Policy and Procedure revealed, in part, all staff shall be trained on preventing an elopement. Further review revealed staff training would include risk factors and interventions for prevention of resident elopement. Review of the facility's Elopement Binder located at Nursing Station j revealed a list dated 12/30/2024 of the following residents who required a WanderGuard transmitter and were considered at risk for elopement: Resident #R4 and #R7. Review of the above…

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

Based on record reviews, observation, and interviews the facility failed to ensure a resident was provided privacy during Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted through the skin into the stomach to provide liquid nourishment) feeding care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for resident rights. Findings: Review of the facility's Enteral Nutrition Therapy (Tube Feeding) policy and procedure dated 01/14/2016 revealed, in part, staff should pull privacy screen and drape the resident during care for privacy. Review of the facility's Residents Rights policy and procedure dated 01/2023 revealed, in part, residents have the right to be treated with respect for their personal privacy. Review of Resident #3's record revealed, in part, Resident #3 had a diagnosis of mild intellectual disability. Observation on 08/28/2024 at 11:57 a.m. revealed S7Licensed Practical Nurse (LPN) entered Resident #3's room to perform PEG tube care without closing the door. Further observation revealed S7LPN raised Resident #3'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 reviews, observations, and interviews, the facility failed to ensure staff wore proper protective equipment for Enhanced Barrier Precautions (EBP) during Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted through the skin into the stomach to provide liquid nourishment) feeding care for 1 (Resident #3) of 1 (Resident #3) sampled residents reviewed for PEG tube feeding care. Findings: Review of the facility's Enhanced Barrier Precautions policy and procedure dated 04/01/2024 revealed, in part, EBP was indicated for residents with indwelling medical devices including feeding tubes. Further review revealed staff should wear a gown when performing high contact activity, such as feeding device care, with residents for whom EBP was indicated. Review of Resident #3's medical record revealed, in part, a diagnosis of age-related cognitive decline, moderate protein-calorie malnutrition, and gastrostomy (a surgical hole made in the skin of the abdomen allowing placement of a PEG tube). Review of Resident #3's physician orders dated 08/2024 revealed, in part, 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.

Based on observations and interviews, he facility failed to ensure water from the shower room did not leak into the hallway for 1 (Shower Room A) of 4 (Shower Room A, Shower Room B, Shower Room C, and Shower Room D) shower rooms observed for physical environment. Findings: Observation on 08/27/2024 at 2:44 p.m. revealed a pool of water was present in the hallway outside Shower Room A's doorway. In an interview on 08/27/2024 at 2:45 p.m., S5Staff Developer confirmed there was a pool of water in the hallway outside of Shower Room A's doorway. Observation on 08/27/2024 at 3:45 p.m. revealed a pool of water was present in the hallway outside of Shower Room A's doorway. In an interview on 08/27/2024 at 3:50 p.m., S6Maintenance confirmed there was a pool of water in the hallway outside of Shower Room A's doorway. Observation on 08/27/2024 at 3:51 p.m. revealed, in part, Shower Room A's floor was uneven, and water had pooled into the low areas of the floor and was draining into the hallway. In an interview on 08/27/2024 at 3:52 p.m., S6Maintenance confirmed Shower Room A's floor was…

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

Based on record reviews and interview, the facility failed to accurately revise a plan of care that addressed a resident's skin condition for 1 (Resident #62) of 2 (Resident #62 and Resident #29) sampled residents investigated for pressure ulcers. Findings: Review of Resident #62's Plan of Care revealed, in part, Resident #62 had a plan of care developed on 06/16/2024 for impaired skin integrity related to irritation/excoriation to Resident #62's sacral area. Further review revealed a revision to Resident #62 impaired skin integrity plan of care on 07/15/2024 indicating Resident #62 now had a stage III pressure ulcer to the sacral area. Review of Resident #62's wound assessment nursing notes dated 07/02/2024 revealed, in part, Resident #62 had a stage III pressure ulcer with slough to the sacral area. In an interview on 07/24/2024 at 10:30 a.m., S2Corporate Nurse confirmed Resident's #62's sacral wound was staged as a stage III on 07/02/2024 and not 07/15/2024 as indicated on Resident #62's care plan. S2Corportate Nurse further confirmed Resident #62's care plan revision was…

