Regalcare At Glen Ridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Review (MRR) conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#11, #81) out of five residents reviewed out of a total sample of 34 Residents. Findings include: Review of the facility policy titled Consultant Pharmacist Reports, dated November 2021, indicated the following: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records, and may include collaboration with other members of the interdisciplinary team, collaboration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide dental services for one Resident (#40) out of a total sample of 34 Residents. Specifically, the facility failed to provide dental care to Resident #40 for an improper fitting upper denture that was documented by facility staff.Findings include:Resident #40 was admitted to the facility in July 2024 with diagnoses including chronic obstructive pulmonary disease and, rheumatoid arthritis. Review of Resident #40's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 14 out of 15 indicating intact cognition. Further review of the MDS indicated that the Resident required substantial/maximal assistance for activities of daily living and does not reject care.During an interview on 9/3/25 at 9:14 A.M., Resident #40 said to the surveyor that he/she is waiting to see a dentist because his/her dentures are too big and do not fit and he/she wants them fixed…

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 medical records were completed for two Residents (#101 and #10) out of a total sample of 34 Residents. Specifically, the facility failed to:1. Ensure the medical providers (nurse practitioner and physician's) clinical encounter notes were accessible in the medical record and 2. Ensure that Resident #10's daily care performed by the Certified Nursing Assistants (CNA) was documented as completed.Findings include: 1.Resident #101 was admitted to the facility in June 2022 and has diagnoses that include but are not limited to major depressive disorder, Alzheimer's disease, unspecified dementia and hyperlipidemia. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/25, indicated staff assessed Resident #101 as having severe cognitive impairment, requires substantial/maximal assistance for activities of daily living including bathing, toileting, hygiene and lower body dressing. During review of Resident #101's clinical record…

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, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically,For one Resident (#54) with a wound, out of a total sample of 34 residents, the facility failed to implement Enhanced Barrier Precautions (EBP).The facility failed to handle clean linen to prevent possible contamination.Findings include:Review of the facility assessment, dated August 2025, indicated the following:-The goal of the infection prevention program is to:decrease risk of infection to residents and personal.maintain compliance with state and federal regulations related to infection prevention. Review of the Centers for Disease Control (CDC) website indicated the following, dated June 28, 2024:-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced…

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 records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they developed and implemented a baseline plan of care within 48 hours of his/her admission.Findings include:The Facility's Policy, titled, Baseline Care Plan, dated as revised 04/2022, indicated a baseline plan of care to meet the resident's immediate needs would be developed for each resident within 48 hours of admission.The Facility's Policy, titled Elopement Risk Scale, undated, indicated newly admitted residents would be evaluated by nursing to determine elopement risk, and indicated an interdisciplinary plan of care would be developed for residents assessed at risk for elopement.Resident #1 was admitted to the Facility in May 2025, diagnoses included diabetes, vascular dementia, chronic kidney disease, and dysphagia.Review of Resident #1's admission Elopement Risk Evaluation, dated 05/30/25 and timed 01:01 P.M., indicated he/she was exit seeking, wandering without purpose, wanted to leave the unit, was watching others go through the doors, was only oriented…

