Sterling Care Riverside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, it was determined that the facility failed to ensure accurate information was placed in residents' records. This was evident for 2 (Resident #2 and #132) residents reviewed during the survey. 1) On 8/21/2025 at 2:13 PM, the surveyor spoke with the DON #2 and asked the question, Who is responsible for reviewing and implementing orders from the doctor after a doctor's appointment? DON #2 explained that the nurse should review the visit summary and update the orders when the resident returns, and the unit manager should also follow up to make sure that the orders are completed. DON #2 was notified that during the surveyor's record review, for Resident #2, there was no documentation of when the Foley was ever changed. DON #2 stated that she is not sure how they document it and that she would get back to the surveyor. When the DON #2 returned, she had brought the ADON #3 back with her. The ADON #3 explained that she had documented on 7/1/25 how Resident #2…

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 interviews the facility failed to: 1.) maintain optimal infection control and prevention precautions in one area of the laundry room and maintain a clean environment around the eye wash station and the laundry hopper, and ensure water pipes were not left exposed in the area next to and above the laundry hopper. This was evident for 1 out of 1 laundry area observed; 2.) ensure proper infection control/sanitization for any medical equipment that was shared among residents. This was evident for 1 out of 2 medication administration observations; and 3.) ensure oxygen equipment was properly dated to prevent potential infection control risks. This was evident for 1 (Resident #101) of 2 residents reviewed for oxygen use during the facility's recertification survey. The findings include: 1.) On 8/25/25 at 11:32AM the Administrator and the surveyor agreed to tour the laundry room on the ground floor of the facility. Laundry Supervisor #20 accompanied the surveyor and the Administrator into 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 a tour of the facility it was determined that the facility staff failed to ensure resident rooms were maintained in a homelike manner. This was evident as a result of random observations. The findings include: An environmental tour of the facility on 3/30/23 and 4/5/23 revealed: room [ROOM NUMBER] had a brown stain on the walls. The coaxle cable box was detached from the wall and hanging freely. Observation on 4/5/23 at 12:42 PM revealed that room [ROOM NUMBER] had a protective covering, door skin, coming off the door. The top left corner could be pulled away from door 2-4 inches revealing the adhesive backing material. The door to room [ROOM NUMBER] had its door skin partially detached from the door. This was observed on 4/5/23 at 12:49 PM. The second floor shower room baseboard molding, on the left hand side of the entrance area, was observed to be partially detached from the wall and the bottom corner of the same wall had a section of drywall damaged. The fall mat for 226 bed B had torn corners 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, interview, and medical record review it was determined that the facility failed to 1.) provide a resident with prompt assistance for positioning and failed to ensure the resident had access to their call bell device (Resident #504) and 2.) failed to document complete assessments of residents when there was a noted change in condition (#305 and #506). This was evident for 1.) 1 of 2 residents reviewed for positioning, and 2.) 2 of 4 residents reviewed for change of condition during an annual survey. The findings include: 1. On 3/27/23 at 10:00 AM surveyors observed a call bell request for assistance from Resident #504. Staff #11, Licensed Practical Nurse, was observed standing in the hallway until 10:03 AM when another staff member verbally told Staff #11 that the resident needed assistance, at which time they responded to the call light. Staff #11 was heard by surveyors telling Resident #504: Let me get somebody, and then was observed leaving the resident's room. An observation was made by surveyors on 3/27/23 at 10:05 AM of Resident #504, no staff was present…

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 medical record review, observation and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#5, #16, #24, #48, #61, #154, #156 and #508). This was evident for 8 of 63 residents selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current, and complete documentation in the medical record is an essential component of quality resident care. 1. Observation of Resident #5 on 3/27/23 at 2:18 PM revealed the Resident had bilateral hand contractures with no splints in place. Review of Resident #5's medical record on 3/30/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include quadriplegia. Quadriplegia refers to paralysis from the neck down, including the trunk, legs and arms. Review of the Resident's orders revealed an order on 1/25/23 that stated: Splint…

