Waldorf Center

Based on observations, medical record review and interviews with facility staff, it was determined the facility failed to follow professional standards of practice during medication administration observation by not signing off a medication for a resident (#40) after administration, and not administering physician ordered medications to residents (#106 and #107) at their scheduled times. This was found to be evident during medication administration observation during the survey.The Findings Include:1. During the initial screening process of residents on the A Unit Wing, a Licensed Practical Nurse (LPN) #5 was observed on 1/15/26 at approximately 9:55 AM in resident #40's room. At this time resident #40 complained of an upset stomach and headache. The surveyor accompanied the nurse to the medication cart, and she retrieved Oxycodone 5 milligrams (mg) (1) tablet labeled for resident #40 from the narcotic drawer and signed the narcotic medication book. She went to resident #40's room and administered the oxycodone 5 mg tablet to the resident.During a medical record review for 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, record review, and interviews with staff, it was determined that the facility failed to ensure the tube feed formula container and bag of flush was labeled. This was evident for 1 (Resident #65) out of 2 Residents reviewed for tube feeding during the facility's recertification survey. The findings include:On 1/15/2026 at 9:24AM, an observation of Resident #65 revealed that he/she was in the process of receiving enteral nutrition by means of tube feeding. During further observation of the tube feeding system, the Surveyor discovered that the facility failed to label the tube feeding formula container with the attached tubing with the resident's name, formula name/type, date/time hung, and administration rate/method. The facility failed to label the clear bag of flush with the resident's name, the volume and type of flush, and the date/time hung.A review of Resident #65's electronic medical record on 1/15/2026 at 12:00PM revealed the resident had a feeding tube for nutritional support due to medical condition. There were physician orders which included NPO…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview it was determined that the facility failed to ensure that Residents were properly assessed for the safe use of bedrails, obtain consent from the Resident or Resident Representative prior to use of bedrails, and obtain a physician's order for the use of bedrails. This was evident for 2 (Resident #15 and # 23) out of 8 Residents reviewed for accidents during the facility's recertification survey.The findings include:Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails.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.

Based on observations and interviews with facility staff it was determined the facility failed to store biologicals in accordance with guidance and ensure that medications opened and refrigerated had a date opened label on it. This was found to be evident for medications found in 1 of 2 medication rooms (B wing) observed during the facility's survey. The Findings Include: An observation was made of a B wing medication room on 1/21/26 at approximately 9:00AM with staff # 3, a Registered Nurse (RN) present. While observing the medications that were stored in the refrigerator, the following concerns were identified: 1. An opened multidose bottle of Tuberculin Purified Protein Derivative with a written date label of 1/9/25 on the bottle. 2. An opened multidose bottle of Tuberculin Purified Protein Derivative that did not have a date label on the bottle indicating when the bottle was opened.Staff # 3 stated at that time that all medications are to be labeled upon opening. She went on to say that the medications are to be discarded after 30 days. On the same date the facility provided 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, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly cleaned food preparation equipment for use and that clean pans were air dried prior to storage. These failures had the potential to increase the risk of foodborne illness and had the potential to affect 103 of 110 residents (seven residents received nutrition via tube feedings with some pleasure foods allowed) in the facility who received dietary services. Findings include: 1. During an observation and interview on 08/13/24 at 9:10 AM, the Account Manager Dietary (AMD) confirmed the meat slicer blade had food remnants on it and needed to be cleaned before it was used. During an interview on 08/13/24 at 9:10 AM, the AMD stated, it's my expectation that . the meat slicer be properly cleaned after each use, it should not have food left on it Review of the facility's policy titled, Equipment, dated 09/2017, revealed, Policy Statement: All food service equipment will be clean, sanitary, and in proper working order. Procedures: 1. All equipment will be routinely cleaned…

