Royal Meadow View Center

Based on observations, interviews and record review, the facility failed to maintain professional standards in the managing and caring for urinary catheter devices for one Resident (#76) out of a total sample of 21 residents. Specifically, the facility failed to ensure the urinary catheter drainage bag and tubing was not placed directly on the floor. Findings include: Review of facility policy titled 'Catheter Care, Urinary', undated, indicated: - Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. Resident #76 was admitted to the facility in October 2024 with diagnoses including Parkinson's disease, enlarged prostate, and retention of urine. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/22/25, indicated that Resident #76 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #76 had an indwelling catheter and was required partial/moderate assistance for bed mobility, toileting, and transfer tasks. Review of Resident #76's physician's order,…

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 interviews, the facility failed to ensure correct installation, use, and maintenance of bed rails for one Resident (#55) out of a total sample of 21 residents. Specifically, the facility failed to assess Resident #55 for risk of entrapment from bed rails prior to installation. Findings include: Review of the facility policy titled 'Bed Safety', undated, indicated, but was not limited to, the following: - Our facility shall strive to provide a safe sleeping environment for the resident. 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as…

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 residents were free of unnecessary medications and were properly assessed for possible adverse reactions to psychotropic medications for two residents (#47 and #22) out of a total of 21 sampled residents. Specifically: 1.) For Resident #47, the facility failed to ensure the use of as needed (PRN) psychotropic medications were limited to 14 days for one Resident (#47). 2). For Resident #22, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed. Findings include: Review of the facility policy titled 'Use of Psychotropic Medication', dated December 2024, indicated: - Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed 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 and interviews, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, the facility failed to ensure medications were dated once opened, according to manufacturer's guidelines, in one out of three medication carts observed. Findings include: Review of the facility policy titled 'Storage of Medications', revised October 2024, indicated: - The facility shall store all drugs and biological in a safe, secure, and orderly manner. - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On 1/30/25 at 6:50 A.M., the surveyor and Nurse #3 observed the following in the Court unit medication cart: - One vial of heparin sodium (porcine) injection solution 5000 UNIT/ML (milliliter), open and undated. - Two vials of insulin glargine subcutaneous solution 100 UNIT/ML, open and undated. During an interview on 1/30/25 at 7:05 A.M., Nurse #3 said the insulin and heparin should have been dated when opened because they have a shortened expiry date…

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 review, the facility failed to maintain accurate medical records for two Residents (#26 and #22), out of a total sample of 21 residents. Specifically: 1.) For Resident #26, the physician and nurse practitioner inaccurately documented the Resident's code status as do not resuscitate (DNR) when the Resident's code status indicated to attempt resuscitation (full code). 2.) For Resident #22, the facility inaccurately documented the Resident's physician's order as a full code (attempt resuscitation) when the Resident's Medical Orders about Life-sustaining Treatment (MOLST) indicated the Resident was DNR, do not intubate (DNI). Findings include: Review of the most recent Minimum Data Set (MDS) assessment, dated 12/27/24, indicated Resident #26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This MDS further indicated: - Advanced Directions: Do Not Resuscitate: not checked (no). 1.) Review of Resident #26's Medical Orders about Life-Sustaining Treatment (MOLST), dated 5/20/23, 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 records reviewed and interviews, for one of three sampled residents (Resident #1), who was found unresponsive, without a pulse, without respirations, and although his/her advanced directives indicated he/she was a Full Code (in the event of cardiac or respiratory arrest, attempts at resuscitation will be initiated) the Facility failed to ensure nursing staff adequately assessed Resident #1 for signs of irreversible death and followed facility policy, before initiating and attempting to perform cardiopulmonary resuscitation (CPR). Findings include: The Facility Policy, titled Sequential Assessment - MA Facilities Only, dated [DATE], indicated the Sequential Assessment purpose is to guide the decision-making of the Registered Nurse and the Licensed Practical Nurse (the nurse) in initiating or withholding cardiopulmonary resuscitation (CPR) when a patient or resident in a long-term facility with 24-hour skilled nursing staff on duty has experienced a cardiac arrest. The Policy indicated this allows 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 records reviewed and interviews, for one of three sampled residents (Resident #1), whose advanced directive indicated he/she was Full Code, (staff to attempt Cardiopulmonary Resuscitation, CPR in the event of cardiac or respiratory arrest) the Facility failed to ensure that nursing staff were competent related to facility policy and procedures in the event of an emergency situation with the need to initiate a Code Blue, which included nursing response, resident assessment and use of necessary life-saving equipment. When on [DATE], at approximately 7:00 A.M., after Nurse #1 found Resident #1 unresponsive, without a pulse or respirations, Nurse #1 did not stay with the resident, Code Blue was not overhead page to alert staff per Facility Policy, and nursing staff were unaware of how to use the Automated External Defibrillator (AED). Findings include: The Facility Policy, titled Code Blue in House Emergency Response Policy and Procedure, dated [DATE], indicated that Code Blue is called for life threatening…