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

Based on record reviews, observation, and interviews, the facility failed to ensure discontinued and expired medication was stored properly and was not available for resident use for 1 ( Medication {Med} cart a) of 4 (Med Cart a, Med Cart b, Med Cart c, and Med Cart d) medication carts observed for expired medications. Findings: Review of the facility's Disposal and Destruction of Medications policy and procedure dated 6/17/2024 revealed, in part, controlled medications that were discontinued would be removed from the medication cart with the individual controlled drug administration record form and retained in a securely locked area with restricted access until destroyed. Review of Resident #7's physician orders revealed Norco 5-325 mg tablets were discontinued on 08/28/2023. Observation of Med Cart a on 07/22/2024 at 1:49 p.m. revealed Resident #7's blister packet of Norco ( a controlled medication used to treat pain ) 5-325 milligrams (mg) with 5 tablets present. Further observation revealed Resident #7's Norco 5-325 mg blister packet had an expiration date of 06/06/2024. In 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 Based on record reviews and interviews, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) was accurately completed to reflect a resident's diagnosis of mental illness for 1 (Resident #121) of 1 (Resident #121) sampled residents reviewed for PASARR. Findings: Resident #121 was admitted to the facility on [DATE] with diagnoses of, in part, Major Depressive and Bipolar Disorder Review of Resident #121's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/2024 revealed, in part, Resident #121 had diagnoses of Depression and Bipolar and was taking antidepressants daily. Review of Resident #121's Psychology Consult dated 06/26/2024 revealed, in part, Resident #121 was referred for psychiatric evaluation due to having a history of bipolar and major depression with symptoms of anxiety and depression, and for having a history of mental health treatment in the past. Resident #121 does have a history of mental health treatment in the past. Further review…

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, observation, and interviews the facility failed to maintain food on the steam table to at least 135 degrees Fahrenheit (F). Findings: Review of Centers for Medicare and Medicaid Services guidelines revealed, in part, maintain potentially hazardous food and temperature control safety foods at safe temperatures at or above 135 degrees F for hot foods. Observation on 07/23/2024 at 11:15 a.m., revealed there were different types of foods such as hamburger, rice, mashed potatoes, and pureed meat being held on the steam table for lunch. Observation further revealed S23Cook was checking the temperature of the pureed sweet potatoes with their thermometer which revealed and revealed a temperature of 130 degrees F. In an interview on 07/23/2024 at 11:16 a.m., S23Cook indicated the pureed sweet potatoes were 130 degrees F. In an interview on 07/23/2024 at 11:30 a.m., S9Dietary Supervisor indicated the steam table should hold the foods at temperature no lower than 135 degrees F. In an interview on 07/24/2024 at 11:35am, S1Administrator indicated the temperature 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to: 1. Ensure the facility's policy was followed by failing to complete a Braden skin risk assessment upon re-admission as required for 1 (Resident #62) of 2 (Resident #62 and Resident #29) sampled residents investigated for pressure ulcer; 2. Ensure a resident's pressure ulcer status was accurately documented for 1 (Resident #62) of 2 (Resident #62 and Resident #29) sampled residents investigated for pressure ulcers, and; 3. Ensure Resident #29's pressure ulcer prevention/treatment interventions were implemented for 1 (Rsident #29) of 2 (Resident #29 and Resident #62) sampled residents investigated for pressure ulcers. Findings: Review of the facility's Skin Care policy and procedure, with an effective date of 11/25/2014 revealed, in part, all residents will have a Braden skin assessment completed upon admission, re-admission, quarterly, annual, with significant changes and as needed. 1. Review of Resident #62's Minimum Data Set tracker revealed, in…

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 reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 2 of 53 sampled observed for self-administration of medications (Resident #122 and Resident #189). Findings: Review of the facility's Self-Administration of Medications policy dated 12/05/2014 revealed, in part, each resident would be assessed upon admission, quarterly, annual, for any signs of significant change in condition, and as needed for self-administration of medications, if applicable. Further review revealed a physician order would be written indicating it was safe for the Resident to self-administer medication and the Nursing staff would monitor the resident weekly and as needed. Further review of the policy revealed the care plan would also be updated. Resident #122 Review of Resident #122's Minimum Data Set with an Assessment Reference Date of 04/17/2024 revealed, in part, Resident #122 had a Brief Interview for Mental Status score of 8 which indicated Resident #122's cognition was moderately impaired. Observation on 07/22/2024 at…