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

Based on observation, interview, and facility policy review, the facility failed to ensure garbage was properly disposed of and contained in one of one dumpster areas which would affect 110 census residents and staff in the facility. This failure had the potential to attract pests. Findings include: Observation on 08/13/24 at 9:35 AM, with the Account Manager Dietary (AMD) of the area in the parking lot, behind the building where the trash dumpsters were located, revealed one of two dumpsters used to contain the facility trash and recycling material were open. The top lid was left open. There was a large trash bag lying on the ground between the two dumpsters that had been ripped open. During an interview on 08/13/24 at 9:35 AM, the AMD stated, The dumpsters should be closed, and bags of trash should be placed inside the dumpsters and not left on the ground. Review of the facility's policy titled, Environment, dated 09/2017, revealed Policy Statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . 6. All trash…

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, record review, and policy review, the facility failed to make preplanned menus and a list of alternative foods readily available to four of four residents (Resident (R) 31, R41, R50, and R101) reviewed for choices in a total sample of 42 residents resulting in the residents not having the opportunity to choose their meal or their choice of an alternative food prior to being served. This increased the risk of residents receiving foods not to their liking and being unaware of alternative food choices available to them. Findings include: 1. During an interview on 08/13/24 at 12:19 PM, R101 stated that no one asked him/her what his/her preferences were for menu selection each day. Review of R101's electronic medical record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/24 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R101 had no cognitive impairment. R101's dietary preferences were requested, and nothing was received. During an observation on 08/15/24 at 8:15 AM, R101…

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 act promptly to the concerns and requests of the resident council to receive meal menus and to consider their preferences for food choices. Five residents (Resident (R)11, R12, R56, R63, and R72 ) who regularly attended resident council expressed that their concerns had repeatedly been unresolved and unanswered. Findings include: During a group interview on 08/17/24 at 3:00 PM with five residents (R11, R12, R56, R63, and R72) in attendance, they reported they have requested a meal menu each week for selecting their food choices and for their food preferences to be considered. The residents expressed they did not receive a rational for their requests not being received. Each resident attending the group meeting was listed on previous month's resident council meeting notes list of attendees. The group of residents indicated they reported the same concerns at every monthly meeting but did not receive an explanation or resolution to their concerns and continued complaints. During the interview, R11 stated they did not receive…

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 review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control measures while caring for two of three residents (Resident (R) 31 and R1) reviewed for infection control out of a total sample of 31 residents. These failures increased the risk of COVID transmission and cross contamination during care for a resident on Enhanced Barrier Precautions. Findings include: 1. Review of R31's electronic medical record (EMR) Orders tab revealed a physician order, dated 08/06/24, for Strict isolation, droplet precaution due to Covid positive diagnosis. During an interview and observation on 08/13/24 at 3:06 PM, Licensed Practical Nurse (LPN) 3 was observed performing wound treatment on R31's right lower leg. R31 stated s/he was not able to leave his/her room due to being positive for COVID. LPN3 was observed to finish the wound treatment, doff (take off) her Personal Protective Equipment (PPE) including gloves and place the PPE in a trash container inside R31's room. LPN3 then left the room without…

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

Based on interviews and record review, the facility failed to invite one of four residents (Resident (R) 41) reviewed for care planning out of a total sample of 31 residents to care plan meetings. This failure increased the risk that the resident would not have any direct input into his/her plan of care. Findings include: Review of the electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R41 was cognitively intact. Review of the EMR Clinical Resident Profile revealed R41's mother was listed as the care conference person. During an interview on 08/15/24 at 12:38 PM, R41 stated that his/her mother attended the care plan meetings but s/he did not but s/he would like to attend. Review of the EMR Progress Notes, dated 08/01/24, revealed R41's mother attended the care plan meeting, but the resident did not. The Progress Note documented a referral to the rehab department along with the resident's full code status were discussed with R41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation of resident rooms, equipment, and interviews, it was determined the facility staff failed to 1.) provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, this was evident on 2 of 3 nursing units observed along with the dining room; and 2.) failed to exercise reasonable care for protecting one supplemental resident's (Resident (R)169) personal property from loss or theft. The findings include: 1.) On [DATE] at 10:58 AM observation was made of room [ROOM NUMBER]. The left wall by the door entrance had a large, spackled area that was not painted over that was at least 2 1/2 ft. by 3 ft. The laminate was peeling off the 4 dresser drawers. The handrail in the bathroom had brown material and brown drip marks near the front of the handrail by the door approximately 5 inches long. On [DATE] at 11:06 AM observation was made of room [ROOM NUMBER]. The privacy curtain was stained with brown and black material. The floor was dirty…

