Norwood Healthcare

Based on record review and interview, the facility failed to ensure one Resident (#24), out of a total sample of 23 residents, was invited to his/her care planning meetings to participate in their plan of care.Findings include:Review of facility's policy titled Care Plans, Comprehensive Person-Centered, last revised on 1/24, indicated but was not limited to the following:-The resident will be informed of his or her right to participate in his or her treatment.-The interdisciplinary team (IDT) may include: the provider, the nurse responsible for the resident, the aide responsible for the resident, nutrition staff, the resident and the resident's legal representative, and other appropriate staff as determined by the resident's needs or as requested by the resident. Resident #24 was admitted to the facility in November 2025 with diagnoses including chronic obstructive pulmonary disease and emphysema.Review of the Minimum Data Set (MDS) assessment, dated 10/24/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively…

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

Based on record reviews and interviews, the facility failed to ensure one Resident (#8), out of a total sample of 23 residents, was free from unnecessary psychotropic medications by ensuring an as needed (PRN) dose of Zyprexa (antipsychotic) was limited to 14 days. Findings include: Review of the facility's policy titled Psychotropic Medication, dated as last revised July 2023, indicated but was not limited to the following:-Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reductions and re-review as needed.-The need to continue PRN orders for psychotropic medications beyond 14 days require that the practitioner document the rationale for the extended orders, the duration of the PRN order will be indicated in the order.-PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the health care practitioner has evaluated the resident for appropriateness of that medication. Resident #8 was admitted to the facility in June 2025 with diagnoses which included depression, vascular dementia with or without…

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 document review and interview, the facility failed to ensure that monthly Medication Regimen Reviews (MRR) were addressed and implemented in a timely manner for one Resident (#6), out of a total sample of 23 residents. Specifically, the facility failed to ensure a recommendation by the pharmacy consultant to obtain a Vitamin D level to consider tapering down the Vitamin D dose and signed by the physician was reviewed by nursing, transcribed, and implemented per the provider's order. Findings include: Review of the facility's policy titled Medication Regimen Review, dated 8/2020, indicated but was not limited to the following:-The consultant pharmacist identifies irregularities.-Resident specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nurses (DON), Medical Director, and/or prescriber as appropriate.-Recommendations are acted upon and documented by the facility staff and/or the prescriber.-The DON or designated licensed nurse address 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 observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure four of four kitchenettes were maintained in a clean, sanitary condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 3-305.11 (A) Except as specified in paragraphs (B) and (C) of this section, food shall be protected from contamination by storing the food (1) in a clean, dry location. 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-101.11 Surface Characteristics. (A) Except as specified in (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted. On 1/14/26, the surveyor…

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

Based on record reviews and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for weekly weights times four (4) weeks, the Facility failed to ensure nursing provided care and services that met professional standards of quality, when his/her weights were not obtained per his/her Physician Order.Findings include:Review of the Facility Policy titled Weight Measurement, dated as last revised 04/2019, indicated each resident's weight will be obtained on admission and then weekly times four (4) weeks, subsequent weights will be monthly, unless physician's orders warrant more frequent.The Policy also indicated that the Registered Dietician will be the responsible for determining the desirable body weight range and will be documented on the initial medical nutrition therapy (MNT) assessment and reassessment.Review of the Facility Policy titled Medication and Treatment Orders, dated as last revised, 09/2024, indicated all orders for medication and treatments will be consistent with regulatory standards.The Policy further indicated medications 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 records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Agent (HCA), the Facility failed to ensure that his/her HCA received written notice, including the reason for the change, when on 12/13/24 Resident #1's was moved to a new room without obtaining consent from and notifying his/her HCA of the room change. Findings include: Resident #1 was admitted to the Facility in December 2024 diagnoses include bilateral pulmonary embolisms (blood clots), left lower extremity deep vein thrombosis (blood clot), low back pain, and dementia. Review of Resident #1's Physician's Orders, dated 12/02/24, indicated that his/her Health Care Agent (HCA) had been responsible for his/her health care decisions. Review of Resident #1's admission Minimum Data Set (MS) Assessment, dated 12/08/24, indicated he/she had moderate cognitive impairment. Review of Resident #1's Nurse Progress Note (written by the Nursing Supervisor), dated 12/13/24, indicated that he/she had been moved to a new room, appears comfortable and he/she was adjusting…