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, record, and policy 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 and transmission of communicable diseases and infections. Specifically: 1. The facility failed to ensure the clean laundry room was free from potentially infectious substances. 2a. For Resident #30, the facility failed to ensure that enhanced barrier precautions (EBP) were implemented during treatment of an open wound. 2b. For Resident #45, the facility failed to ensure that EBP was implemented during treatment of his/her feeding tube. 3. The facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task. Findings include: 1. On 8/12/24 at 8:20 A.M., the surveyor observed the laundry room, accompanied by the Director of Laundry Services and Laundry Staff #1. A ceiling tile above one of the four dryers was stained brown and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #30 was admitted to the facility in June 2024 with diagnoses including dementia, acute respiratory failure and cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #30 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #30 has three pressure areas and is at risk for the development of pressure areas. Review of the facility document titled RC Norton Plus Pressure Ulcer Scale and dated 7/9/24, indicated that Resident #30 scored a 10 indicating high risk for pressure ulcer development, Review of the doctor's orders dated August 2024 indicated an order dated 6/11/24 for Pressure relief heel boots to Bilat feet when in bed remove as needed for skin checks or patient tolerance. Further review of the doctor's indicated an order, with an initiation date of 7/9/24 at 11:00 P.M., for Prevalon boot to R heel, offload R heel every shift for R heel pressure ulcer. Review 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 review, observations and interviews, the facility failed to ensure a physician's order was implemented for two Residents (#263, #81) out of a total sample of 46 residents. Specifically, 1. For Resident #263, the facility failed to ensure his/her weight was reported to the Nurse Practitioner (NP) or Medical Doctor (MD) as ordered; 2. For Resident #81, the facility failed to treat and accurately report a Stage 2 wound to the physician. Findings include: 1. Resident #263 was admitted to the facility in August 2023 with diagnoses that included acute and chronic respiratory failure, dementia, hypertensive heart and chronic kidney disease. Review of Resident #263's Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has a moderate cognitive impairment. Review of Resident #263's medical record indicated a weight on 8/6/24 was 123 lbs (pounds) and on 8/7/24 his/her weight was 143.6 lbs. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically: 1. The facility failed to properly secure medication carts on two of four units, 2. The facility failed to properly secure treatment carts on two of four units, 3. The facility failed to properly secure the medication room on the Oak Grove Unit, 4. The facility failed to ensure opened insulin was labeled with resident's name, the prescription label, or opening and expiration dates for two medication carts on the [NAME] unit, 5a. and b. The facility failed to ensure staff stored medications and biologicals in accordance with State and Federal laws. Findings Include: Review of the facility policy titled Medication Storage, revised 3/22, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation the facility failed to accurately document in the clinical record for six Residents (#81, #30, #16, #63, #5, #90) of 46 sampled residents. Specifically: 1. For Resident #81 the facility failed to accurately document a Stage 2 pressure injury assessment. 2. For Resident #30 the facility failed to accurately document the wearing of Prevalon boots on the treatment sheet. 3. For Resident #16 the nurse staff failed to consistently follow the Physician's orders regarding dialysis care as indicated in the Treatment Administration Record (TAR). 4. For Resident #63, the facility failed to accurately document a Stage 3 pressure injury assessment 5. For Resident #5 the facility failed to accurately document that medications had been administered when they had not. 6. For Resident #90 the facility failed to accurately document wearing of bilateral upper extremity Geri sleeves. Findings include: 1. Resident #81 was admitted to the facility in May 2021 and had a primary…

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 review and interview the facility failed to provide a dignified existence for three Residents (#50, #30 and #86) out of a total sample of 46 residents. Specifically: 1. For Resident #50 and #30 the facility failed to provide a dignified dining experience. 2. The facility failed to serve meals in a homelike atmosphere evidenced by meals served on institutional trays on the [NAME] Unit. 3. For Resident #86 the facility failed to provide privacy while toileting. Findings include: Review of the facility policy titled Dignity, dated April 2022, indicated that residents are treated with respect and dignity at all times. Further review indicated that residents are provided a dignified dining experience including while assisting at meal time. Further review indicated that staff are to promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care. 1a. Resident #50 was admitted to the facility in March 2022 with diagnoses including stroke, vision…

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 interviews, the facility failed to obtain informed consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#3) out of a sample of 46 residents. Findings include: Review of the facility policy titled Psychotropic Medication, revised 4/22, indicated an informed consent from the resident (or legally authorized individual in the case of resident incompetence) is required for administration of psychoactive medication. Resident #3 was admitted to the facility in January 2024 with diagnoses that included Alzheimer's disease, depression, and lymphedema. Review of Resident #3's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated the Resident receives an antipsychotic medication and an antidepressant medication. Review of Resident #3's physician order, dated 2/22/24,…

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 review and interview, the facility failed to accommodate the needs of one Resident (#63) out of a total of 46 sampled residents. Specifically, the facility failed to provide a shower chair able to fit Resident #63, resulting in Resident #63 not receiving a shower since his/her admission. Findings include: Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #19 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 is dependent on staff for all functional tasks. Review of Resident #63's current Activity of Daily Living (ADL) care plan, last revised 6/4/24, indicated…

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, policy review, and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#3), out of a total sample of 46 residents. Findings include: Review of the facility policy titled Advance Directives, revised April 1022, indicated: advanced directives will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The plan of care of each resident will be consistent with his or her documented treatment preferences and/or advance directive. Resident #3 was admitted to the facility in January 2024 with…