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 documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) (Resident #15, #55). This was evident for 2 of 17 residents reviewed for allegations of abuse, neglect or an injury of unknown origin during an annual survey. The findings include: 1. On 8/14/24 review of facility reported incident MD00179419 revealed Staff #8 reported she witnessed Staff #7 hit Resident #15's hand on 5/19/22. Review of the Comprehensive and Extended Care Facilities Self-Report Form revealed the facility submitted the initial report to OHCQ on 5/26/22 with a date and time of the incident of 5/19/22 at 4:00 PM, 7 days after the alleged incident. Interview with the Director of Nursing and Administrator on 8/14/24 at 4:00 PM confirmed the facility failed to report an allegation of abuse to OHCQ timely.2) On 8/20/24 at 9:00 AM facility reported incident MD00208736 was reviewed and revealed Resident #55 alleged that…

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

Based on documentation review and interview, it was determined the facility failed to thoroughly investigate an allegation of abuse for a resident (Resident #15). This was evident for 1 of 17 residents reviewed during an annual survey. The findings include: On 8/14/24 review of facility reported incident MD00179419 revealed Staff #8 reported she witnessed on 5/19/22 Staff #7 hit Resident #15's hand. Review of the facility investigation provided by the facility on 8/14/24 revealed it was incomplete. It did not contain the name of Staff #8 or a statement from Staff #8. It did not contain any other statements from staff that worked the day of the alleged incident other than Staff #7. Further review of the facility investigation also revealed the facility failed to obtain any statements from residents that also were receiving care from Staff #7 to see if there were any other concerns of abuse. Interview with the Administrator and Director of Nursing on 8/14/24 at 4:00 PM confirmed the facility staff failed to complete a thorough investigation of alleged abuse of Resident #15 on 5/19/22.

Based on interview and record review, the facility failed to provide a written notice of transfer to the resident or family/representative for one of three residents (Resident (R) 471) reviewed for hospitalizations of 31 sampled residents. This failure had the potential for the residents or their representatives to lack the knowledge of where and why they were transferred and how to appeal the transfer if desired. Findings include: Review of the electronic medical record (EMR) significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/23 revealed R471 was severely impaired cognitively and dependent on all Activities of Daily Living (ADLs) except eating. Review of the EMR Progress Notes tab revealed a nurse's note, dated 10/07/23, stating R471was found with his/her head against the side rail and bleeding from the forehead. The progress note stated after the nursing staff provided first aid it was determined that R471 had a laceration on his/her forehead from either the side rail or the resident's long jagged fingernails. According to the progress note,…

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 an accurate pre-admission screening and resident review (PASARR) Level II of a resident for a mental disorder (MD) or intellectual disability (ID) was utilized for one of five residents (Resident (R) 81) reviewed for PASARR. The failure to ensure R81 received a Level two PASARR evaluation for MD/ID or a related condition, could prevent the resident from attaining or maintaining his/her highest practicable level or result in a decline in the resident's physical, mental or psychosocial well-being. Findings include: Review of R81's undated admission Record, located in R81's electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/06/23 and diagnoses included but not limited to: moderate intellectual disabilities, bipolar disorder, schizoaffective disorder, unspecified psychosis, and anxiety disorder. Review of R81's annual ''Minimum Data Set (MDS),'' located in the EMR under the ''MDS'' tab, with an Assessment…