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 medical record review it was determined the facility failed to maintain the safest practicable level of precautions to prevent and control the spread of infectious disease. This was evident during multiple random observations throughout the facility. Review of the CDC website for Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 9/27/22, revealed the following guidance; Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Implement source control measures by; 1.use of respirators or well-fitting facemasks or cloth masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. 2. HCP who enter the room of 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 the review of medical records, interview with facility staff and review of pertinent documentation including facility policy, it was determined that the facility failed to implement and monitor the usage of antibiotics for the residents. This was identified during the review of the facility line listing during the annual Medicaid/Medicare survey and the infection control task. Random residents selected for review from the facility line listing included (R #80, #106 and #504) The findings include: Surveyor conducted initial review of the facility line listing related to the monitoring of infections in the facility with the facility Assistant Director of nursing/infection control nurse, staff #2 on 4/6/23 at 7:57 AM. Surveyors had immediate concerns with the provided line listings provided for the months of February though April. Through the titled 'Antibiotic Review' spreadsheet provided by the ADON and DON contained the expected columns and places to enter the appropriate and needed information to monitor and track antibiotics had many blank areas. For each month the name,…

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 medical record review and interview with facility staff, it was determined that the facility staff failed to consistently acquire resident vital signs timely for the Daily COVID-19 tool assessments. This was evident for 3 of 3 residents reviewed during the infection control part of the annual survey. The findings include: On 3/27/23 Surveyor reviewed random selection of residents identified as new admissions and monitored for COVID-19. 1. During the review of the medical record regarding COVID-19 daily screenings for Resident #95 on 3/27/23 revealed the following: Daily Covid Tool completed 3/26/23 at 3:45 AM with vital signs for 3/15/23 at 6:20 PM, these vital signs also were put in for the 3/15/2023 11:31 PM assessment. 2. Review of the medical record for Resident #505 on 3/28/23 at 7:30 AM revealed the following: The Daily COVID Tool completed for 3/12/23 and 3/13/23 had vital signs that documented as acquired on 3/12/23 at 12:37 PM and 3/11/23 2:26 PM. Vital signs acquired on 3/13/23 at 12:28 PM documented on two of 3/14/23 Daily COVID Tool's and one of the 3/15/23…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure residents were offered the opportunity to either provide a copy of already written Advanced Directives and/or create a set of Advanced Directives (#28 and #506). This was evident for 2 out of the 63 residents in the survey sample. The findings are: 1. A review of Resident #28's clinical record on 3/29/23 at 8:00 AM revealed that a copy of an Advanced Directive or a progress note indicating that the resident was offered the opportunity to create an Advanced Directive could not be found in the electronic health record. This surveyor requested evidence of an Advanced Directive on 3/29/23 at 1:00 PM from the Director of Nursing (DON). The social worker (Staff #21) was interviewed on 3/31/23 at 9:03 AM. She said the resident signed a form designating a Power of Attorney. Another request was made for a copy of the Advanced Directives. A review of the clinical records on 3/31/23 at 11:01 AM revealed that Staff…

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 medical record review and interview with facility staff, it was determined that the facility failed to notify family and the physician timely when notified of a residents change in condition. This was evident during a random observation. The findings include: Surveyor completed observations and interviews with Resident #95 on 3/27/23 10:34 AM. S/he was interviewed just after returning from a session at rehabilitation. Surveyor observed Resident #95 to have increased work of breathing and coughing which s/he also verbalized to the surveyor. Surveyors left the room and immediately reported the observations and reported concerns from the resident to LPN Staff #11 at 10:40 AM. The surveyor returned to the hallway on 3/27/23 to where Resident #11 resides to follow-up on Resident #95's status. Resident #95's son/RP was in the room visiting at that time. On 3/29/23, surveyor reviewed Resident #95's medical record. According to the completed 'SBAR' situation, background, assessment, recommendation, change in condition form initiated on 3/27/23, the resident 'RP' representative 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 while touring the facility it was determined that the facility staff failed to protect the privacy of its residents (#9). This was evident as a result of three random observations. The findings are: 1. While touring the facility as part of an environmental review two tops of medication bingo cards were found stuck between the small handrail in the middle of rooms [ROOM NUMBERS] and the wall. Resident #9's medications were Lasix (a diuretic) and Potassium Chloride. The tops were handed to the unit manager for Unit One who then disposed of the tops. 2. On 3/27/23 at 8:30 AM, Staff #11 was observed walking away from their medication cart, off the unit, to obtain the blood pressure machine leaving patient information on their computer screen visible. At 8:31 AM Staff #11 returned and proceeded to walk past their medication cart, at which time surveyors communicated the concern to Staff #11, their response to surveyors was Oh, I just left it. Surveyors then observed Staff #11 lock their computer…

