Hillcrest Commons Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure one Resident (#40) received dialysis care in accordance with professional standards of practice for three applicable residents receiving dialysis, out of a total sample of 36 residents. Specifically, the facility failed to ensure nursing assessments, including assessment of the dialysis access site, vital signs and blood sugar levels, were performed when Resident #40 returned from dialysis. Findings include: Review of the facility policy titled Coordination of Care of Dialysis Residents, revised 11/19/18, indicated the nursing facility was responsible for the overall quality of care and services the resident receives and provides the services, consistent with professional standard of practices, to residents receiving dialysis as outlined by their comprehensive person-centered plan of care. The policy also included the following: -a comprehensive person-centered plan of care is developed and implemented based on comprehensive assessment in collaboration with the Dialysis Center, in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that triggers relative to a past trauma were identified to create an individualized trauma care plan for one Resident (#199) out of a total sample of 36 residents. Specifically, for Resident #199, the facility failed to ensure that an individualized care plan addressed Resident #199's triggers so they could be reduced in his/her environment. Findings include: Review of the facility policy titled Trauma Informed Care, revised 6/17/24, indicated the following: -Social service department will develop a person-centered trauma-informed care plan that addresses the assessed emotional and psychosocial needs of the resident. -Interdisciplinary team (IDT) to provide ongoing assessment, evaluation, and revision of care plan. Resident #199 was admitted to the facility in June 2024 with diagnoses including Cerebral Infarction (stroke) with left sided hemiplegia and hemiparesis and Major Depressive Disorder. Review of the most recent 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, interview, and record review, the facility failed to provide appropriate medical care and supervision for one Resident (#224) out of a total sample of 36 Residents. Specifically, for Resident #224, the facility failed to ensure that the Provider was aware of the Resident's weight loss and oversaw his/her nutritional status. Findings include: Resident #224 was admitted to the facility in February 2025 with diagnoses including Anoxic Brain Damage, posterior reversible Encephalopathy, Aphasia and Gastrostomy Status. Review of Resident #224's Minimum Data Set (MDS) assessment dated [DATE]. indicated: -based on staff assessment the Resident had some difficulty with daily decision making in new situations only. -the Resident received 25 - 50% of his/her caloric intake from Tube Feeding. Review of Resident #224's weights indicated the following: -2/21/25: 196.6 pounds (lbs) -3/4/25: 189 lbs. -3/5/25: 186.6 lbs. (a 5% loss in less than 30 days) Review of Resident #224's medical record failed to…

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

Based on interview, and record review, the facility failed to ensure that appropriate competencies related to medication administration was completed for one Licensed Nurse (Nurse #9) out of 5 staff records reviewed. Specifically, the facility failed to provide documentation that Nurse #9 had completed the appropriate nursing competencies for medication administration and controlled substances (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) documentation. Findings include: Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/2022, indicated: -It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy. Purpose: -To provide for proper ordering, storage, disposal, and security of controlled substances. -To minimize the opportunity for abuse or diversion of controlled substances.…

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 maintain accurate documentation of controlled substance (a drug or chemical that the government regulates for its manufacture, possession and use, that are classified into schedules based on their potential for abuse) for two units (Unit 2, side one and Unit 2, side two) out of five units reviewed. Specifically, the facility failed to maintain accurate documentation in the controlled substance register (Narcotic Book Documentation). Findings include: Review of the facility policy titled Management of Controlled Substance in Skilled Nursing Facilities, revised 10/19/22, indicated: -It is the responsibility of staff to administer or otherwise manage medications to safeguard controlled substances in a manner consistent with Federal and State law, and organizational policy. Purpose: -To provide for proper ordering, storage, disposal and security of controlled substances. -To minimize the opportunity for abuse or diversion of controlled substances. -To promote occupational and patient safety. -Medication information is logged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation, the facility failed to provide routine dental services for two Residents (#47 and #186) out of a total sample of 36 residents. Specifically, 1. For Resident #47, the facility staff failed to follow through on a Doctor of Medicine in Dentistry (DMD) recommendation to have the Resident seen by an Oral Surgeon for a tooth extraction resulting in delayed dental care and services. 2. For Resident #186, the facility failed to assist the Resident in making an appointment for recommended dental extractions in a timely manner which resulted in a delay in dental care and increased risk for oral pain and infection. Findings include: Review of the facility policy titled Consulting Services Podiatry/Dental/Optometry/Audiology, dated 11/22/16, included but was not limited to the following: -The facility has a contract with credentialed providers for inhouse services of podiatry, dental, optometry and audiology. -Facility will arrange appointments as requested by…