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), the Facility failed to report ensure they reported an allegation of abuse to the Department of Public Health (DPH) within two hours, as required. On 01/02/25, Resident #1 was observed with an injury of unknown origin and the Facility did not report the incident to DPH, until 02/02/25, a month after the injury had been identified. Findings include: Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last reviewed 2/2024, indicated each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. The Policy defines Injury of Unknown Etiology as any resident injury where the source of injury was not observed, or the source of injury cannot be explained by the resident. The Policy further indicated that the Facility must report to DPH and local law enforcement any reasonable suspicion…

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), the Facility failed to ensure a thorough investigation was conducted related to an injury of unknown origin, when on 01/02/25 after staff found a bump on Resident #1's left forehead, the Facility was unable to provide documentation to support they conducted an investigation, into the injury. Findings include: Review of the Facility Policy titled Abuse Investigation and Reporting, dated as last reviewed 2/2024, indicated each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. The Policy defines Injury of Unknown Etiology as any resident injury where the source of injury was not observed, or the source of injury cannot be explained by the resident and the Nursing Supervisor will notify, the provider, Health Care Proxy, Responsible Party, Administrator, and Director of Nurses. The Policy indicates to do…

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 two of three sampled residents (Resident #1 and #2), who upon admission were each identified as at risk for falls, the Facility failed to ensure after they experienced a witnessed and/or unwitnessed fall, that their plans of care were reviewed and revised for new interventions goals, and outcomes, as needed. Findings include: Review of the Facility Policy titled Fall Prevention and Management, dated as last revised 11/2024, indicated to prevent or minimize resident fall risk through identification of fall risk factors and implementation of interventions to prevent falls. The Policy further indicated the following; -If a resident falls, the nurse will conduct a physical assessment of the resident and notify the Provider and Responsible Party; -If a fall is unwitnessed or the resident hits his/her head during the fall, Neurological Assessment should be conducted. -Statements should be obtained from staff on the unit at the time of the fall; and -A new intervention will be added to the resident's care plan. 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.

Based on interview and record review, the facility failed to employ a full time Social Worker as required for any facility with more than 120 beds. Findings include: During the Entrance Conference meeting on 10/22/24 at 10:00 A.M., the Administrator and Regional Nurse said there has been no full time Social Worker in the facility since July 2024. Review of the Facility Assessment indicated total licensed bed capacity of 170, with 162 active beds. During an interview on 10/23/24 at 10:00 A.M., the Administrator said the facility had consulting Social Workers in the facility from July to current covering a few hours per week, but the coverage was not for full time hours. Review of the Consulting Social Worker Hours indicated the following: - 7/1/24 through 7/6/24: 10.75 hours - 7/7/24 through 7/13/24: 23.32 hours - 7/14/24 through 7/20/24: 14.02 hours - 7/21/24 through 7/27/24: 4.00 hours - 7/28/24 through 8/3/24: 15.00 hours - 8/4/24 through 8/10/24: 23.65 hours - 8/11/24 through 8/17/24: 7.33 hours - 8/18/24 through 8/24/24: 19.05 hours - 8/25/24 through 8/31/24: 6.00 hours - 9/1/24…

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 record review and interview, the facility failed to ensure a [NAME] treatment plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for two Residents (#16 and #25), out of 39 sampled residents with legal guardians (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated). The facility identified an additional 21 residents with legal guardians that are being administered antipsychotic medication and require a [NAME] Treatment plan. Of these 21 residents, the facility failed to ensure 19 residents had valid, court approved [NAME] treatment plans in place for the administration of antipsychotic medication. Findings include: 1. Resident #16 was admitted to the facility in [DATE] and had diagnoses including paranoid schizophrenia and dementia. Review of the Minimum Data Set (MDS)…