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, the facility failed to ensure that; 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For 2 Residents (#50 and #86) the facility failed to provide care when requested out of a total of 27 residents sampled. Findings include: 1. On 2/27/24, at 7:30 A.M., the surveyor observed that there was one Certified Nurse's Aide (CNA) working on the Court Unit. The surveyor also observed there were 18 residents currently residing on the Court Unit. During an interview on 2/27/24 at 9:58 A.M., The Director of Nursing said that staffing the units has been an ongoing challenge. Review of the facility assessment dated as reviewed 10/25/23, indicated that the average daily census in the building is between 80 and 90 residents per day. Further review indicated that the amount of Certified Nurse's Aides (CNA's) needed to care for the residents, at the acuity level of the residents as determined by the facility, is 33 full time equivalents…

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 interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of two units. Findings include: A group meeting was held on 2/28/24 at 11:00 A.M. During this meeting, 12 out of 12 participants said the food was not hot when it was served to them. A test tray was completed on 2/28/24 on the Meadows Unit at 12:27 P.M. with the following findings using the facility thermometer: *Meatloaf was 90 degrees Fahrenheit and tasted warm. *Green beans were 80 degrees Fahrenheit and tasted luke warm and bland. *Potatoes were 84 degrees Fahrenheit and tasted luke warm and bland and had a grainy/gritty texture. *Apple pie was 60 degrees Fahrenheit and tasted cold with a gummy texture. *Milk was 40 degrees Fahrenheit and tasted cold. *Apple juice was 50 degrees Fahrenheit and tasted cold. A test tray was completed on 2/28/24 on the Dementia Unit at 12:56 P.M. with the following findings: *Meatloaf was 135.1 degrees Fahrenheit and tasted warm. *Green beans were 123.4 degrees Fahrenheit and tasted luke warm and bland.…

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 review of the Quality Assurance Performance Improvement (QAPI) meeting minutes for 2023, the facility staff failed to ensure an effective QAPI plan was in place. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) dated June 2023 indicated the following: The QAA (Quality Assessment and Assurance) program committee will prioritize topics for PIPs (Performance Improvement Projects) based on current needs of the residents and our organization. Review of all the 12 months of QAPI meeting minutes for 2023 failed to indicate a prioritizing process was implemented, failed to indicate that a root cause analysis was completed for identified problems and failed to indicate the tracking of outcomes for any interventions put in place to determine their effectiveness. Review of the Quarterly December 2023 QAPI meeting minutes failed to indicate that, for known areas of concern, a performance improvement plan was implemented to ensure the following: 1. Adequate staffing. 2. Food quality. 3. Environmental…

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, policy review and interviews the facility failed to ensure infection control standards of practice for the prevention of infections were implemented. Specifically, the facility failed to 1) ensure nursing staff performed hand hygiene appropriately during medication administration and follow recommended disinfectant guidelines and 2) complete a risk management assessment for the possible development and spread of legionella. Findings include: 1. Review of the facility policy titled Infection Prevention and Control Program, not dated, indicated An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. a. (3) Educating staff and ensuring that they adhere to proper techniques and procedures. Review of the facility policy titled Administering Medications, Dated August 2023, indicated Medications shall be administered in a safe and timely manner, and as prescribed. 19.) Staff shall follow established…