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

Based on observations and interviews the facility failed to ensure a resident's wheelchair was in good repair and maintained in a sanitary manner for 1 resident (Resident #77) of 3 Residents (Resident #4, Resident #77, and Resident #168) sampled residents reviewed for environment. Findings: Observation on 07/22/2024 at 9:51 a.m., revealed Resident #77's wheelchair had an unknown blackish brownish substance was covering both brake levers. Further observation revealed the arm pad for the right arm of the wheelchair was missing. Observation on 07/23/2024 11:41 a.m. revealed Resident # 77 was rolling himself down the hall and the wheelchair's right arm pad was missing and the left arm pad was torn, which displayed exposed foam. Observation on 07/24/2024 at 10:10 a.m., revealed Resident #77 was in his wheelchair and the right arm pad was missing and the left arm pad was torn, which displaced exposed form. In an interview on 07/24/2024 at 10:14 a.m., S22Licensed Practical Nurse confirmed Resident #77's wheelchair's right arm pad was missing, the left side arm pad was torn, and it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure site care was provided to a peripherally inserted central catheter (PICC) as per professional standards of practice for 1 (Resident #596) of 2 (Resident #177 and Resident #596) sampled residents investigated for PICC site care. Findings: Review of Resident #596's Minimum Data Set with an Assessment Reference Date of 04/11/2024 revealed Resident #596 was receiving intravenous medications. Review of Resident #596's record revealed no documented evidence and the facility was unable to produce documented evidence that PICC site care was provided for the time period of 04/04/2024 through 05/05//2024. In a telephone interview on 07/23/2024 at 9:36 a.m., Resident #596, indicated he was admitted to facility for rehabilitation for knee surgery and antibiotics through a PICC line 04/04/2024 and left the faciity on [DATE]. He further indicated the PICC site was never cleaned or the bandage changed from 04/04/2024 through 05/05/2024. In an interview 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 interview, and record review, the facility failed to notify a resident's representative of a change in condition. This deficient practice was identified for 1 (Resident #268) of 5 (Resident #23, Resident #30, Resident #43, Resident #84, and Resident #268) sampled residents. Findings: Review of Resident #268's Medication Administration Record (MAR) dated September 2023 revealed, in part, Risperdal (a medication used to treat mood disorders) 0.5 milligrams (mg) was not administered on 09/08/2023 and 09/19/2023, Donepezil (a medication used to treat confusion) 10 mg was not administered on 09/19/2023, Fluoxetine (a medication used to treat depression) 20mg was not administered on 09/20/2023. In an interview on 09/202/2023 at 9:51 a.m., S10Licensed Practical Nurse (LPN) stated when Resident #268 refused medications she documented medication not given. In an interview on 09/21/2023 at 10:04 a.m., S10LPN stated Resident #268 refused medications this morning after 2 attempts. There was no documented evidence and the facility did not present any documented evidence that 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 Based on observation, interview, and record review the facility failed to ensure a resident was free from unnecessary isolation without results of a positive culture for 1 (Resident #518) of 1 (Resident #518) sampled resident for transmission based precautions. Findings: Review of the facility's Isolation Policy and Procedure revealed, in part, the resident will be isolated only to the degree necessary to isolate the infecting organism. Further review revealed, in part, a resident will be discharged from isolation when deemed appropriate by physician or negative culture is obtained. Review of Resident #518's medical record revealed, in part, Resident #518 was admitted to the facility on [DATE]. Review of Resident #518's stool for clostridium difficile (C. diff) result dated 09/10/2023 revealed, in part, C. diff antigen and C. diff toxins was negative. In an interview on 09/18/2023 at 11:45 a.m., Resident #518 stated she doesn't know why she was on isolation. In an interview on 09/21/2023 at 10:20 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (Resident #48 and Resident #53) of 2 (Resident #48 and Resident #53) sampled residents reviewed for PASARR. Findings: Resident #48 Review of Resident #48's medical record revealed, in part, Resident #48 was readmitted to the facility on [DATE]. Review of Resident #48's Level 1 Pre-admission Screening and Resident Review dated 09/24/2019 revealed, in part, Resident #48 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review. Review of Resident #48's diagnosis list revealed, in part, an active diagnosis of unspecified psychosis with an onset date of 10/17/2020, major depressive disorder with an onset date of 06/24/2020, and anxiety disorder with an onset date of 04/08/2020. Review of Resident #48's Minimum Data Set (MDS) with an Assessment…