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 and interview, the facility failed to provide a safe, clean, comfortable and homelike environment on one unit out of a total of four units. Specifically, the facility failed to ensure the North Two unit temperature was maintained between 71-81 degrees Fahrenheit. Findings include: On 10/28/24 at 8:31 A.M., the surveyor entered the North 2 unit between rooms [ROOM NUMBERS]. The temperature was noticeably colder than the rest of the facility. During an interview on 10/28/24 at 8:31 A.M., Resident #24 said, It is cold on the unit and it has been all weekend. It was reported to the nurse over the weekend but nothing had been done. During an interview with observation on 10/28/24 at 9:14 A.M., Resident #98 said, It's been cold in here for a few days now. It feels like there is no heat. It's very cold. The surveyor observed Resident #98 to be wearing long flannel pants and a long sleeve shirt. During an interview on 10/28/24 at 9:20 A.M., the Regional Facility Engineer said he was trying to figure…

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

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services to three Residents (#51, #31, #17), out of a total sample of 39 residents. Specifically, the facility failed to maintain sanitary conditions of respiratory equipment, including nasal cannula tubing, nebulizer mask/tubing, bilevel positive airway pressure (BiPAP) mask/tubing, and/or continuous positive airway pressure (CPAP) mask/tubing to decrease the risk of potential contamination of germs and/or exposure to infection. Findings include: Review of the AARC (American Association for Respiratory Care) Clinical Practice Guideline, updated 2014: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1063.pdf indicates: -Undesirable results or events may result from noncompliance with physicians' orders or inadequate instruction for oxygen therapy. -Equipment maintenance and supervision: All oxygen delivery equipment should be checked at least once daily. 1. Resident #51 was admitted to the facility in September 2021 with diagnoses including complete C1-C4…

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 address a history of trauma (results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) identified on trauma assessments and failed to thoroughly assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#8), with a self-reported history of trauma, out of a total sample of 39 residents. Findings include: Review of the facility's policy titled Trauma Informed Care, last revised 10/2019, indicated but was not limited to: -As part of the comprehensive assessment, identify history of trauma or interpersonal violence when such information is provided to the facility. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.…

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 interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure the treatment carts were locked when not in direct supervision of the licensed nurse on three of three units. Findings include: Review of the facility's policy titled Storage of Medications, dated September 2018, indicated but was not limited to: - Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. The surveyor made the following observations on: -10/23/24 at 8:51 A.M., a treatment cart unlocked and unattended on the North 1Unit. -10/23/24 at 12:34 P.M., a treatment cart unlocked and unattended on the South 2 Unit. -10/23/24 at 12:41 P.M., a treatment cart unlocked and unattended on the South 2 Unit. -10/23/24 at 2:11 P.M., a treatment cart unlocked and unattended on the North 2 Unit, 1 resident walked by the treatment cart. -10/23/24 at 3:12 P.M., a treatment cart unlocked 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 observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products in the main kitchen. Findings include: Review of the facility's policy titled Food and Supply Storage, last revised 6/2018, indicated but was not limited to: - Policy: Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes. - Labeling and rotating food supply -Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and use by dates. -Follow recommendations from the manufacturer when indicated on the product for storage time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain medical records that were complete and accurate within accepted professional standards of practice for six Residents (#86, #96, #24, #12, #45 and #54), out of a total sample of 39 residents. Specifically, the facility failed to: 1. Ensure physician visits were available in the medical record within a timely manner for Residents #86 and #96; 2. Ensure the medical record contained accurate information regarding Residents #24 and #12's suprapubic tube (a tube surgically placed to empty the bladder of urine); and 3. Ensure clinical Substance Abuse assessments and notes were readily accessible and part of the medical record for Residents #45 and #54. The facility identified an additional 32 residents diagnosed with alcohol abuse and/or substance abuse. Of these 32 residents, the facility failed to ensure 32 residents' Substance Abuse assessments and notes were readily accessible and part of the medical record. Findings include: 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.