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

Based on record review and interview the facility staff failed to inform two out of three residents reviewed, or their representatives, with potential liability for payment for non-covered services including estimated cost of services received while accessing their Medicare benefit. Findings include: The Advanced Beneficiary Notice (SNFABN) is a form which provides information to Residents and/or their beneficiaries to decide if they wish to continue receiving the skilled services they are receiving at the facility that may not be paid for by Medicare and assume financial responsibility for these services. Review of the facilities' SNFABN form failed to include the cost of rehab services for two of three applicable residents. During an interview on 8/7/24, at 2:40 P.M., The Minimum Data Set Nurse said the cost indicated on the form was for room and board and did not include skilled services, such as rehab.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviewed, the facility failed to identify and assess the use of pillows under the fitted sheet as a potential restraint for one Resident (#23) out of a total of 46 sampled residents. Findings include: Review of the facility policy titled, Use of Restraints dated as revised April 2022, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls. -Physical restraints are defined as any manual method or physical or medical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, which restricts freedom of movement or restricts normal access to one's body. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to effectively carry out their abuse policy related to the reporting of an alleged abuse for one Resident (#78) out of a total sample of 25 residents. Findings include: Review of the facility policy titled Abuse: Investigation, dated March 2022, indicated the following: - The facility will investigate all alleged/potential incidents of resident abuse, neglect, mistreatment, injuries of unknown etiology, and misappropriation of property. Resident #78 was admitted in May 2024 with diagnoses including depression and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated Resident #78 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the progress note, dated 9/17/24, indicated the following: Resident #78 reported to this nurse that she is going to go home and kill herself by taking all of his/her medicine. He/She said that the conditions of this place make him/her want to kill…

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 report allegations of neglect related to the provision of incontinence care to the state agency as required for two Residents (#10 and #63) out of a total of 46 sampled residents. Findings include: Review of the facility's policy titled Abuse Prohibition dated 7/1/13, and revised 10/24/22, indicated the following: To ensure that center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, exploitation, involuntary seclusion, injuries of unknown source, and misappropriation of property for all patients. Report allegations to the appropriate state and local authorities involving neglect, exploitation, or mistreatment, including injuries of unknown source, suspected criminal activity, and misappropriation of patient property within 24 hours, if the event does not result in serious bodily injury. Provide subsequent reports to the department as often as necessary to inform the department of significant…

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 2. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment, dated 5/29/24, indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 is dependent on staff for all functional tasks. During an observation on 8/8/24, at 1:50 P.M., Resident #63 was observed laying in bed. The Resident said his/her incontinent brief had not been changed since 9:00 P.M. the night before, (a total of 17 hours without incontinence care) and that he/she was wet and uncomfortable. On 8/8/24 at 1:58 P.M., Corporate Nurse #1, Corporate Nurse #2 and Nurse #9 observed the Resident laying in bed. Corporate Nurse #1 removed the blankets to provide…

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 accurately code in the Minimum Data Set (MDS) for three Residents (#28, #100 and #112) of 46 sampled residents. Specifically; 1. For Resident #28, the use of non-invasive mechanical ventilation was inaccurately coded in the MDS. 2. For Resident #100 a significant weight loss was inaccurately coded in the MDS. 3. For Resident #112 the discharge status was inaccurately documented on the MDS. Findings include: 1. Resident #28 was admitted to the facility in July 2023 with diagnoses that included vascular dementia, chronic kidney disease, obstructive sleep apnea, heart failure and asthma. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident utilizes non-invasive mechanical ventilation. Review of Resident #28's nursing progress note, dated 4/25/24,…

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 baseline care plan that includes the instructions needed to provide effective and person-centered care for one Resident (#16) out of a total sample of 46 residents. Specifically, the facility failed to develop a baseline care plan including resident specific interventions for a Resident who requires Dialysis three times a week. Findings include: Resident #16 was admitted to the facility in February 2024 and has diagnoses that include Type II diabetes mellitus with diabetic chronic kidney disease, End Stage Renal Disease (ESRD) and dependence of renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/10/24, indicated that on the Brief Interview for Mental Status exam Resident #16 scored a 3 out of a possible 15, indicating severely impaired cognition. Review of the Resident #16's Physician orders from his/her admission in February 2024 indicated Resident #16 required dialysis 3 times a week. Review of the medical record failed to indicate a baseline care plan for dialysis was created…

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 review, and interviews, the facility failed to ensure care plans were reviewed and revised with the interdisciplinary team (IDT) as required for three Residents (#28, #16 and #77), out of a total sample of 46 residents. Specifically: 1. For Resident #28, the facility failed to ensure his/her sleep apnea care plan was revised. 2. For Resident #16, the facility failed to ensure his/her care plan was revised in May 2024 to include the dialysis plan of care, when it was not developed upon admission or with the initial comprehensive plan of care in February 2024. 3. For Resident #77 the facility failed to ensure his/her activities of daily living care plan was revised. Findings include: 1. Resident #28 was admitted to the facility in July 2023 with diagnoses that included vascular dementia, chronic kidney disease, obstructive sleep apnea, heart failure and asthma. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of 15 on the Brief…