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 medical record review, observation and staff interview, it was determined that the facility staff failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment (Resident #50, #73 and #80). This was evident for 3 out of 63 residents selected for review during an annual survey. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The findings include: 1. Observation of Resident #73 on 3/27/23 at 8:11 AM revealed the Resident to be edentulous (without teeth). Interview with the Resident at that time, the Resident stated he/she had his/her teeth pulled and is waiting on dentures. Review of Resident #73's medical record on 3/30/23 revealed the Resident was admitted to the facility on [DATE]. On 12/3/21 the facility staff completed an oral evaluation…

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 clinical record review and staff interview it was determined that the facility staff failed to ensure its residents had a complete and accurate Preadmission Screening and Record Review (PASRR). This was evident for 1 out of 63 residents in the survey sample. The findings are: A review of Resident #24's clinical record on 3/29/23 at 9:46 AM revealed the resident had a PASRR completed on 2/15/23. Section B Intellectual Disability (ID) and related conditions has four questions and if one or more is checked as yes then the resident is considered to have ID or a related condition. The facility staff answered one question as yes but marked no to whether or not the resident had ID or a related condition. A review of Section D revealed it was left blank. Staff are instructed to complete the section if a resident is scored to have ID or a serious mental illness. The social worker (staff # 23) was interviewed on 3/30/23 at 12:36 PM. She said they sent it to Adult Evaluation and Review Services (AERS) and a Level II evaluation was deemed unnecessary. The findings were explained 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 and medical record review it was determined the facility failed to address presence and care of a resident's foley catheter (tube that drains urine from the bladder) in the resident's baseline careplan. This was evident for one out of three residents reviewed for catheters. The findings include: On 3/28/23 at 9:00 AM, surveyors observed Resident #506's foley catheter bag laying on the floor under their bed. During record review on 3/31/23 at 1:05 PM, the hospital discharge summary for Resident #506. The hospital Discharge summary dated [DATE] addressed recommendations for the resident being discharged with a foley catheter in place. Upon further record review on 3/31/23 at 1:05 PM, the baseline careplan dated 3/20/23 and signed on 3/23/23 for Resident #506 was reviewed. The baseline careplan revealed Resident #506 was admitted to the facility on [DATE], approximately four days prior to the effective date of the baseline careplan. The baseline careplan provides for identification 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 resident medical records, the facility failed to take a resident to the bathroom (Resident #458), change a resident in a timely manner (Resident # 27) and provide showers (Resident #508). This was evident for 3 out of 7 residents reviewed for ADL care during an annual survey. Findings include: 1. Resident # 458 was admitted to facility on 12/3/22 and discharged on 2/23/23. According to a complaint from daughter of resident # 458, resident was left for over 4 hours before she/he was changed. Daughter stated he/she is expected to eat his/her lunch while needing to be changed. Daughter stated, 'we have tried to resolve the issues with the staff, but they just don't care. She/he has also been double diapered so they would not have to changed him /her so much. Daughter stated ' My niece is there every day and has spoken to them regularly about the problems. Physical therapy does not do therapy every day as it should be done, and did not try to help get her changed when this happened. Medical record review was conducted on 4/3/23 at 9:38 AM. Resident# 458 has a BIMS of 15 out 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 medical record review, observation and interview, it was determined the facility staff failed to provide supplements as recommended by the dietitian for a resident (#64). This was evident for 1 of 4 residents selected for review for nutrition during the annual survey. The findings include: Observation of Resident #64 on 3/27/23 at 10:06 AM revealed the Resident appeared to be thin. Review of Resident #64's medical record on 3/29/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dementia. Dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities. Further review of the Resident's medical record revealed the Resident weighed 148.9 pounds on 3/1/23. The Resident was assessed by the Dietitian on 3/5/23 for weight loss. At that time the Dietician wrote in the Dietitian Progress Note for the Resident to have Ensure Plus twice a day. Ensure Plus is 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 medical record review and interview, it was determined the facility staff failed to include provider notes in the medical record in a timely manner with accurate date of visit (Resident #508). This was evident for 1 of 63 residents reviewed during an annual survey. The findings include: Resident #508 was admitted to the facility beginning on 3/22/23. Staff #49, Nurse Practitioner, documented they performed an initial visit with the resident on 3/23/23. Documentation of the visit via a progress note with a date of service for 3/23/23 was electronically signed and uploaded on 3/27/23 at 8:30 AM after surveyors were present in the facility. During an interview with the Director of Nursing (DON) on 3/30/23 at 9:16 AM concerning this resident's records, they reported the facility's medical records department is responsible for uploading of provider notes and keeping track of provider visits. After surveyor brought the concern to the DON's attention on 3/30/23 at 9:16 AM, Staff #49 electronically signed a progress note on 3/30/23 at 9:46 AM for a visit with Resident #508…