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

Based on observation, interview, and record review, the facility failed to ensure each resident received food and drink that was palatable and served at an appetizing temperature on two (Unit One and Unit Four) out of four units, where test trays were conducted. Specifically, the facility failed to ensure: 1. Pureed (food prepared as a smooth, pudding-like texture) asparagus was served consistent with pureed texture and at an appetizing temperature for Residents requiring pureed food on Unit One. 2. For Unit Four, the facility failed to serve palatable food at an appetizing temperature. Findings include: Review of the facility's Standard Guidance for Food and Liquid Textures for Individuals Requiring Modified Texture Diets, undated, indicated the following: -A pureed diet is food with a very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture. -No solid pieces or parts can be noticed in the food. -Pureed food has no lumps and feels very soft and smooth in the mouth. During an interview on 3/18/25 at 8:25…

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 safety and awareness related to resident's food allergies for two Residents (#163 and #215) out of a total sample of 36 residents. Specifically, 1. For Resident #163, the facility failed to ensure that the Resident with a chocolate allergy was not provided with food that included the documented allergen. 2. For Resident #215, the facility failed to maintain Resident safety relative to a coconut allergy putting him/her at risk for anaphylaxis (a life-threatening allergic reaction). Findings include: 1. Resident#163 was admitted to the facility in December 2024 with diagnoses including Alzheimer's Disease. Review of the recent comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #163: -required substantial to max assist to eat his/her meals -long-term memory and short-term memory were impaired. Review of Resident #163's Nursing/Dietary Communication form dated 10/9/24, indicated the Resident was allergic…

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 provide a Pneumococcal Immunization to one Resident (#25) of five applicable residents, out of a total sample of 36 residents. Specifically, the facility failed to administer an updated Pneumococcal Immunization to Resident #25 within the appropriate timeframe as indicated by CDC (Centers for Disease Control and Prevention) guidelines placing Resident #25 at increased risk for complications associated with Pneumococcal infection. Findings include: Review of CDC guidelines for Pneumococcal immunization at www.cdc.gov indicated that adults who have received the Pneumococcal Polysaccharide Vaccine 23 (PPSV23) Immunization after age [AGE] years should have shared clinical decision making to decide whether to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) Immunization one year after the PPSV23 had been administered. Review of the facility policy titled Resident Pneumococcal Immunization, dated September 2011, revised 9/1/23, included but was…