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 resident rooms were maintained in good repair, clean and homelike on 2 of 3 resident care units. Findings include: On 2/27/24 & 2/28/24, the following observations were made on the Meadow unit in the following rooms: room [ROOM NUMBER]- The nightstand had dark scuff marks, chipped paint, and bubbling paint on the pull-out drawer. The bathroom door had dark scuff marks on the bottom right side near the wall. The exterior door to the hallway had gouges in the wood, chipped paint, and chipped lamination with discoloration. room [ROOM NUMBER]- The left armrest of the wheelchair was peeling with yellow foam exposed. The nightstand had scuff marks, and peeling paint throughout. The bottom left side of the exterior bathroom door had chipped paint with scuff marks, bottom right of the bathroom wooden door was chipped and had discoloration. The white dresser bureau had three drawers that would not close, and the middle drawer had a broken hinge. 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.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of two nurses observed made 4 errors out of 33 opportunities resulting in a medication error rate of 12.12 %. Those errors impacted two Residents (#23, and #28), out of 4 residents observed. Findings include: Review of the facility's policy titled Administering Medication, dated August 2023, indicated the following: 1.) Medications shall be administered in a safe and timely manner, and as prescribed. 2.) Medications must be administered in accordance with the orders, including any required time frame. Medications cannot be given without an order. 3.) Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 1. For Resident #23, Nurse #5 administered a medication within 30 minutes of eating breakfast. On 2/28/24 at 8:10 A.M., Nurse #5 prepared and administered the following medication for Resident #23: - Glipizide Oral Tablet 5 mg…

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 that a system was developed to conduct comprehensive inspections of resident's mattresses in zone 7, to reduce the potential hazard of entrapment for beds in the facility. Specifically, the facility failed to identify a greater than 12 inch bed gap for one Resident (#67) and a 5.5 inch gap for one Resident (#72) out of a total sample of 27 residents. Findings include: According to The Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006 by the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, The HBSW (Hospital Bed Safety Workgroup) identified 7 potential entrapment zones for hospital beds. Further review indicated that to prevent entrapment a space of no greater that four and 3/4 inches should exist between the bed frame, the mattress and the side rails. Review of the facility policy…

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 provide a dignified dining experience for 2 Residents (#80 and #85) out of a total sample of 27 Residents. Specifically, the facility failed to ensure that staff members were not standing over Residents #80 and #85 while providing feeding assistance. Findings include: Review of the undated facility policy titled Resident Rights indicated the following: -The resident has the right to be treated with respect and dignity. 1. Resident #80 was admitted to the facility in October 2022 with diagnoses including Alzheimer's Disease. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #80 scored a 4 out of 15 on a Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Further review of the MDS indicated Resident #80 was dependent on staff for partial/moderate feeding assistance. On 2/27/24 at 9:08 A.M., the surveyor observed a staff member providing feeding assistance to Resident #80 in the dining…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for one Resident (#72), out of a total sample of 27 residents. Findings include: Review of the undated facility policy, titled Use of Restraints, indicated the following: -Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or restricts access to one's body. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. Resident #72 was admitted to the facility in February 2024 with diagnoses including stroke…

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 develop and implement a baseline care plan within 48 hours of admission for one Resident (#90), who was at risk for elopement, out of a total sample of 27 residents. Findings include: Review of the facility policy titled Care Plans - Baseline, dated May 2023, indicated the following: -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. -The interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy Services; e. Social services; and f. PASARR recommendation, if applicable. Resident #90 was admitted to the facility in January 2024 with diagnoses including…

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, the facility failed to develop a care plan for the use of pillows under a fitted sheet as a potential restraint for one Resident (#72), out of a total sample of 27 residents. Findings include: Resident #72 was admitted to the facility in February 2024 with diagnoses including stroke with resulting left sided hemiplegia (Paralysis affecting one side of the body). Review of the Minimum Data Set, dated [DATE], indicated Resident #72 scored a 5 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment. Further review indicated that Resident #72 was dependent on staff for all aspects of daily living. On 2/27/24 at 7:51 A.M. and 9:56 A.M., the surveyor observed Resident #72 lying in bed with pillows under the fitted sheet on the right side of the bed and a pillow on the left side of the mattress below the side rail. On 2/28/24 at 7:44 A.M., two surveyors observed two pillows under the fitted sheet on the right side of the bed,…