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 provide routine vision services to obtain new eyeglasses for one Resident (#20) out of a total sample of 46 residents. Findings include: Review of the facility's policy titled, Ancillary Physician, revised April 2022, indicated: Policy: -Routine and emergency optometry, podiatry and audiology services are available to meet the resident's health services by the resident's assessment and plan of care. Guidelines: -All services provided are recorded in the resident's medical record and a copy of the resident's record is provided to any facility to which the resident is transferred. Resident #20 was admitted to the facility in November 2023 with diagnoses that included hemiplegia affecting the left non-dominant side, and Type Diabetes Mellitus. Review of Resident #20's most recent Minimum Data Set (MDS) 5/22/24 indicated Resident #20 has a Brief Interview for Mental Status (BIMS) exam score of 8 out of a possible 15 which indicated he/she has moderate cognitive deficits. The MDS assessment also indicated Resident #20 requires…

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 falls assessment and falls investigation were initiated timely following a fall with injury for one Resident (#103) out of a total sample of 46 residents. Findings include: Review of the policy titled Accidents, dated as revised 4/2022, indicated the following: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Resident #103 was admitted to the facility in March 2024 and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and legal blindness. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/19/24, indicated that on the Brief Interview for Mental Status exam Resident #103 scored a 9 out of a possible 15, indicating moderately impaired cognition. Review of the falls care plan for Resident #103 indicates that Resident #103 is at high risk for falls. Interventions on the care plan include: -Follow facility fall protocol…

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, policy review and interview the facility failed to maintain acceptable parameters of nutrition status for two Residents (#103 and #45) out of a total sample of 46 residents. Specifically: 1. For Resident #103, the facility failed to a.) obtain weekly weights as ordered and b.) address a significant weight loss timely. 2. For Resident #45, the facility failed to obtain a Registered Dietitian (RD) consult. Findings include: Review of the facility policy titled Weight Measurement, revised 4/17, indicated the frequency of weights will be determined by the IDT post-admission based on the resident's individual needs. All residents will be weighed at a minimum monthly. Monthly weights should be completed by the 10th of the month. Residents with a weight variance of 5 lbs more or less than the previous month will be re-weighed. The RN supervisor will notify the physician, responsible party and dietitian when a 5 lb more or less variance is noted. The resident plan of care will be updated…

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, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice two Residents (#6, and #30) out of a total sample of 46 residents. Specifically: 1. For Resident #6, the facility failed to ensure his/her oxygen (02) tubing was changed; 2. For Resident #30, the facility failed to ensure oxygen tubing was changed as ordered by the physician. Findings include: 1. Resident #6 was admitted to the facility in March 2023 with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia and heart failure. Review of Resident #6's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored 11 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating a moderate cognitive impairment. On 8/6/24 at 8:13 A.M. and 12:16 P.M., the surveyor observed Resident #6 in bed receiving oxygen via nasal cannula, the 02 tubing was dated for 5/15/24.…

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, record review, policy review and interviews, the facility failed to ensure for one Resident (#16), who required dialysis, that they received services consistent with professional standards of practice, out of a total sample of 46 residents. Specifically for Resident #16 the facility failed to ensure: a.) nursing consistently obtained the Resident's blood pressure from the correct arm to prevent harm or injury; b.) create a complete and resident specific care plan regarding Resident #16's dialysis care; and c.) nurses consistently followed the Physician orders regarding dialysis care. Findings include: Resident #16 was admitted to the facility in February 2024 with diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease, End Stage Renal Disease (ESRD) and dependence of renal dialysis. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/10/24, indicated that on the Brief Interview for Mental Status exam Resident #16 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated…

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, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#58) who had a history of trauma out of a total sample of 46 residents. Specifically, for Resident #58, the facility failed to develop a comprehensive trauma care plan, with individualized triggers. Findings include: Review of the facility policy titled Trauma Informed Care, dated 5/2022, indicated the following: Preparation: -Nursing staff are trained on screening tools trauma assessment and how to identify triggers associated with re-traumatization. General Guidelines: -Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Resident #58 was admitted to the facility in March 2024, with diagnoses including traumatic Post-Traumatic Stress Disorder (PTSD), dementia, and major depressive disorder. Review of Resident #58's most recent Minimum Data Set (MDS) assessment, dated 6/12/24, indicated that Resident #58 has severe cognitive deficits. Further…

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, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#28, and #104) out of a total sample of 46 residents. Findings Include: 1. Resident #28 was admitted to the facility in July 2023 with diagnoses that included vascular dementia, chronic kidney disease, obstructive sleep apnea, heart failure and asthma. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Review of Resident #28's Medication Record Review, dated 3/7/24 and 5/15/24, indicated that the Resident is currently receiving metoprolol succinate 25 mg (milligrams) twice a day. This formulation is dosed once daily (metoprolol tartrate is dosed every 12 hours). Recommend changing order to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure that PRN [as needed] psychotropic drugs were limited to 14 days for one Resident (#3) out of a total sample of 46 residents. Specifically, for Resident #3 the facility failed to ensure his/her Lorazepam had a stop date. Findings include: Resident #3 was admitted to the facility in January 2024 with diagnoses that included Alzheimer's disease, depression, and lymphedema. Review of Resident #3's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. Review of Resident #3's physician order, dated 7/17/24, indicated Lorazepam (anti-anxiety medication) 2 MG/ML (milligram/milliliter) give 0.25 milliliter by mouth every 4 hours as needed for anxiety. During an interview on 8/9/24 at 1:07 P.M., Nurse #6 said the expectation is that if a resident has an order for Lorazepam as needed, it needs to have a stop…