Based on observation, interview, and document 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 potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain a complete and accurate system of surveillance and analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program; 2A. For Resident #86, who has a gastrostomy tube (feeding tube), ensure staff use appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) when providing care; B. For Resident #3, ensure staff use the appropriate PPE for EBP when providing catheter care; and C. For Resident #107, ensure staff wore PPE while providing care for the Resident who was on EBP for a Central venous catheter (CVC) inserted into their right jugular vein. Findings include: 1. Review of the facility's policy titled…

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

Based on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for two Residents (#86 and #8), out of a total sample of 39 residents. Specifically, the facility failed: 1. For Resident #86, to notify the Physician of recommendations from the Dietitian for a change in nutritional formula to enhance the caloric intake of the malnourished Resident; and 2. For Resident #8, to notify the Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) when the Resident developed a deep tissue injury to the left heel and a stage 3 pressure wound (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are NOT exposed) to the left buttock. Findings include: Review of the facility's policy titled Change in Resident's Condition or Status, last revised 7/2024, indicated but…

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 develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for two Residents (#109, #58), out of a total sample of 39 residents. Specifically, the facility failed: 1. For Resident #109, to develop and implement a care plan to address the Resident's chronic pain and pain management; and 2. For Resident #58, to develop and implement a care plan to address the care and management of the Resident's left hand and elbow contracture. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, last revised 1/2024, indicated but was not limited to: - A comprehensive, person-centered care plan will be developed for each resident. - The care plan will include objectives that meet the resident's physical, psychosocial and functional needs and is developed for each resident. - The Interdisciplinary Team (IDT) in conjunction with the resident 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 observation, interview, and document review, the facility failed to ensure professional standards of care were met for one Resident (#107), out of a total sample of 39 residents. Specifically, the facility failed to ensure staff provided care and maintained the central venous catheter (CVC) tunneled into the right jugular (vein in the neck) of Resident #107 for medication infusions in accordance with current standards. Findings include: Review of the Massachusetts 244 CMR Board of Registration in Nursing, Section 3, dated 6/11/21, indicated but was not limited to the following: -A registered nurse shall bear full and ultimate responsibility for the quality of nursing care he or she provides to individuals or groups. Included in such responsibility is health maintenance, teaching, counseling, collaborative planning and restoration of optimal functioning and comfort. -A registered nurse shall systematically assess health status, plan, and implement nursing intervention, evaluate outcomes and initiate…

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 monitor and document the range of motion (ROM) for a resident admitted with left arm contractures, failed to implement recommendations from the Occupational therapy assessments for contracture management, and failed to educate the staff on proper application of the position devices currently in use for one Resident (#58), out of a total sample of 38 residents. Findings include: Resident #58 was admitted to the facility in January 2023 with diagnoses which included: non-traumatic intracerebral hemorrhage (brain bleed), aphasia (unable to formulate language due to brain injury), dysarthria and anarthria (complete loss or partial loss of speech), cerebral infarction (stroke), hemiplegia (paralysis on one side) affecting left dominant side. Review of the Minimum Data Set (MDS) assessment, dated 9/13/24, indicated Resident #58 scored 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive…

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

Based on observation and interview, the facility failed to ensure staff provided residents with an environment free from accident hazards. Specifically, the facility failed to ensure: 1. On one unit of three units, hazardous items were stored in a secure location and were not easily accessible to residents on the South 2 Unit; and 2. For Resident (#54) and one unit (Unit 2) of three units in the facility, nail clippers, diabetic testing supplies and medications (not prescribed by the Resident's physician) were not stored in the Resident's bureau and were not easily accessible to the Resident and wandering residents on the unit. Findings include: Review of the facility Matrix (used to identify pertinent care categories for residents) provided to surveyors by the Director of Nursing on 10/22/24 indicated the South 2 Unit had 29 out of 34 residents with diagnoses of Alzheimer's disease/Dementia. 1. On 10/23/24 at 12:38 P.M., the surveyor observed in the South 2 Unit hallway: - A yellow bucket (unattended) containing: - Three metal scrappers - A box of nails - A metal trowel - Loose…