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 reviews the facility failed to: 1. Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) care was completed as ordered for 1 (Resident #22) of 1 (Resident #22) sampled residents investigated for catheter care; and 2. Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) was changed monthly as ordered for 1 (Resident #22) of 1 (Resident #22) sampled residents investigated for catheter care. Findings: Review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/2023 revealed, in part, Resident #22 had an indwelling catheter. Review of Resident #22's physician orders dated September 2023 revealed, in part, suprapubic stoma cleanse with normal saline, pat dry, apply cover with T-Drain secure with tape daily and change suprapubic catheter monthly. Review of Resident #22's Medication Administration Record (MAR) revealed, in part, Resident #22'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, observation, and interview the facility failed to ensure a resident's oxygen tubing and nebulizer tubing was dated and stored properly when not in use for 2 (Resident #20 and Resident #668) of 2 residents (Resident #20 and Resident #668) reviewed for respiratory care. Findings: Resident #20 Review of Resident #20's medical record revealed, in part, a diagnosis of Acute Respiratory Failure with hypoxia and acute pulmonary edema. Review of Resident #20's nursing notes revealed, in part, Resident #20 was started on oxygen on 09/14/2023 due to a change in condition. Review of Resident #20 September 2023 Physician Orders revealed, in part, an order for oxygen at 2 liters per nasal cannula as needed and to change nasal cannula every week. Observation on 09/18/2023 at 10:15 a.m. revealed, in part, Resident #20 oxygen tubing was not contained in a plastic bag and was not dated. Observation on 09/18/2023 at 11:40 a.m. revealed, in part, Resident #20 oxygen tubing was not contained in a plastic bag and was not dated. Observation further revealed Resident #20's tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's medications were available to be administered as ordered for 1 (Resident #159) of 4 (Resident #14, Resident #121, Resident #159, and Resident #268) sampled residents investigated for mood and behavior. Findings: Review of Medication Administration policy revealed, in part, the facility should notify the pharmacy immediately to fill the order during regular pharmacy hours. Further review revealed, in part, after hours, retrieve the medication from the emergency medication kit. Further review revealed if the medication is not available in the emergency medication kit, alert the Charge Nurse, the physician/provider for additional orders if appropriate, and contact the on-call Pharmacist for further instruction. Review of Resident #159's Physician Telephone Orders, revealed, an order with a start date 09/15/2023 that read Xanax (a medication used to treat anxiety) 0.25 milligrams (mg) by mouth three times a day. Review of 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 Based on record review and interview, the facility failed to ensure a resident's medication administration was documented accurately for 1 (Resident #159) of 4 (Resident #14, Resident #121, Resident #159, and Resident #268) sampled residents investigated for mood and behavior. Findings: Review of Resident #159's Minimum Data Set with an Assessment Reference Date of 08/23/2023 revealed, in part, Resident #159 had a Brief Interview for Mental Status score of 15 which indicated Resident #159 was cognitively intact. Further review revealed Resident #159 had diagnoses of Anxiety Disorder, Depression, Bipolar Disorder, and Schizophrenia. Review of Resident #159's Physician Telephone Orders revealed, in part, an order for Resident #159 to receive Xanax (an antianxiety medication) 0.25 milligram (mg) tablet by mouth three times a day with a start date of 09/15/2023. In an interview on 09/18/2023 at 12:20 p.m., Resident #159 stated she had an anxiety disorder, and she struggled with sleeping ever since her brother passed…

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, record reviews and interviews, the facility failed to have a written order for the physical restraint for 1 (Resident #132) of 3 (Resident #67, Resident #70 and Resident #132) sampled residents reviewed for restraints. Findings: Review of Restraint/Safety Devices Policy and procedure revealed, in part, each resident has the right to be free from any physical restraint imposed for purposes of discipline or convenience and is not required to treat the resident's medical symptoms. The procedure revealed, in part, the facility must obtain a physician order for all restraints and/or safety devices. Review of Resident #132's medical record revealed, Resident #132 was admitted to the facility on [DATE] with diagnoses of dementia, pain, history of falling, insomnia, and cerebral infarction. Review of Resident #132's medical record revealed the Restraint Consent Form was signed by family representative on 03/08/2023 for consent for use of Geri chair with lap buddy. Review of Resident #132's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to: 1. Ensure a resident's interventions were updated after a fall for 1 (Resident #58) of 3 (Resident #53, Resident #56, and Resident #58) sampled residents reviewed for falls; and 2. Utilize a communication board as indicated in care plan for 1 (Resident #80) of 2 (Resident #48 and Resident #80) sampled residents reviewed for communication. Findings: Review of the facility's Incident and Accident Policy and Procedure revealed, in part, the Director of Nursing (DON) or designee should discuss all accidents daily including intervention and update plan of care. Review of Resident #58's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/16/2023 revealed, in part, Resident #58 had a Brief Interview Mental Status (BIMS) of 13, which indicated Resident #58 was cognitively intact. Review of Resident #58's care plan revealed, in part, Resident #58 was at risk for falls. Further review of Resident #58's care plan revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident with a newly developed stage 2 pressure ulcer was assessed in a timely manner by a registered nurse for 1 (Resident #23) of the 3 residents (Resident #1, Resident #23, and Resident #30) review for skin conditions/pressure ulcer care. Findings: Review of Resident #23 medical records revealed, in part, Resident #23 was admitted to the facility on [DATE]. Current diagnosis list include Diabetes, Hemiplegia due to cerebrovascular accident, and history of pressure ulcers. In an interview on 09/18/2023 at 10:30 a.m., Resident #23 complained of pain and soreness to her buttocks due to a yeast rash. Resident stated the pain is increasing and the skin on her buttocks may be broken. Observation on 09/19/2023 at 9:43 a.m. during incontinence care revealed, in part, redness to Resident #23's groin and buttocks. Further observation revealed a break in the skin to Resident #23's left buttock. In an interview on 09/19/2023 at 9:46…