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 observation for two of five sampled Residents (#45, and #90), the facility failed to ensure the pneumonia vaccinations were offered. Findings include: Review of the facility's policy Pneumonia Vaccination dated as revised January 2024, indicated: - All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. - Upon admission, residents will be assessed for eligibility to receive the pneumococcal series, and when indicated, will be offered the vaccine unless medically contraindicated, refusal by the resident or health care representative, or the resident has already been vaccinated. 1. Resident #45 was admitted to the facility in April 2024. Review of Resident #45's electronic medical record indicated there was no documented history of him/her having received or declined the pneumonia vaccine, or any contraindication to receiving the vaccine. Review of Resident #45's Massachusetts Immunization Information System (MIIS) record printed on 8/12/24, indicated the pneumonia vaccine was due, but not given. 2. 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.

Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the Policy titled Quality Assessment and Performance Improvement Plan dated 1/31/2022, indicated the following: * The QAPI program is ongoing, integrated, data driven and comprehensive, addressing all aspects of care, quality of life and resident-centered rights and choice. * The Center Executive Director leads the Center's QAPI processes and involves all departments, staff and stakeholders-balancing a culture of safety, quality and resident centeredness. * The QAPI processes and improvements are based on evidence drawing data from multiple sources, prioritizing improvement opportunities and benchmarking results against developed targets. * Improvement activities and performance improvement…

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 and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will develop acceptable performance parameters and; (d) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings include: Review of the facility policy titled Agency Quality Assurance Performance Improvement Plan (QAPI) and dated 1/31/2022 failed to indicate the following: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will develop acceptable…

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, record review and interview for two residents (Resident #427 and #36) out of a total sampled of 35 residents, the facility failed to implement infection control precautions. Specifically: 1) For Resident #427 who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), the facility failed to implement contact precautions. 2) For Resident #36, the facility failed to clean a blood pressure before or after use. Findings include: Review of the facility policy titled Contact Precautions dated and revised 10/24/22 indicated the following: *Purpose: To reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact. *Process: Print Precautions sign in color. Instruct staff, patient and their representative, and visitors regarding peculations and the use of Personal Protective Equipment (PPE). *PPE must be worn before contact with the patient or the patient's environment. Wear gown and gloves, wear eye protection if splashing of infectious material is likely, before exiting room, remove and bag gown and gloves…

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, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program (ASP) to promote and monitor the appropriate use of antibiotics. Findings include: Review of the facility policy titled Antibiotic Stewardship, dated revised 8/7/23, indicated that the infection Prventionist (IP) is responsible for the Infection Prevention and Control program that includes ASP. Further review indicated that the purpose of the ASP is to reduce inappropriate antibiotic use and prevent development of antibiotic-resistant organisms. During an interview on 10/25/23, at 5:04 P.M. the Corporate Nurse said that the previous IP recently left a couple of months ago and the infection control binder containing the ASP has gone missing. The Corporate Nurse then said that the Director of Nursing is responsible for the oversight of the infection control nurse and did not monitor for the completion of the infection control processes in the facility, including the Antibiotic Stewardship program. During an interview on 10/26/23, at 7:30 A.M., the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure residents were treated with dignity. Specifically: 1) Staff failed to provide a dignified dining experience for residents on three of four units in the facility. 2) Staff failed to close a laptop screen in the hallway which displayed confidential medical information. Findings include: 1. The surveyor made the following observations on the [NAME] unit: *During breakfast service on 10/24/23, at 8:51 A.M., residents were being served breakfast with plastic cutlery and drinking juice out of plastic cups. *During lunch service in the dining room on 10/24/23, at 12:49 P.M., residents were being served breakfast with plastic cutlery and drinking juice out of plastic cups. *During breakfast service in the dining room on 10/25/23, at 8:47 A.M., residents were being served breakfast with plastic cutlery and drinking juice out of plastic cups. The surveyor made the following observation on the [NAME] Unit: *On 10/25/23, at 8:30 A.M., a Certified Nursing…