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

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling suprapubic catheter (tube that drains urine from the bladder through a small incision in the lower abdomen and into a collection bag outside the body) for one Resident (#12), out of total sample of 29 residents. Specifically, the facility failed to ensure the Resident's suprapubic catheter device was maintained in a sanitary way. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated March 2024, indicated but was not limited to the following: -Do not rest the bag on the floor. Resident #12 was admitted to the facility in October 2020 and had diagnoses including neuromuscular dysfunction of the bladder and hydronephrosis (excess fluid in a kidney due to a backup of urine) with renal and ureteral calculus (stone) obstruction. Review of the Minimum Data Set (MDS) assessment, dated 9/6/24,…

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 interviews and records reviewed, for one of three sampled Residents (Resident #1), whose medical history included a traumatic subarachnoid hemorrhage without loss of consciousness and unspecified intracranial injury without loss of consciousness (traumatic brain injury/TBI), after being hit by a car as a pedestrian, he/she had limited attention and concentration, impaired judgement/insight, was assessed and care planned for the need for staff supervision while smoking and using smoking materials, the Facility failed to ensure that 1) staff consistently implemented and followed interventions from his/her Plan of Care related smoking safety with the need for staff supervision while he/she was in possession of smoking materials, and 2) that he/she was accurately assessed by nursing based on criteria identified on the facility elopement risk form related risk factors that needed to be considered, and that a plan of care should be developed and implemented. Findings included: 1) The Facility Policy titled Smoking Policy-Residents, dated as last revised 3/2024, indicated that…

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. For Resident #1 the facility failed to maintain his/her dignity during the breakfast meal when a Certified Nursing Assistant (CNA) fed Resident #1 standing up, resulting in Resident #1 having to look up at the CNA. Resident #1 was admitted to the facility in June of 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dysphagia, and dementia. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) which indicated a severe cognitive impairment and required limited assistance of one person for eating. The surveyor made the following observations: -On 7/18/23 at 8:55 A.M., CNA #6 entered Resident #1's room and began to feed him/her in his/her bed. CNA #6 was standing above Resident #1's eye level and Resident #1 had to look up as he/she was being fed. - On 07/20/23…

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 observations and interviews the facility failed to maintain a homelike environment by 1) replacing a broken television for 1 Resident (#20), 2) identifying and replacing a ripped and worn mattress for 1 Resident (#85) and 3) ensuring water temperatures were meeting warm temperature levels in the facility bathroom sinks, out of a total sample of 33 residents. Findings include: 1. Resident #20 was admitted to the facility in May 2008 with diagnoses including dementia, anxiety, and major depression. Review of Resident #20's most recent Minimum Data Set (MDS) dated [DATE] indicates he/she has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating he/she has severe cognitive impairment. During an interview on 7/20/23 at 2:04 P.M., Resident #20 said he/she wanted to watch television and the television was not working. The Resident said he/she needed the television, and it hasn't been working all week. During an interview on 7/20/23 at 1:13 P.M., Certified Nursing Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility 1) failed to implement the plan of care to off-load heels for 2 Residents (#8 and #47), 2) failed to develop a care plan for an orthotic device for 1 Resident (#54) and 3) failed to implement a care plan to provide padded side rails for 1 Resident (#39), out of a total sample of 33 residents. Findings include: 1 A. Resident #8 was admitted to the facility in January 2016 with diagnoses including dementia. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicates the Resident has a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicates Resident #8 is dependent on staff for all bed mobility tasks. On 7/19/23 at 7:25 A.M., 8:20 A.M., and 1:00 P.M., Resident #8 was observed lying in bed. Both of his/her heels were directly on the mattress and not offloaded from pressure. On 7/20/23 at 8:19 A.M. and 10:00 A.M., Resident #8 was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2b. Resident #1 was admitted to the facility in June 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dementia and dysphagia (difficulty in swallowing.) Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating a severe cognitive impairment and requires limited assistance from one person for eating. On 7/18/23 beginning at 8:45 A.M., the surveyor made the following observations: -At 8:45 A.M., a Certified Nursing Assistant (CNA #7) delivered a breakfast tray to Resident #1 consisting of puree food. CNA #7 set up the tray and left the room. -At 8:47 A.M., Resident #1 was alone in his/her room holding his/her meal tray ticket in his/her hand. -At 8:52 A.M., Resident #1 was observed holding a spoon with his/her eyes closed. Staff was observed passing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide an individualized activity program for 4 Residents (#61, #88 and #94) out of a total sample of 33 residents. Findings include: 1. Resident #61 was admitted to the facility in May 2016 with diagnoses including dementia, depression, anxiety, mild cognitive impairment, frontotemporal neurocognitive disorder, major depressive disorder, insomnia, Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #61 was unable to complete a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. Further review of the MDS indicated Resident #61 requires extensive assistance and supervision with locomotion. Throughout all days of survey 7/18/23 through 7/21/23, Resident #61 was observed walking around the unit unsupervised wandering into empty dining rooms and hallways where staff were not present. There were no activity staff observed going into his/her room for one-on-one visits or to bring any activity…