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

Based on observation, interview, record and policy review, the facility failed to provide adequate nutritional care and services for two Residents (#193 and #60), out of a total sample of 36 residents. Specifically, the facility failed to: 1. Re-evaluate Resident #193's nutritional needs, identify a severe weight loss, monitor weights as ordered, and accurately monitor meal intake percentages when the Resident had been identified as having a poor appetite, being at nutritional risk, and had experienced a severe weight loss greater than 7.5 percent (%) in less than three months; and 2. For Resident #60, a) provide nutritional supplements as ordered, and b) maintain an accurate weight record in the Electronic Medical Record (EMR) in order to identify significant weight loss timely and monitor and assess meal intakes consistently when the Resident was identified at nutritional risk and experienced severe weight loss. Findings include: Review of the facility's policy, titled Nutrition Management, dated 12/5/08 and revised 6/6/22, indicated: -The purpose was to provide nutritional care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure that one Resident (#156) out of a total sample of 36 residents was assessed to self-administer medication prior to allowing self-administration of his/her medications. Findings include: Review of the facility policy titled Self Administration of Medication, revised June 30, 2021, indicated the following: -If the resident wishes to self-administer, the Nurse will determine the interdisciplinary team (IDT) will determine the resident's ability to safely self-administer. {sic} -Upon admission the Self-Administration of Medications Informed Consent and Assessment Tool will be completed. Resident #156 was admitted to the facility in May 2022. Review of the Resident's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS) indicating he/she was cognitively intact. During an observation and interview on 1/2/24 at 10:03 A.M., 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 observation, interview, record and policy review, the facility failed to notify the Physician/Non-Physician Practitioner (NPP- Nurse Practitioner) and Dietitian of a severe weight loss of greater than 7.5 percent (%) in less than three months for one Resident (#193) out of a total sample of 36 residents. Specifically, the facility failed to notify the NPP and Dietitian of the Resident's severe weight loss when the Resident had been previously identified as being at nutritional risk. Findings include: Review of the facility's policy titled Nutrition Management, dated 12/5/08 and revised 6/6/22, indicated: -The purpose was to provide nutritional care and services to each resident, consistent with the resident's comprehensive assessment . to recognize, evaluate, and address the nutritional needs of every resident, including, but not limited to, the resident at risk or currently experiencing impaired nutrition . -Staff will consistently observe and monitor residents for changes . -Consult with the Dietitian when .unplanned weight loss or gain (greater than three pounds (lbs)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to provide or arrange for services that accepted standards of practice dictate should have been provided for two Residents (#6 and #193), out of a total sample of 36 residents. Specifically, 1. For Resident #6, the facility staff failed to document where subcutaneous (under the skin) injections of Insulin (medication used to treat Diabetes [chronic, metabolic disease characterized by high blood sugar levels]) was administered on the Resident's body, putting the Resident at risk for lipohypertrophy (a lump of fatty tissue under the skin caused by repeated injections in the same area) development. 2. For Resident #193, the facility staff failed to obtain a Pulmonology consult as ordered when the Resident had a history of malignant (potentially deadly condition that will likely worsen with time) breast cancer, was identified to have nodular (growth of abnormal tissue) lesions (area in an organ or tissue which has been damaged due to disease) in both lungs…

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 appropriate treatment and services for one Resident (#108) out of a total sample of 36 residents, with limited range of motion (ROM) to prevent further decrease in ROM. Specifically, for Resident #108, the facility staff failed to re-assess the Resident's condition relative to hand contractures upon return from a hospitalization, and resume Occupational Therapy (OT) when the Resident had known bilateral hand contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity, and rigidity of joints), increasing the risk for further decrease in ROM, impaired skin integrity, and infection. Findings include: Resident #108 was admitted to the facility in February 2023, with diagnoses including Quadriplegia (paralysis that affects all four limbs and body from the neck down) and Respiratory Failure (condition that develops when the lungs cannot get enough oxygen into the blood, 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 record and policy review, the facility failed to notify and solicit the assistance of the appropriate authorities for one Resident (#283), out of four sampled residents, when the Resident left the facility, did not return as indicated, and was unable to be contacted by facility staff. Specifically, the facility staff failed to notify the Police Department when Resident #283 was considered missing for failing to return to the facility from a leave of absence (LOA), and the facility could not verify the Resident whereabouts, care, or safety. Findings include: Review of the facility policy titled, Elopement Prevention and Response revised April 24, 2023, included but was not limited to: -Elopement: when a resident leaves the premises or a safe area without knowledge (i.e., an order for discharge or leave of absence) -Elopement Response: >At first notice that the resident does not seem to be in his/her usual/immediate living space, the resident is considered missing. >If the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure that the Oxygen flow rate (measurement of how much Oxygen is being administered) was set at the correct liters per minute (LPM - the amount of oxygen flow that is being received) for one Resident (#156), out of a total sample of 36 residents. Specifically, the facility staff failed to ensure that the Resident's oxygen flow rate was maintained at 2 LPM as prescribed by the Physician, putting him/her at risk for adverse outcomes like hypercapnia (failure of the body to remove carbon dioxide in the blood) and Respiratory Failure (condition that results when the blood does not have enough oxygen or too much carbon dioxide). Findings include: Review of the facility policy titled Oxygen Administration, Revised November 3, 2016, indicated the following: -Verify Physician's order of Oxygen administration . Updated AARC Clinical Practice Guidelines at https://www.aarc.org/wpcontent/uploads/2014/08/08.07.1063.pdf, titled Precautions…