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 records reviewed, interviews and observations for five Residents ( #177, #99, 379, #7, #22) of 35 sampled residents, the facility failed to ensure it maintained oxygen equipment, and implemented physician orders and care plans for oxygen administration. Specifically: 1) For Resident #177 the facility failed to clean the external oxygen concentrator filter. 2) For Resident #99 the facility failed to clean the external oxygen concentrator filter. 3) For Resident #379 the facility failed to obtain a physician's order for the administration of oxygen. 4) For Resident #7 the facility failed to change outdated oxygen tubing. 5) For Resident #22 the facility failed to follow the physician's order for oxygen flow rate and to date oxygen tubing. Findings include: The facility's policy Respiratory Equipment /Supply Cleaning/Disinfecting dated 7/15/21, indicated, but was not limited to: * Oxygen concentrators: rinse and dry the external filter weekly and PRN [as needed] when visibly dusty. * Oxygen delivery…

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 policy review, the facility failed to ensure 1.) medications were labeled, and dated once opened, according to manufacturer's guidelines in one out of four medication carts sampled, 2.) a medication cart was observed unlocked and unattended, and 3.) ensured medications were stored in locked compartments on one nursing unit. Findings include: Review of the facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, dated as revised 8/7/23, indicated: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart that is inaccessible by residents and visitors. 5. Once an medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration…

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 resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve nutritional value, flavor, palatability and at appetizing temperatures on three of four units. Findings include: During the initial Resident screening process, numerous residents voiced concerns and displeasure about the overall food quality, temperature, and variety they are provided. During the resident council group meeting on 10/25/23, at 11:00 A.M., 9 out of 18 participating residents complained that the food had no flavor, and the temperatures were not good. On 10/25/23, at 12:08 P.M., the food truck arrived on the Edgewood unit. After all resident trays had been served, the surveyor received the test tray at 12:31 P.M., 23 minutes later. The following was recorded: *Macaroni and Cheese: temperature of 101 degrees Fahrenheit, warm to taste not hot. *Milk: temperature of 42 degrees Fahrenheit, not cold to taste. *Ice Cream: temperature of 20…

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, record review, and interview for one Resident (#85) out of a total sample of 35 residents, the facility failed to assess for self-administration of medication. Findings include: Review of the facility policy titled 'Medications: Self-Administration', dated as revised 3/1/22, indicated but was not limited to the following: * Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer: * A physician/advanced practice provider (APP) order is required. * Self-administration and medication self-storage must be care planned. Resident #85 was admitted to the facility November 2020 with diagnoses including dementia and vision loss. Review of Resident #85's medical record failed to indicate he/she had been assessed for the safe self-administration of medication. Review of Resident #85's physician orders dated October 2023, indicated he/she may not self-administer medication. On 10/24/23, 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 records reviewed and interviews, for one Resident (#31) , who was alert, oriented and whose preference included being able to receive a shower, the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of receiving a weekly shower, out of 35 sampled residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) dated revised 5/1/23, indicated that a patient that is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good personal hygiene. Resident #31 was admitted to the facility in May 2022 with diagnoses including post traumatic stress disorder (PTSD), morbid obesity and spinal stenosis. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #31 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating that Resident #31 was cognitively intact. Further review indicated that Resident #31 is totally dependant for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to investigate an injury of unknown origin timely for one Resident (#61) out of a total of 35 sampled Residents. Findings include: Review of the facility's Abuse Prohibition Policy dated 10/24/23, indicated: *Injuries of an unknown source are defined as an injury with both of the following conditions; The source of the injury was not observed by any person or the source of the injury could not be explained by the patient and the injury is suspicious because of the extent of the injury or the location of the injury. *Staff will identify events - such as suspicious bruising of patients, occurrences, patterns and trends that may constitute abuse - and determine the direction of the investigation. *Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless…

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, record review and interview, the facility failed to develop and implement the plan of care for two Residents (#7 and #427) out of a total sample of 35 Residents. Specifically, the facility failed to 1) develop a care plan for an automatic implantable cardiac defibrillator device for Resident #7 and 2) develop a communication care plan for Resident #427. Findings include: 1) Resident #7 was admitted to the facility in March 2023 with diagnoses including chronic obstructive pulmonary disease and heart failure. Review of Resident #7's most recent Minimum Data Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #7 requires extensive assistance with all activities of daily living. Review of Resident #7's medical diagnoses indicated that he/she has an automatic implantable cardiac defibrillator device (ICD) (a device implanted in the chest to detect and stop irregular heartbeats by delivering…

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 apply a left hand splint per doctor's order and recommendation from physical therapy for one Resident (#67) out of a total sample of 35 Residents. Findings include: Resident #67 was admitted to the facility in January 2021 with diagnoses including left hemiparesis, diabetic nephropathy, major depressive disorder, and falls. Review of Resident #67's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she has intact cognition. Further review indicated Resident #67 requires supervision for functional tasks. Review of Resident #67's October 2023 physician's orders indicated the following: * Please help patient doff (remove) LUE (left upper extremity) splint to prep for daytime use of extremity. Check for skin breakdown/redness in the morning Refer to rehab. * Please help patient don (put on) LUE splint. Check for skin…