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 have quarterly care plan meetings for residents, and to invite the resident and/or the resident representative to participate in the development of the resident's care plan and This was evident for 3 of 44 residents (Resident (R) 51, #901 & # 923) reviewed for care planning. This failure placed the residents at risk of unmet care needs and a decrease in quality of life. Findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan…

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 provide nail care to two of four residents (Resident (R) 1 and R41) reviewed for activities of daily living (ADLs) out of a total sample of 31 residents. This failure increased the risk for scratches to the skin which increased the risk of skin breakdown and infection. Findings include: 1. Review of R1's electronic medical record (EMR) revealed an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/24. Further review of this MDS revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R1was cognitively intact but totally dependent on staff for all ADLs. Review of the EMR Care Plan tab revealed a care plan, revised on 02/25/24, Resident/Patient requires dependent for ADL care in; bathing, grooming, personal hygiene . related to MS [Multiple Sclerosis], functional quadriplegia [paralysis of arms and leg] . Residents/ Patients ADL care needs will be anticipated and met throughout the next review period . During an observation on 08/13/24 at 4:27 PM,…

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 staff interview it was determined the facility failed to schedule a follow-up colonoscopy per physician's orders. This was evident for 1 (#906) of 40 residents reviewed for the complaint portion of the annual survey. The findings include: On 8/15/24 at 8:12 AM Resident #906's medical record was reviewed and revealed the resident was admitted to the facility in August 2022 with diagnoses that included gastrostomy status, GERD (gastrointestinal reflux disease), and peptic ulcer. A G-tube (gastrostomy) is a small, soft tube that is surgically inserted through the abdomen and into the stomach to provide direct access for feeding, hydration, or medicine. Review of Resident #906's paper medical record revealed a Report of consultation that was dated 4/19/23 which documented, poor colon prep. Solid stool throughout colon. No visualization. Repeat colonoscopy in 1 month. On the lower right-hand corner of the consultation paper was, schedule in 1 month with initials. On 8/15/24 at 9:04 AM Staff #6 was interviewed and stated she was responsible to coordinate…

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 and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #901). This is evident for 1 of 3 residents reviewed for pressure ulcers during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). Review of Resident #901's medical record on 8/14/24 revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility staff failed to ensure a resident received proper foot care and treatment. This was evident for 1 of 45 residents (Resident #904) selected for review during the complaint survey process. The findings include: On 8/19/24 at 12PM, investigating complaint MD00196654 revealed that Resident #904 was admitted to the facility on [DATE] with a diagnosis of amputation of left #2 toe. On 8/16/23 the physician ordered: Cleanse left 2nd toe surgical site with wound cleanser, pat dry. Cover with dry dressing daily. Every day shift. Further medical review revealed on 8/16, 8/18, 8/20, 8/23, and 8/26 that the 2nd toe surgical site was not cleaned and Cover with dry dressing daily as ordered by the physician. On 8/20/24 at 3:30PM an interview of the Director of Nursing revealed that there is no nursing progress notes or wound notes in the medical record to indicate that the wound care was done per physician orders.

Based on observations, record review, interviews, and policy review, the facility failed to consistently apply a hand splint ordered to prevent further contractures (deformity of a joint or joints due to the shortening of muscles and/or tendons) in one of seven residents (Resident (R) 72) reviewed for positioning and mobility in a total sample of 31 residents. This failure increased the risk of further loss of mobility and increased contractures. Findings include: Review of the electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R72 was cognitively intact. Further review of this MDS revealed R72 had impaired range of motion of the left upper extremity. Review of the Orders tab of the EMR revealed a physician's order dated 12/10/23 for a left hand roll splint to be worn for four consecutive hours during day shift. Further review of the Orders tab revealed an order dated 03/29/23 for Occupational Therapy splinting and contracture…