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

Based on record review and interview, the facility staff failed to ensure Quarterly Minimum Data Set (MDS) Assessments were completed within the required timeframe for 11 sampled Residents (#2, #3, #4, #5, #73, #81, # 122, #123, # 147, #170 and #176), out of a total of 37 sampled residents. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). Findings include: 1. Resident #2 was admitted to the facility in December 2019. Review of the medical record indicated the 4/14/22 Quarterly MDS Assessment was completed on 5/15/22. 2. Resident #3 was admitted to the facility in January 2022. Review of the medical record indicated the Quarterly MDS Assessment due in April 2022 was not completed. 3. Resident #4 was admitted to the facility in April 2015. Review of the medical record indicated the 4/14/22…

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

Based on record review and interview, the facility staff failed to ensure Admission/Annual Minimum Data Set (MDS) Assessments were completed within the required timeframe for six sampled Residents (#73, #81, #122, #442, #443 and #490), out of a total sample of 37 residents. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Annual MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). Further review of the CMS RAI Version 3.0 Manual indicated an admission MDS Assessment must be completed no later than 14 calendar days after the ARD. 1. Resident #73 was admitted to the facility in June 2021. Review of the medical record indicated the Annual MDS Assessment, dated 5/24/22, was not completed. 2. Resident #81 was admitted to the facility in June 2021. Review of the medical record indicated the Annual MDS Assessment, dated 5/24/22, was not…

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 reviews, and interviews, the facility staff failed to ensure complete and accurate medical records for four sampled Residents (#7, #126, #147 and #170), out of 37 sampled residents. Findings include: Review of the facility policy titled, Clinical Documentation, revised 5/11/21, included but was not limited to: -Nursing Notes required Daily on skilled resident (ex. Medicare, case managed) to describe pertinent assessments and interventions provided for the resident. -Final Nursing Note describes the condition of the resident at the time of discharge and addresses destination, mode of transportation, medications sent with resident, those who accompanied the resident and what time the resident left the facility. -If the condition of the resident calls for his/her transfer to an acute care facility, the date, time of admission, name of the healthcare facility and the mode of transportation surrounding the transfer will be documented in the nursing notes. -Change of condition/Incidents: complete documentation for change in resident condition or incidents,…

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 staff failed to follow infection control guidelines: 1. during a medication administration pass and, 2. for three sampled Residents (#115, #147 and #170), out of a total sample of 37 residents. Findings include: 1. During an observation of a medication administration pass on 6/10/22 at 7:50 A.M., Nurse #9 removed a Spiriva (a bronchodilator-medication that relaxes the muscles in the lungs to make breathing easier) capsule from a foil wrapper with his ungloved hands and placed it into the specialized inhaler. He then administered the inhaler to the resident. Review of the Licensed Nurse Medication Administration Competency Evaluation indicated to demonstrate proper procedure for administering medication, medication is expelled directly into souffle cups. During an interview on 6/10/22 at 7:55 A.M., Nurse #9 said he did not wear gloves when he removed the Spiriva capsule from the foil wrapper, as required. 2 a. For Resident #147, the facility staff failed to wear gloves appropriately when assisting a resident with a meal. Resident…

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

Based on observations and interviews, the facility staff failed to ensure dignity was maintained for four Residents (#66, #114, #115 and #490) out of a total of 37 sampled residents by displaying signs relative to resident care over two Residents' beds (#490 and #114), and standing over two Residents while feeding them (#66 and #115). Findings include: 1. Resident #66 was admitted to the facility in March 2022. On 6/10/22 at 8:05 A.M., the surveyor observed Unit Manager (UM) #3 standing over Resident #66 while feeding him/her breakfast. UM #3 said she was not aware she should have been seated beside the Resident while feeding him/her. Certified Nursing Assistant (CNA) #2 said UM #3 should have been seated while feeding Resident #66. 2. Resident #115 was admitted to the facility in April 2022. On 6/10/22 at 8:18 A.M., the surveyor observed CNA #1 feeding Resident #115, while standing over his/her bed. UM #3 arrived to assist CNA #1 and told CNA #1 and the surveyor that he should have been seated while feeding the Resident. 3. Resident #490 was admitted to the facility in May 2022…