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 assistance with meals for one Resident (#103) out of a total sample of 35 residents. Findings include: Resident #103 was admitted to the facility in July 2021 with diagnoses including vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic cough, and major depressive disorder. Review of Resident #103's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status exam which indicated he/she had a severe cognitive deficit. The MDS also indicated Resident #103 requires extensive assistance with meals. During an observation on 10/24/23, at 8:43 A.M., Resident #103 was sitting up in bed with his/her breakfast meal uncovered affront of him/her. Resident #103 was attempting to reach a bowl of oatmeal with his/her hands. The Resident was not visible from the hallway and there were no staff present to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews and observations for two Residents (#99 and #103) of 35 sampled residents, the facility failed to implement interventions to prevent skin breakdown. Specifically: 1) For Resident #99 the facility failed to place Prevalon boots on his/her feet while in bed, or use a pillow under his/her left heel while sitting in a wheelchair. 2) Resident #103 the facility failed to elevate his/her feet while lying in bed. Findings include: Review of the facility policy Skin Integrity and Wound Management dated 2/1/23, indicated, but was not limited to: * Implement pressure injury prevention for identified, modifiable risk factors * Determine the need for heel off-loading. 1) Resident #99 was admitted to the facility in February 2023 and had diagnoses which included history of left heel pressure ulcer, diabetes mellitus, dementia, and hip fracture. Review of Resident #99's physician order dated 4/19/23, indicated Offload left foot with pillow while on wheelchair, every day and evening shift.…

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 review, policy review, and interview, the facility failed to identify a possible hazard for one Resident (#19), out of a total sample of 35 residents. Specifically, Resident #19 had 16 used Lidocaine patches in his/her room. Findings include: Review of the facility's policy titled Storage and Expiration of Dating of Medications, Biologicals, revised [DATE], indicated the following: * Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. *Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier *Facility should not administer/provide bedside medications or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#47) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 35 sampled Residents. Specifically for Resident #47 the amount of tube feeding infused did not correspond with the rate of infusion times and the hours infused. Additionally, the facility failed to date the G-tube feeding solution bottle per policy. Findings include: Review of the facility policy titled Enteral Management and dated revised 3/1/22, indicated that the purpose of the policy was intended to provide safe and effective management of Enteral tubes. Further review failed to indicate the process by which the Enteral feeding is monitored for accuracy of infusion or for ensuring the changing of the Enteral feeding tubing and Enteral feeding every 24 hours. Resident #47 was admitted to the…

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

Based on observation, record review and interview, the facility failed ensure intravenous medications were administered in accordance of professional standards of practice for one Resident (#72) out of a total sample of 35 residents. Specifically, for Resident #72, the facility failed to ensure nursing obtained confirmation of placement of a PICC line (peripherally inserted center catheter) prior to use and nursing did not obtain information regarding the PICC line. Findings include: Review of the facility policy titled, 5.10 Peripherally Inserted Center Catheter (PICC) Insertion, dated as Revised June 2021, indicated: 51. Do not administer medication through PICC until chest x-ray verifies that the tip of the catheter is in the resident's superior vena cava or cavoatrial junction, or as determined by other approved technology. 53. Documentation in the medical record includes, but is not limited to: 53.5 Catheter Brand, lot number and size 53.6 Total Length of catheter Resident #72 was admitted to the facility in October 2023 with diagnoses including diabetes, osteomyelitis and…

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

Based on observations, record review, policy review, and interviews, the facility failed to ensure for one Resident (#27), who required dialysis, received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 35 sampled residents. Specifically, the facility failed to ensure nursing implemented a physician's order and care plan for emergency equipment at the Resident's bedside (smooth clamp). Findings include: Resident #27 was readmitted to the facility in February 2023 with diagnoses including diabetes, end stage renal disease with dependence of renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 8/24/23, indicated Resident #27 required dialysis. Review of the physician's order, dated 9/23/22, indicated: - Check Smooth clamps at the bedside and on patient wheelchair (if applicable) every shift. Review of the Treatment Administration Record, dated October 2023, indicated nursing staff were verifying the smooth clamps were at bedside. Review of the plan of care related to dialysis, dated 2/19/23,…