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 a complaint, medical record review, and staff interview, it was determined the facility failed to administer respiratory inhalers as ordered for a resident who required respiratory treatment. This was evident for 1 (Resident #909) of 31 residents reviewed for complaints. The findings include: On 8/19/24 at 9:51 AM a review of complaint MD00190541 alleged that the facility was not doing breathing treatments correctly for Resident #909 and that no one was assisting the resident who had a diagnosis of dementia. On 8/19/24 at 9:51 AM Resident #909's medical record was reviewed and revealed a Physicians History and Physical dated 3/20/23 which documented that Resident #909 was admitted from the hospital to the facility for treatment following respiratory failure secondary to COPD/Asthma exacerbation. Resident #909 was in intensive care, started on steroids, antibiotics, and nebulizer treatments. Review of March and April 2023 physician's orders revealed Resident #909 was to receive 2 inhalers: Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)) 4 ml.…

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 a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident during the complaint survey for Resident #903. The findings include: On 8/15/24 at 12 PM a review of Resident #903's clinical record revealed that the resident's primary physician on 11/13/23, ordered Dilaudid (Hydromorphone) Oral Tablet 2 MG, give 1 tablet by mouth every 6 hours as needed for Pain. This medication is used to help relieve moderate to severe pain. Dilaudid (Hydromorphone) belongs to a class of drugs known as opioid analgesics. A review of the December 2023, Control Medication Utilization Record revealed Dilaudid (Hydromorphone) on the following days and times was removed from the controlled lock box on 12/13 with no time noted, 12/15 @ 8:30PM, 12/16/at 8:30PM, 12/17 at 11:30 PM,…

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, interviews, and policy review, the pharmacist failed to identify that adverse consequences and target behaviors were not identified or monitored for one of five residents (Resident (R) 107) reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of residents receiving an antipsychotic medications without proper monitoring. Findings include: Review of the electronic medical record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/24 revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R107 was severely cognitively impaired. Further review of this MDS revealed R107 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and Parkinsonism with no hallucinations, delusions, or verbal or physical behaviors towards self or others. Review of the EMR Orders tab revealed a physician's order, dated 07/22/24, for Seroquel (antipsychotic) 12.5…

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, observation, and policy review, the facility failed to identify and monitor potential adverse consequences and target behaviors for one of five residents (Resident (R) 107) reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of residents receiving antipsychotic medication without proper monitoring. Findings include: Review of the electronic medical record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/24 revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating R107 was severely cognitively impaired. Further review of this MDS revealed R107 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and Parkinsonism with no hallucinations, delusions, or verbal or physical behaviors towards self or others. Review of the EMR Orders tab revealed a physician's order, dated 07/22/24, for Seroquel (antipsychotic) 12.5 milligrams…

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, staff interview, and documentation review it was determined that facility staff failed to keep medication and treatment carts locked when unattended. This was evident on 2 of 3 nursing units observed during random observations made during a complaint survey. The findings include: On 8/14/24 at 6:50 AM observation was made on the B wing nursing unit of an unlocked and unattended medication cart sitting in the hallway outside of the clean utility room. A second observation was made of the same medication cart on 8/14/24 at 7:03 AM. The medication cart remained unlocked and unattended. The surveyor was able to open all drawers of the medication cart. A second medication cart in the same hallway, outside of room [ROOM NUMBER] was also unlocked and unattended. The surveyor was able to open all drawers which contained resident medications. On 8/14/24 at 7:04 AM Licensed Practical Nurse (LPN) #1 was informed. LPN #1 stated, Oh, I didn't know that. On 8/14/24 at 7:06 AM observation was made 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 medical record review and interview, the facility staff failed to follow up with outside resources for the care of resident (Resident #903). This was evident for 1 of 45 residents reviewed during a complaint survey. The findings include: The facility staff failed to follow up with outside facility for oral surgery post-operative instructions for Resident #904. Review of Resident #904's medical record on 8/9/2024 revealed the Resident was transported to the oral surgeon on 1/9/24, by a friend. Resident #904 had 3 teeth extracted and was given written post-operative instructions. Further, medical record review revealed no oral surgery post-operative instructions was noted in the medical record. Interview with the Administrator on 8/15/24 at 1 PM confirmed the facility staff failed to follow up with the Resident's Oral Surgeon at an outside facility for post-operative instructions.