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 complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs. Findings include: During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for CNA #1, CNA #2, CNA #3, CNA #10 and CNA #11. During an interview on 7/21/23 at approximately 9:30 A.M., the Director of Nursing (DON) said that CNA's are required to have annual performance reviews and was aware that the 5 CNA's reviewed did not have the required performance reviews completed.

Based on observation, interview and record review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness in accordance with professional standards for food service safety and 2) failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness. Findings include: 1. Review of the facility policy titled, Food and Storage, dated 6/2018, indicated the following: *Food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration food code, state regulations, and city/county health codes. *Food products that are opened and not completely used; transferred from its original package to another storage container; or prepared at the facility and stored should be labeled as to its contents and used by dates. *Refrigerated, ready to eat food prepared on site that is held longer than 24 hours should be properly labeled with the…

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

Based on observations and interviews, the facility failed to protect personal healthcare information on 1 out of 3 units. Findings include: Review of the facility policy titled, Resident Rights, dated 12/2022, indicated the following: *Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: - privacy and confidentiality On 7/19/23 at 9:39 A.M. Nurse #1 left her medication cart unattended with the computer screen unlocked and visible to anyone in the hallway. Private healthcare information of the residents residing on the unit was visible to 2 housekeepers and 1 resident who walked by the screen. The screen was visible until 9:44, 5 minutes later. Nurse #1 left the screen unlocked and visible again between 9:45 A.M. and 9:53 A.M. During this time 3 residents walked by the screen where personal healthcare information could be seen. Nurse #3 left her screen unlocked and visible again from 10:03 A.M. to 10:07 A.M. During this period, 3 residents walked by the screen where personal healthcare information could…

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 two Residents (#72 and 97) were free from restraints out of a total sample of 33 residents. Specifically, the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint. Findings include: Review of facility policy titled 'Use of Restraints' date revised 10/2022 indicated the following but not limited to: Policy: 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. Guidelines: * Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. *The definition 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, record review, policy review and interviews, the facility failed to investigate a bruise of unknown origin in a suspicious area for 3 Residents (#30, #99 and #94) out of a total sample of 33 residents. Findings include: Review of the facility policy titled, Abuse Investigation and Reporting, dated 6/2022, indicated the following: *All reports of resident abuse, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. * If an incident or suspected incident of resident abuse, mistreatment, exploitation, neglect or injury of unknown sources reported and will be investigated. * The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms. b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to follow a physician order for prevention of pressure ulcer for one Resident (#47) out of a total sample of 33 residents. Findings include: Resident #47 was admitted to the facility in June 2023, with diagnoses including cerebral infarct (stroke) and generalized weakness, Review of Resident #47's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15, indicating he/she has moderately impaired cognition. The MDS further indicated Resident #47 requires extensive assistance of two person for bed mobility. Section M of the MDS indicated a stage 4 pressure ulcer (deep wounds that may impact muscle, tendons, ligaments, and bone) and the use of pressure reducing device bed/ chair. Review of the physician's orders indicated: -5/18/23 Low air loss mattress, check placement and functioning every shift set at 200. -5/4/23 Left lateral foot…