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 ensure proper positioning of a resident receiving a tube feeding for 1 (Resident #88) of 1 resident investigated for services related to tube feedings. Findings: Review of the facility's Enteral Nutritional Therapy (Tube Feeding) Policy and Procedure revealed, in part, check position of tube by placing the stethoscope over the stomach and instill a small amount of air into enteral feeding tube and listen for air to enter the stomach. Review of Resident #88's medical record revealed, in part, Resident #88 admitted to the facility on [DATE] with diagnosis of dysphagia and gastrostomy status. Review of Resident #88's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2023 revealed, in part, Resident #88 had a feeding tube. Review of Resident #88's Comprehensive Care Plan revealed, in part, an intervention to check placement before initiating my feedings. Observation on 09/19/2023 at 1:06 p.m., revealed S22Licensed…

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 interviews, the facility failed to maintain communication with a dialysis center for 1 (Resident #49) of 1 (Resident #49) sampled resident investigated for dialysis services. Findings: Review of Dialysis Resident's Care Policy and Procedure revealed, in part a dialysis communication form should be reviewed when the resident returned from dialysis. Review of Resident #49's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/2023 revealed, in part, resident received dialysis and had a diagnosis of chronic kidney disease stage 3. Review of Resident #49's current physician orders, revealed an order for dialysis on Monday, Wednesday, and Friday. Further review revealed, in part, the only dialysis communication sheet presented by staff was dated 07/26/2023. In an interview on 09/21/2023 at 2:15 p.m., S18Licensed Practical Nurse stated Resident #49 went to dialysis and she did not know where any other Dialysis Communication Forms were, if they were not in the chart. In an interview on 09/21/2023 at 2:45 p.m., S4Assistant…

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: 1. Ensure food was not stored on the freezer floor; 2. Ensure expired beverages were not available for resident consumption; 3. Ensure kitchen appliances were free of a buildup of a yellow and brown substance; and, 4. Ensure the flooring of the kitchen was free of a buildup of brown substance under appliances and along the kitchen's baseboards. Findings: 1. Observation of the facility's freezer on 09/18/2023 at 12:29 p.m. revealed 2 boxes of sandwich bread were stored on the floor of the freezer. In an interview on 09/18/2023 at 12:30 p.m., S7Dietary Manager confirmed the 2 boxes of sandwich bread should not have been stored on the freezer floor. 2. Observation of the facility's refrigerator on 09/18/2023 at 12:31 p.m. revealed two containers of thickened orange juice with a use by date of 06/09/2023 available for resident's consumption. In an interview on 09/18/2023 at 12:32 p.m., S7Dietary Manager stated the thickened orange juice had been served to residents earlier in the morning. S7Dietary Manager confirmed 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 observations and interviews the facility failed to ensure the resident's ice supply was maintained according to infection control practices for 2 (Ice Chest A and Ice Chest B) of 2 (Ice Chest A and Ice Chest B) observed for infection control practices. Findings: Observation on 09/19/2023 at 9:34 a.m., revealed Resident #118 opened Ice Chest B, grabbed the ice scoop, and scooped ice into his personal cup. While Resident #118 scooped ice out of Ice Chest B, his arm was touching the inside of Ice Chest B. Resident #118 then scooped ice out of Ice Chest B, placed the ice scoop into his personal cup, then placed the remaining ice in the scoop back into Ice Chest B. Observation then revealed Resident #118 placed the ice scoop on the side of Ice Chest B, and left the ice scoop uncontained. Observation on 09/19/2023 at 3:02 p.m., revealed the ice scoop lying next to Ice Chest B uncontained. Observation on 09/20/2023 at 8:30 a.m., revealed the ice scoop lying next to Ice Chest B uncontained. Observation on 09/20/2023 at 11:00 a.m., revealed the ice scoop lying next to Ice Chest B…

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.