Based on interviews and observation, it was determined the facility failed to have an effective pest control program as evidenced by numerous gnats seen throughout the facility. This was evident on 1of 3 nursing units and public areas observed during a complaint survey. The findings include: On 8/15/24 at 11:06 AM an interview was conducted with Resident #74. Resident #74 sat on the side of the bed and complained about the gnats in his/her wheelchair. Observation was made of a folded blanket on the seat of the wheelchair with a minimum of 10 gnats flying around the seat. At that time Certified Medicine Aide (CMA) #3 walked in the room and was shown the gnats. When asked if this was normal, CMA #3 stated that the gnat problem was throughout the building and that the facility just got a new pest control company last week. On 8/15/24 at 12:42 PM observation was made in the dining room of Resident #41 sitting at a table with a lunch tray. There were gnats flying on the resident's fruit cocktail and BBQ sandwich. During the survey there were also several gnats observed in the 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 review of the medical record and interview with facility staff, it was determined that the facility failed to ensure that physician progress notes from federally required physician visits reflected a review of a resident's total program of care, including medications and treatments, and were legible. This was evident for 1 (#154) of 2 residents reviewed for hospitalization. The findings include: Resident #154's medical record was reviewed on 6/7/19 at 11:10 AM. During the review, it was noted that the resident was admitted to the facility in 2016 and left the facility in mid May of 2019. Physician notes were reviewed and three were found that were dated in 2019. All were handwritten and were difficult to read. Those notes were reviewed by three surveyors to attempt to determine their content. The first note, dated 1/20/19, appeared to state, Will get audiology consult with loss of hearing. The second note, dated 2/16/19, appeared to state, Hearing better by [right] ear. [Left] ear wax being addressed. In good spirits _______ one assist can get up. The third note, dated…

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 review of kitchen staff documentation, the facility failed to record food temperatures for the beginning of June 2019 Findings include: On 6/4/19 at approximately 8:30 AM, a tour of the kitchen was conducted. Review of the kitchen food temperature log revealed there were no recorded food temperatures for June, 1, 2, 3, and 4, 2019. Staff member #6 (manager of the kitchen) was shown the log blank temperature log for June and acknowledged the lack of documentation.

Based on observation of the kitchen on 6/4/19, the facility failed to label the dry storage bin or kitchenware that was not to be used, as appropriate. Findings include: On 6/4/19 at approximately 8:30 AM a tour of the kitchen was conducted. In the dry storage room there were chafing pans no longer used by the facility stored there. The chafing dishes were dirty, dusty and not covered or labeled to indicate that they were no longer to be used. The chafing dishes were shown to the manager (staff #6). During inspection of dry storage room, there was also a container filled with bread crumbs that was not labeled with an expiration or opened date. Staff #6 was made aware.

Based on review of resident medical records and interview with facility staff, it was determined that facility staff failed to document the administration of as-needed oxygen in a resident's medication administration record. This was evident for 1 (Resident #154) of 2 residents reviewed for Hospitalization. The findings include: Resident #154's medical record was reviewed on 6/7/2019 at 9:43 AM. It was found that the resident had been admitted in 2016 and was discharged mid May of 2019. During the review, it was found that the resident had the following oxygen order dated 7/26/18: Oxygen at 2 Liters / minute via nasal cannula as needed for pulse oximeter less than 92%. Review of the resident's Treatment Administration Record (TAR) revealed that there was no documentation of this as-needed oxygen order in May, 2019. A nasal cannula is a device designed to deliver oxygen directly to a patient's nose via a plastic tube that is tucked behind the ears and has two small soft flanges that aim oxygen into the nostrils. Concurrent review of nursing notes demonstrated that 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.