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, policy review and interviews the facility failed to maintain a suprapubic catheter (a tube that drains urine directly through the abdominal wall) in a manner to reduce infection for one Resident (#97) out of a total 33 sampled residents. Findings Include: Review of facility policy titled 'Catheter Care of Indwelling Urinary' date last revised April,2018, indicated but not limited to the following: Policy: Catheter care will be performed at least daily and as needed (PRN) and in accordance with physician's and/or nursing orders. Guidelines: *Ensure that catheter tubing is secured to the thigh with leg strap and to prevent urinary tract infections caused by urinary reflux, always keep the drainage bag below the level of the residents bladder and off the floor. Position catheter tubing for straight drainage. Resident #97 was admitted to the facility in June 2023 with diagnoses including ESBL (Extended Spectrum Beta-Lactamase), Parkinson's disorder of the autonomic nervous system, chronic…

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 address significant weight loss for 1 Resident (#8) out of a total sample of 33 residents. Findings include: Review of the facility policy titled, Weight Management, dated 4/4/19, indicated the following: *All residents with significant weight changes will have verification of weight measurement for accuracy and documentation purposes. If verification of weight indicates significant weight change (suggested parameters for evaluating significance of unplanned and undesired weight loss are: 5% in 30 days, 7.5% in 90 days and 10% in 180 days) the resident and/or family representative and I DT will be notified in the plan of care will be revised as appropriate. *Residents with significant unintended weight changes will be added to weekly weights x 4 weeks or until weight stabilizes. *The registered dietitian will be responsible for determining the desirable body weight range. This will be documented on the initial medical nutrition therapy…

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 provide care and services consistent with professional standards for one Resident (#19) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 33 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident (#51) for emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: Review of the facility policy titled 'End-Stage Renal Disease, Care of a Resident with (sic)', last revised date November 2017, indicated the following but not limited to: Policy: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Guidelines: * Education and training of staff includes specifically: -Signs and symptoms of worsening condition and or implications of end stage renal…

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 1 Resident's (#104) medication regimen was free from unnecessary drugs out of a total sample of 33 Residents. Findings include: Review of the facility policy titled, Psychoactive Medication, dated 7/23, indicated The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. Resident #104 was admitted to the facility in March 2023 with diagnoses including dementia, major depressive disorder, and hypertension. Review of Resident #104's most recent Minimum Data Set (MDS) dated [DATE] indicated he/she scored a 1 out of a possible 15 which indicated he/she had severe cognitive impairment. Review of Resident #104's July 2023 physician orders, start date of 3/17/23, indicated Ativan (benzodiazepine) oral tablet 0.5 mg (milligrams), Give one tablet by mouth every 6 hours as needed 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.

Based on observation, interview and facility policy review the facility failed to ensure that 1. the medication cart was locked and secured on 1 of 3 units observed and 2. medications were properly labeled after opening on 1 of 3 units observed. Findings include: Review of the facility policy titled, Storage of Medications, dated 8/20, indicated Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. 1. During an observation on 7/19/23 at 7:14 A.M., the surveyor observed the medication cart unlocked in the hallway with no staff present. During an interview on 7/19/23 at 7:16 A.M., Nurse #3 said that the medication cart should be locked at all times if the nurse is not present. Nurse #3 said that she left the medication cart open. During an interview on 7/20/23 at 11:22 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 observation, interview and record review, the facility failed to provide dental services for 1 Resident (#83) out of a total sample of 33 residents. Findings include: Resident #83 was admitted to the facility in February 2023 with diagnoses including Parkinson's Disease, dementia, anxiety, and major depressive disorder. Review of Resident #83's most recent Minimum Data Set (MDS) dated [DATE] indicates that he/she has a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating he/she is cognitively intact. Further review of Resident #83's admission MDS indicated he/she had broken teeth. During an interview on 7/18/23 at 9:24 A.M., Resident #83 said he/she has not been seen by a dentist and he/she is missing 2 crowns. Resident #83 was asked if he/she reported it to staff, he/she said yes. Review of Resident #83's medical record indicated a doctor's order dated 2/16/23 for dental service consult. Further review of the medical record indicated a consent form for dental services…