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 develop a comprehensive trauma informed care plan for one Resident (#31) out of a total sample of 35 residents. Findings include: The facility failed to produce a policy and procedure for trauma informed care when asked. Resident #31 was admitted to the facility in May 2022 with diagnoses including post traumatic stress disorder (PTSD), morbid obesity and spinal stenosis. Review of the Minimum Data Set (MDS) dated [DATE], indicated that Resident #31 scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) exam indicating that Resident #31 was cognitively intact. Further review indicated that Resident #31 has a diagnosis of PTSD. Review of the medical record indicated a diagnosis of PTSD. Review of the Care Plan failed to indicate a care plan focus for PTSD. Further review failed to indicate potential triggers and interventions for symptoms of Resident #31's PTSD. During an interview on 10/26/23, at 9:05 A.M. the Director 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 employee record review and interview, the facility failed to complete performance reviews annually for two of two Certified Nursing Assistants (CNA) reviewed, as required. Findings include: On 10/26/23, at 7:39 A.M., the surveyor reviewed four employee records. Two of two CNA employee records failed to indicate annual performance reviews had been completed. During an interview on 10/26/23, at approximately 9:30 A.M., Corporate Nurse #1 said that they were unable to locate annual performance reviews for the CNAs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmacy recommendations were 1) reviewed by the physician as required for one Resident (#105) and 2) reviewed by the physician in a timely manner for one Resident (#5) out of a total of 35 sampled Residents. Review of the facility policy titled Medication Regimen Review, revised and dated 8/17/23, indicated the following: *Facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team members, resident, or Responsible Party as needed. *Facility should encourage Physician receiving the medication regimen review (MRR) and Director of Nursing to act upon recommendations contained in the MRR. *For those issues that require Physician intervention, facility should encourage Physician to either accept or act upon the recommendations contained within the MRR or reject all or some and provide an explanation as to why the recommendation was rejected. *Facility…

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 for one Resident (#177) of 35 sampled residents, the facility failed to ensure a gradual dose reduction (GDR) was attempted by the physician. Specifically: On 9/22/23, Resident #177 was prescribed Clonazepam as needed (PRN) and a GDR attempt was required by 10/4/23, but a GDR did not occur until 10/11/23, seven days after the required review date. Findings include: Review of the facility policy 'Psychotropic Medication Use' dated October 2022, indicated, but was not limited to: * PRN [as needed] psychotropic medications should be ordered for no more than 14 days. Each resident who is taking a PRN psychotropic drug will have his or her prescription reviewed by the physician or prescribing practitioner every 14 days and also by a pharmacist every month. For psychotropic medications, excluding antipsychotics, that the attending physician believes a PRN order for longer than 14 days is appropriate, the attending physician can extend the prescription beyond 14 days for 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 observation, interview, and record review, the facility failed to provide a diet of personal preferences to one Resident (#67) out of a total sample of 35 residents. Findings include: Resident #67 was admitted to the facility in January 2021 with diagnoses including diabetic nephropathy, major depressive disorder, falls and left hemiparesis. Review of Resident #67's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she has intact cognition. The MDS indicated Resident #67 requires supervision for functional tasks. During an observation on 10/24/23, at 8:25 A.M., Resident #67 was observed eating breakfast alone in his/her room. The breakfast meal included a ham and cheese sandwich on wheat toast. Resident #67 said he/she does not like eating wheat toast and has requested to only receive white bread toasted for all meals. Resident #67 said he/she will eat the wheat toast because he/she is…

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 review, and interview for one Resident (#45) of 35 sampled residents, the facility failed to provide adaptive eating equipment. Specifically, the facility failed to provide adaptive eating utensils to maximize food intake for Resident #45, who lacked coordination to both hands. Findings include: Resident #45 was admitted to the facility July 2022 with diagnoses including multiple sclerosis, muscle weakness, failure to thrive, and severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/17/23, indicated Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating he/she is cognitively intact. The MDS, dated [DATE], indicated Resident #45 required set-up for eating and had no behaviors of rejection of care. During an interview on 10/24/23, at 8:04 A.M., Resident #45 said he/she has trouble holding regular eating utensils because of numbness and poor coordination from multiple sclerosis. Resident #45 said…

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, record review and interview, the facility failed to accurately document in the medical record for one Resident (#7) out of a total sample of 35 Residents. Specifically, the facility documented that oxygen tubing was changed two times and when it was not. Findings include: Resident #7 was admitted to the facility in March 2023 with diagnoses including chronic obstructive pulmonary disease and heart failure. Review of Resident #7's most recent Minimum Data Assessment (MDS) indicated that the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #7 requires extensive assistance with all activities of daily living. Review of the facility policy titled Respiratory Equipment/Supply Cleaning/Disinfection dated and revised 6/1/21, indicated the following: *Cleaning and disinfection of respiratory equipment is performed by a respiratory therapist, licensed nurse, or equipment technician. Disinfection is performed on all equipment on 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.