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

Based on observation and interview, the facility staff failed to respect the residents' right to privacy of personal information by leaving a document with information for multiple residents in a resident's room on one out of the five units. Findings include: Review of the facility policy titled Resident's Rights Policy, dated January 2017, indicated that residents have a right to personal privacy and confidentiality of their personal information. On 06/13/22 at 8:32 A.M., the surveyor entered Resident #443's room on unit two and observed a paper with the names of the residents on the unit and their diet information lying on the Resident's room table. Resident #443 said that the paper had been on the table for a couple of days and should not have been left in the room. During an interview on 6/13/22 at 8:49 A.M., Nurse #5 said that having the paper in the residents room with other residents names on it was a privacy issue and a violation of the confidentiality of resident information. During an interview on 6/13/22 at 10:29 A.M., the Director of Nurses said that the paper with…

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

Based on record review and interview, the facility staff failed to complete a Minimum Data Set (MDS) Significant Change assessment within the required timeframe when one Resident (#19) was placed on Hospice, out of the 37 residents sampled. Findings include: Resident #19 was admitted to the facility in February 2022. Review of the record indicated that the Resident was placed on Hospice during a hospital admission in May of 2022 and returned to the facility. Review of the MDS assessments indicated that on 5/25/22, an MDS significant change assessment was initiated but never completed. During an interview on 6/14/22 at 12:55 P.M., MDS Nurse #2 said the resident had a significant change MDS assessment due on 6/2/22 and it was not completed as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) Assessment related to presence of a pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure), for one sampled Resident (#169), out of 37 sampled residents. Findings include: Resident #169 was admitted to the facility in October 2021. Review of the Physician Progress Note, dated 3/14/22, indicated the resident had a pressure ulcer located on his/her ankle. Review of the Wound Care Specialist Progress Note, dated 4/13/22, indicated the Resident had pressure ulcers on both his/her right and left ankle. Review of the Nurse Practitioner Progress Note, dated 4/14/22, indicated the resident had a pressure ulcer on his/her ankle. Review of the MDS Assessment, with the reference date of 4/14/22, indicated that Resident #169 did not have a pressure ulcer. During an interview on 6/14/22, at 8:58 A.M., the MDS Coordinator said that the MDS assessment dated [DATE] was not coded…

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

Based on record review and interview, the facility failed to ensure its staff developed a Baseline Care Plan for one Resident (#126) out of a total sample of 37 residents. Findings include: Review of the facility policy titled, Care Planning, revised on 6/21/19, included but was not limited to: - Within 48 hours of admission, members of the interdisciplinary team will meet with the resident/resident representative to identify the resident's needs, strengths, goals, life history and preferences and will initiate the Baseline Care Plan. -The Baseline Care Plan will focus on the primary reasons for admission, and at minimum any: safety issues .activities of daily living needs . Resident #126 was admitted to the facility in October 2021. Review of the clinical record indicated no Baseline Care Plan had been developed upon admission. During an interview on 6/13/22 at 11:44 A.M., Unit Manager #1 said there was no Baseline Care Plan in the clinical record and there should have been, as required.