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 and interview the facility failed to ensure for 1 Resident (#92) out of a total sample of 33 residents, that food provided to the Resident met his/her individual needs. Resident #92 was admitted to the facility in November 2020 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #92 was unable to complete a Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #92 requires physical assistance with eating. On 7/19/23 at 9:18 A.M., Resident #92 was observed walking around the unit unsupervised, eating from a small bag of chips. Resident #92 walked up and down the halls, in a back dining room area and turned back around and walked past several staff members. On 7/19/23 at 9:26 A.M., Resident #92 was observed walking around the unit and nurses' station unsupervised, eating from a small bag of chips. On 7/19/23 at 9:29 A.M., there were no bags of chips observed in Resident #92's room. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and meal tray ticket review, the facility failed to provide the dietary preferences for one Resident (#97) out of a total sample of 33 residents. Findings include: Resident #97 was admitted to the facility in June 2023 with diagnoses including dysphagia, metabolic encephalopathy. Review of Resident #97's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident was cognitively intact and scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) score. On 7/18/23 at 11:40 A.M., Resident #97 said that he/she has food concerns as he/she dislikes potatoes and has been receiving potatoes with most of his/her meals. On 7/19/23 at 1:04 P.M., Resident #97 was observed in his/her bed with a lunch tray in front of him/her untouched. The tray had mashed potatoes as part of the lunch. The Resident stated he/she was not interested in having the meal. Review of the lunch meal ticket for 7/19/23 indicated Resident disliked potatoes. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility 1.) failed to ensure for one Resident (#54) that rehabilitation services were provided in accordance with the physician's order and after Resident #54 was provided a new orthotic, 2.) failed to ensure physical therapy was provided to one Resident (#158) in accordance with the physical therapy treatment plan of care, and 3.) failed to provide Occupational Therapy for one Resident (#97) in accordance with the occupational therapy treatment plan of care, out of a total sample of 33 residents. Findings include: 1. For Resident #54 the facility failed to ensure physical therapy services were provided per the physician's order and after Resident #54 was provided an orthotic device for his/her right ankle following an appointment with an orthopedic doctor. Resident #54 was admitted to the facility in December 2018 and has diagnoses that include but not limited to chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility 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 observation, record review and interview the facility failed to ensure an accurate medical record for 1 Resident (#1), out of a total sample of 33 residents. Specifically, Nursing staff documented that Resident #1 was administered a left-hand roll splint. Findings include: Resident #1 was admitted to the facility in June 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dysphagia, and dementia. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating a severe cognitive impairment and is dependent on staff for daily care including bed mobility, transfers, bathing, dressing and hygiene. On 7/18/23 Resident #1 was observed resting in bed. The fingers on his/her left hand were curled in and contracted. There was no device observed. Review of Resident #1's medical record on 7/18/23 indicated the following: -A…

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

Based on interview and observations, the facility failed to disinfect shared resident equipment during medication pass. Findings include: On 7/19/23 at 7:45 A.M., Nurse #5 was observed going into a resident's room and measure his/her blood pressure. The nurse returned to his medication cart and placed the blood pressure machine on the cart. He did not disinfect the blood pressure machine. On 7/19/23 at 8:15 A.M., Nurse #5 was observed going into a different resident's room, the surveyor stopped Nurse #5 before he could reach the resident for blood pressure measurements. During an interview on 7/19/23 at 8:17 A.M., Nurse #5 said he should have disinfected the blood pressure machine as it is shared medical equipment. During an interview on 7/20/23 at 11:31 A.M., the Director of Nursing said the facility's expectation is that shared medical equipment should be sanitized after each use.