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 with facility staff it was determined the facility failed to address and identify the use of a medication in a resident's plan of care (Resident #508). This was evident for one out of three residents reviewed for unnecessary medications. The findings include: On 3/31/23 at 9:26 AM, review of the medical record for Resident #508 revealed they required a necessary anti-depressant medication: fluoxetine. The facility's medication order for fluoxetine states the medication is being given to the resident for depression. Staff #49, Nurse Practitioner, documented via progress notes as having seen Resident #508 on the following dates: 3/23/23, 3/28/23, and 3/29/23. Staff #49's progress notes for visits occurring on 3/23/23, 3/28/23, and 3/29/23 revealed that fluoxetine use was not identified and addressed in the resident's plan of care. During an interview with the facility DON on 3/31/23 at 10:09 AM, surveyor concern was reviewed.

Based on observations of the facility's kitchen and interviews of the dietary staff it was determined that 1) the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety and 2) ensure the food maintained an acceptable serving temperature. These deficient practices have the potential to affect all residents. The findings include: Wet nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. FDA guidelines mandate that all wares should be air dried. Using towels to dry dishes is never permitted. 1) During the initial tour of the kitchen on 03/27/2023 at approximately 12:14 PM, the surveyors and food service manager #15 observed large metal pans stacked inside of each other on a drying rack. On closer observation the surveyors and the food service manager observed wet nesting in several of the large metal pans. The food service manager confirmed the metal pans should not have been stacked inside one another preventing 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 it was determined the facility staff failed to properly label and date food stored in the walk-in refrigerator. This was evident during the initial tour of the kitchen during the investigative portion of the survey. The findings include: Observation was made during the initial tour of the kitchen on 12/18/2018 at 18 08:17 AM: 1. The egg salad sandwich in the walk-in refrigerator did not have an expiration date. 2. Two packages of yellow cheese in the reach-in refrigerator was wrapped in plastic wrap and did not have an expirations date. 3. The butter was open to air in the reach-in refrigerator and did not have an open or expirations date. 4. On 12/21/18 10:50 AM tour of kitchen revealed a floor fan blowing air in the direction of the prep table. These deficiencies were confirmed with the food service manager on 12/18/2018 and 12/21/18.