Based on observation, interview and record review the facility failed to ensure its staff: 1.) implemented a care plan relative to behaviors for one Resident (#120) and, 2.) developed a comprehensive care plan relative to a hearing deficit for one Resident (#126) out of a total sample of 37 residents. Findings include: 1. For Resident #120 the facility staff failed to implement a care plan relative to intrusive and rummaging behaviors. Resident #120 was admitted to the facility in December 2017 with diagnoses including Wernicke's encephalopathy (a disorder that affects the brain and symptoms may include confusion, loss of mental activity, loss of muscle coordination and vision changes). On 6/07/22 at 4:00 P.M., the surveyor observed Resident #120 remove a plastic drinking cup containing apple juice from the nurse's station counter and begin to drink it. Other resident's sitting in the dayroom began yelling at Resident #120, stating that the drink was not his/hers and to put it down. The Resident continued to drink the apple juice and put the empty cup back onto the counter. 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 observations, interviews and record review, the facility staff failed to revise care plans for three Residents (#43, #94 and #114) out of a total of 37 sampled residents. Findings include: 1. For Resident #94, the facility staff failed to revise the care plan relative to requiring supervision while eating and the removal of his/her nephrostomy tube (a tube inserted into the kidney to drain urine), and discontinuation of a urinary catheter (a tube inserted through the urethra into the bladder to drain urine). Resident #94 was admitted to the facility in May 2018. Review of the Resident's clinical record included the following care plans: - Activities of Daily Living (ADLs): the Resident requires continual supervision of a 1:8 ratio (one staff member to eight residents) while eating, initiated on 12/24/20. The Resident has a urinary catheter in place, initiated on 2/2/22. - Renal: the Resident is at risk for complications related to bilateral nephrostomy tubes. Ensure placement in order to ensure the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility staff failed to provide wound care treatment and services in accordance with professional standards of care for one sampled Resident (#441), out of a total sample of 37 residents. Findings include: Review of a facility policy titled Skin Integrity Management, revised 3/16/22, indicated the facility will ensure the resident receives the necessary treatment to promote healing and prevent infection. Review of Facility Wound Care Protocols, undated, indicated specific protocols for wounds of any stage, including non-healing /chronic wounds, and all protocols indicated the following: -Document every shift the condition of skin impairment -Documentation must include appearance of the skin surrounding the intact skin, warmth and color of the skin -Document assessment of the wound bed (define), drainage, peri wound (the area surrounding the wound itself), erythema (redness), and pain with every dressing change Resident #441 was admitted to the facility…

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

Based on interview and record review, the facility failed to ensure its staff adhered to their Falls policy related to the assessment of a fallen resident prior to being moved,and increasing the potential for injury, for one Resident (#440) who fell, out of a total sample of 37 residents. Findings include: Review of the facility policy titled Guidelines for Fall Aftercare, revised May 2013, indicated: -The nurse will assess the resident after a fall. -Do not move resident until assessed by the nurse. Resident #440 was admitted to the facility in June 2022 with a diagnosis of Chronic Pain Syndrome. On 6/14/22 at 9:53 A.M. the surveyor observed Resident #440 seated on the side of his/her bed and the Resident told the surveyor that he/she fell a couple days ago. He/she said that he/she was seated on the side of the bed, fell asleep, slid to the floor, and tried to get off the floor when a kid came in and helped him/her off the floor. Resident #440 said that the nurse came in and did a concussion assessment. During an interview on 6/14/22 at 10:00 A.M., Nurse #5 said Resident #440 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide appropriate treatment and services, specific to care of the site, to one Resident (#443) with a Jejunostomy Tube (a surgically created opening through the stomach wall into the small bowel to provide access for the administration of liquid nutrition and fluids via a tube, J-Tube), out of a total sample of 37 residents. Findings include: Resident #443 was admitted to the facility in May of 2022 with a diagnosis of severe protein and calorie malnutrition and had a J-Tube. On 6/13/22 at 8:32 A.M., the surveyor observed Resident #443 in his/her room. Resident #443 said the J-Tube is fine but the dressing is supposed to be changed every day and had not been changed in three days. The Resident held up his/her shirt to allow the surveyor to observe the dressing which was a stack of loose split gauze sponges which were not secured with tape,or dated and timed. Review of the Minimum Data Set assessment dated [DATE] indicated the Resident…