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

Based on observations, record review and interviews the facility failed to maintain professional standards of practice for medication administration for one Resident (#54) out of a total sample of 27 residents. Specifically, for Resident #54, who resides on the facility's Dementia Speciality Care Unit, the nurse failed to ensure Resident #54 had swallowed the medication that she administered. Findings include: Review of the facility policy titled Administering Medications, dated August 2023, indicated the following: -Medications shall be administered in a safe and timely manner, and as prescribed. -Residents may self administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Resident #54 was admitted to the facility in July 2023 with diagnoses that include dementia and essential hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/24/24, indicated that on the Brief Interview for Mental Status exam Resident #54…

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, observation and interview the facility failed to provide the necessary services to ensure 1 Resident (#85) out of a total sample of 27 residents, was able to effectively communicate his/her needs. Findings include: Review of the undated facility policy, titled Translation and/or interpretation of Facility Services, indicated, but was not limited to, the following: -This facilities language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. -Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): a. A staff member who is trained and competent in the skill of interpreting. b. A staff interpreter who is trained and competent in the skill of interpreting; c. Contracted interpreter service;…

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 and interviews the facility failed to ensure supervision with meals was provided for one Resident (#44) out of a total sample of 27 residents. Findings include: The facility policy titled Activities of Daily Living (ADLs), dated as reviewed October 2021, indicated the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: d. Dining (meals and snacks) Resident #44 was admitted to the facility in March 2023 and has diagnoses that include Alzheimer's disease and epilepsy. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/6/23, indicated that on the Brief Interview for Mental Status exam Resident #44 scored a 9 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated that Resident #44 had no behavior of refusing care. Review of the current Activities of Daily Living (ADL) care plan included the following…

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 policy review, record review and interview the facility failed to maintain acceptable parameters of nutrition status for 1 Resident (#13) out of a total sample of 27 residents. Specifically, the facility failed to review or implement the Registered Dietitian's (RD's) recommendation for increasing the frequency of Resident #13's nutritional supplement. Findings Include: Review of the undated facility policy titled Weight Surveillance, indicated, but was not limited to, the following: -Significant weight change is considered if 5% or more gain or loss within one month, 7.5% or more gain or loss in three months, or 10% or more gain or loss in six months. -Dietitian to reassess and document interventions to address significant weight loss or gain. Resident #13 was admitted to the facility in August 2023 with diagnoses including dementia and adult failure to thrive. Review of the Minimum Data Set (MDS), dated [DATE], indicated that a Brief Interview for Mental Status (BIMS) was unable to be completed as…

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 that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to conduct an assessment for trauma per the facility policy, and develop a comprehensive plan of care for Post Traumatic Stress Disorder (PTSD) including triggers for re-traumatization for two Residents (#67 and #24) who had an active diagnosis of PTSD out of a total sample of 27 Residents. Findings include: Review of the facility policy titled Trauma Informed Care, dated reviewed December 2023, indicated the following: A. an assessment is completed consisting of several questions that are worded to assess past experiences and not trigger an episode. B. If a resident has a history of trauma that is documented . the Social…

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 accommodate a food intolerance for 1 Resident (#19) out of a total sample of 27 Residents. Specifically, the facility failed to ensure that gluten-containing food was not served to a Resident with celiac disease (an auto-immune condition triggered by the consumption of gluten, a protein found in wheat, rye, barley, and triticale, which results in inflammation and damage to the lining of the small intestine). Findings include: Review of the facility policy titled Food Allergies and Intolerance's, dated May 2023, indicated the following: -Residents are assessed for a history of food allergies and intolerance's upon admission and as part of the comprehensive assessment. -All resident reported food allergies and intolerance's are documented in the assessment notes and incorporated into the resident's care plan. -Residents with food intolerance's and allergies are offered appropriate substitutions for foods that they cannot eat. Resident #19…

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, policy review and interview the facility failed to handle food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure that nursing staff did not touch resident food directly with their bare hands during set-up and feeding assistance in the dining room of the View unit. Findings include: Review of the facility policy titled Food Preparation and Service dated May 2023, indicated the following: -Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. On 2/27/24 the surveyor made the following observations in the View unit dining room during the breakfast meal: -At 8:41 A.M. a staff member picked up a Resident's toast with her bare hands to apply jelly and then served the toast to the Resident. At 8:44 A.M. a staff member picked up a Resident's toast with her bare hands to apply jelly and then served the toast to the Resident. -At 8:47 A.M. a staff member opened a Resident's milk using her bare hands, the staff member stuck her finger into the spout of the milk to open it.…

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.