Based on observation, it was determined that the facility staff failed to treat each resident in a dignified manner for. This was evident for 8 of 40 residents (#13, #55, #39, #87, #12, #73, #100, and #63) reviewed during the annual survey. The findings include: 1. During an observation of Resident #13 on 12/20/18, at 9:18 AM and 9:56 AM, it was observed that employee #18 failed to knock on the door before entering Resident #13's room on two separate occasions. 2. On 12-18-18 from 12:00 PM to 12:35 PM in the second floor dining room meal service was observed. Resident #55, #39 and #87 were seated at a table. At 12:00 PM Resident #87 had been served and was eating. By 12:15 PM Resident #55 who had not been served was grabbing for Resident #87's meal. Resident #55's meal was served at 12:18 PM and when served Resident #55 yelled Hallelujah. Resident #39 was not served until 12:20 PM. On 12-18-18 at noon Resident #12 was seated at a table with Resident's #73 and #100. Resident's #73 and #100 had been served and were eating. Resident #12 had not been served. At 12:20 PM Resident #12 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, review of a medical record, and staff interview, it was determined the facility staff failed to 1) obtain a physician's order to use a restraint on a resident, 2) evaluate the use of a restraint on a resident, and 3) initiate a care plan for the use of the restraint on a resident. This was evident for 1 (Resident #55) of 1 resident reviewed for physical restraints during an annual recertification survey. The findings include: Review of Resident #55's medical record on 12/20/18, revealed staff documentation of a phone call with Resident #55's health care power of attorney (HCPOA) on 08/14/18 that detailed Resident #55's HCPOA giving the facility staff permission to apply a body alarm to Resident #55 for the reason that Resident #55 attempted to get up unassisted, was unable to follow directions due to cognitive loss, and a benefit to deter falls. Review of Resident #55's care plans revealed a fall care plan that listed the following nursing interventions: check the function and placement of body alarm, ensure the environment is free of clutter, use floor mats…

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 staff interview, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by trimming the resident's finger nails. This was evident for 2 (#13, #96) of 6 residents reviewed for ADL care during an annual recertification survey. The findings include: 1. During an observation of Resident #13 on 12/20/18 at 9:56 AM with employee #18, Resident #13's finger nails were observed to be long and pressing into both palms of his/her hands. No wounds were observed to Resident #13's palms. Resident #13 did not have any type of splint in place to both hands to protect his/her palms from his/her long finger nails. Employee #18 stated that Resident #13 was to have bilateral hand splints in place also. 2. This surveyor interviewed Resident #96 on 12/18/18 at 1:47 PM. During the interview it was observed that the resident's fingernails were long. The resident said a staff member told him/her they do not have fingernail clippers in the facility, so they can't be cut to the resident's liking. The resident 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 and interview, the facility staff failed to apply ace bandage wraps for Resident #89 and Ted stockings for Resident #351. This was evident for 2 of 40 residents during the investigative portion of the survey. The findings include: 1. Medical record review for Resident #89 revealed on 11/28/18 the physician ordered: ace bandage wrap apply in am/remove at bedtime. To be applied before getting out of bed for orthostatic blood pressure control. Surveyor observation of the resident on 12/19/18 at 11:30 AM and on 12/20/18 at 9:30 AM, revealed the resident sitting in his/her wheelchair in the room, however the facility staff failed to apply the ace bandage as ordered by the physician. 2. Medical record review for Resident #351 revealed on 12/14/18 the physician ordered: Ted stockings, knee high apply in AM remove in PM. Surveyor observation of the resident on 12/19/18 at 10:30 AM, the resident was sitting in his/her wheelchair near the nursing station and on 12/20/18 at 2:00 PM revealed the resident sitting in his/her room however, the facility staff failed to apply…

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, medical record review and staff interview it was determined the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (Resident #13) of 4 residents reviewed for mobility during an annual recertification survey. The findings include: Review of Resident #13's December 2018 physician's orders revealed the order Right and left-hand soft palm guard as tolerated. Remove for hygiene. Check skin every shift. with a start date of 03/13/18. There was also an order elevate heels while in bed every shift, and an order foam heel protectors to bilateral heels for pressure reduction, check for positioning every shift. Observation was made of Resident #13 on 12/20/18 at 9:56 AM with employee #18. Resident #13 was lying in bed with both legs pointed straight out to the end of the mattress. Both of Resident #13's hands were contracted with hands in fists. Resident #13 did not have hand splints on hands and both legs were lying directly 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 review of employee files and staff interview, it was determined that the facility failed to perform an annual performance review for a geriatric nursing assistant (GNA, Staff #5). The findings include: Review of Staff #5's employee file on 12-19-18 at 1:00 PM revealed an annual performance evaluations completed on 5-30-17 with none for 2018. On 12-19-18 at 1:30 PM confirmed with the Director of Nursing that the required annual performance evaluation for Staff #5 was not done.