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

Based on observation, interview and record review, the facility staff failed to provide respiratory care that was consistent with professional standards for one Resident (#443) receiving oxygen, out of a total sample of 37 residents. Findings include: Review of a facility policy titled Oxygen Administration, revised 11/16, indicated that oxygen set up should be replaced every seven days and should be dated and stored in a treatment bag when not in use. Review of a facility policy titled Oxygen and Respiratory Equipment, dated 2/27/2013, indicated that it is the policy of the facility to maintain respiratory therapy equipment according to acceptable standards of practice, and that disposable equipment will be changed on a weekly basis and if it becomes contaminated, and should be date/time labeled when changed. Resident #443 was admitted to the facility in May 2022 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set assessment, dated 5/25/22, indicated Resident #443 had a diagnosis of COPD, received oxygen therapy and scored 15/15 on 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, interviews and record reviews, the facility failed to ensure the staff responded to pharmacy recommendations/irregularities timely for one sampled Resident (#61) out of a total of 37 sampled residents. Findings include: Review of the facility policy titled Drug Regimen Review/Medication Regimen Review, revised on 10/17/18, indicated the following: 7. Follow-up on recommendations: a. Urgent recommendation(s) pertaining to a potential or actual clinically significant medication issue shall be resolved by midnight the next calendar day. b. Any non-urgent recommendation(s)/irregularities must be addressed within 30 days of the consultant pharmacist monthly visit. Resident # 61 was admitted to the facility in June 2021, with a diagnosis of other persistent atrial fibrillation (irregular heartbeat). Review of the pharmacy recommendation, dated 8/13/21, indicated the following: Eliquis (a blood thinning medication) is usually administered twice daily (BID). Please address the current once daily (QD) dosing. The recommendation was signed as agreed on 8/18/21. Review…

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

Based on observations and interviews, the facility staff failed to secure medications when a medication cart was unlocked and unattended on two of three nursing units observed. Findings include: Review of the facility policy titled, Storage of Medications, revised 6/10/22, included but not limited to that only licensed nurses and pharmacy personnel are allowed access to medications. Medication rooms, carts and medications are locked or attended by persons with authorized access. The facility Licensed Nurse Medication Administration Competency Evaluation indicated the licensed staff should demonstrate proper procedure for administering medications which included medication carts are always visible to the nurse or locked. a. On 6/10/22 at 7:50 A.M. on Unit One, the surveyor observed medication Cart C parked against the wall in hallway C. The medication cart was unattended and unlocked. Staff members were observed walking past the cart. During an interview on 6/10/22 at 7:53 A.M., Nurse #9 was observed exiting a closed resident's room. He said he did not lock the medication cart when…

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 that staff stored and prepared food in accordance with professional standards for food service safety, regarding the cleanliness of equipment, in two of five kitchenettes. Findings include: Review of the Dietary Department Guidelines Policy, dated May 2018, indicated all food preparation equipment must be maintained in a clean, sanitary and safe manner and used and repaired according to manufacturer's recommendations. On 6/10/22 at 8:05 A.M. of Unit Four Kitchenette, the surveyor observed the interior of the microwave oven to have multiple dark spots covering the top panel of the microwave. A large spot, approximately two inches in diameter was observed as lifted and flaky. The seams connecting the sides and top were observed to be darkened. During an observation of the Unit Four Kitchenette on 6/10/22, at 8:16 A.M., the Director of Nurses said the microwave should be replaced. On 6/10/22 at 8:21 A.M. in the Unit Five Kitchenette, the surveyor observed the bottom drawer of the refrigerator with multiple packets of…

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

Based on interview and record review the facility failed to ensure its staff 1.) documented if the Resident was offered and received an influenza immunization or did not receive the immunization due to medical contraindication or refusal for one Resident (#62) and 2.) documented if the Resident was offered and received a pneumococcal immunization or did not receive the immunization due to medical contraindication or refusal for one Resident (#174) out of 37 sampled residents. Findings Include: Review of the facility policy titled Resident Influenza (Seasonal Immunization), revised April 8, 2021, indicated the following: -The seasonal influenza vaccine will be offered annually unless the vaccine is unavailable, medically contradicted, the resident/patient refuses immunization or the resident/patient's representative, legal guardian, or healthcare agent refuses immunization on the resident/patient's behalf. -The Immunization Record inside the Electronic Health Record (EHR) will be used to document vaccine administration. - .If the risk of immunization outweighs the benefit, 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.