Based on observation, staff interviews and review of facility daily narcotic and amphetamine count per shift records, it was determined that the facility failed to accurately complete the narcotic and amphetamine count per shift records. This was evident for 2 of 4 medication storage carts reviewed. The findings included: On 12-19-18 at 1:15 PM the narcotic and amphetamine count per shift record on their medication cart was reviewed with Staff #5. On 12-18-18 at 3:00 PM and 12-19-18 at 7:00 AM the nurse relinquishing the narcotic key did not sign the record. On 12-18-18 at 11:00 PM the nurse receiving the narcotic key did not sign the record. On 12-19-18 at 1:45 PM the narcotic and amphetamine count per shift record on their medication cart was reviewed with Staff #7. The record revealed on 12-16-18 at 11:00 PM and 12-19-18 at 7:00 AM the nurse receiving the narcotic key did not sign not the record. On 12-17-18 at 7:00 AM the nurse relinquishing the narcotic key did not sign the record. The inaccurate narcotic and amphetamine count records was confirmed with the Director of Nursing…

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

Based on observation, medical record review, and staff interview, it was determined that the facility failed to obtain dental services for a resident. This was evident for 1 (Resident #36) of 5 residents reviewed for dental services during an annual recertification survey. The findings include: Review of Resident #36's medical record revealed an annual minimum data set (MDS) assessment, dated 10/08/18, under section D - 0200, which indicated Resident #36 likely had cavities and broken teeth. The facility staff initiated a dental care plan at this time with nursing interventions that included: to refer resident to a dentist/hygienist for evaluation and treatment. During an observation of Resident #36 on 12/18/18 at 12:57 PM, Resident #36 was noted to have missing teeth. In an interview with employee #3 on 12/21/18 at 9:27 AM, employee #3 stated that resident had not had a dental referral or consult since admission to the facility. Review of Resident #36's MOLST form revealed Resident #36's guardian of person wanted Resident #36 to receive all types of care and treatment while…

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

Based on interview, medical record review, and staff interview, it was determined that the facility failed to obtain dental services for a resident. This was evident for 1 (Resident #55) of 5 residents reviewed for dental services during an annual recertification survey. The findings include: Review of Resident #55's medical record revealed a dental care plan on 08/20/18 with nursing interventions that included: Resident's dentures will be properly store & maintained in good repair, Resident will not lose dentures, check linens/ wastebasket for dentures before discarding, instruct resident in proper handling/ storage of dentures, Refer to dentist/ hygienist for evaluation/recommendations re: denture realignment, new fitting, teeth pulled, repair of carious teeth as needed. During an interview with Resident #55's representative on 12/18/18 at 11:12 AM, Resident #55's representative indicated the facility had lost Resident #55's upper denture. In an interview with employee #3 on 12/20/18 at 11:32 AM, employee #3 confirmed Resident #55 had an upper denture and had not been seen by 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 it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection. This was evident during observation of an Indwelling Foley Cather for Resident #99. This was evident for 1 of 2 resident's selected for review of Indwelling Foley Cather. The findings include: A review of Resident #99's clinical record revealed that the resident had an Indwelling Foley Catheter related to urinary retention. During surveyor observation of Resident #99 on 12/18/18 at 9:45 AM, Resident #99 was sitting in the wheelchair in his room with the Foley Cather drainage bag attached to the bottom of the wheelchair causing it to rest on the floor. Another observation on 12/18/18 at 11:39 AM, The resident was being transported up the hall with Foley Cather drainage bag still attached to the bottom of the wheel chair dragging on the floor. An observation on 12/19/2018 at 12:53 PM, the resident was sitting in the wheelchair in his/her room and the Foley Cather drainage bag was noted to be hanging 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.