Coastal Manor

Based on observations, interviews and record review the facility failed to provide residents a whirlpool/shower/shampoo as directed by the resident's shower schedule for 1 of 1 resident reviewed for Activities of Daily Living (ADL's)(Resident #32).Finding:On 12/1/25 at 9:12 a.m., during an interview and observation of Resident #32, the surveyor observed resident with oily/greasy hair. When asked if he/she has a shower weekly he/she stated, not always, and once in a while he/she will refuse a shower but hasn't recently.On 12/1/25 during a record review for resident #32 the most recent MDS 3.0, showed the resident is dependent on one staff for showers and needs partial moderate assist of one staff for personal hygiene.Review of the shower/whirlpool list updated on 11/30/25 indicates Resident #32 is to receive a shower on Wednesday evenings.Review of Resident #32's Certified Nurses Aid (CNA) documentation for whirlpools/showers indicated that he/she received no showers for the month of November, when resident should have had 4 showers in that time frame. On 12/3/25 at 12:29 p.m.,…

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 care plan reviews, observations and interviews, the facility failed to provide residents with a continuous resident centered activities program for 1 of 4 residents reviewed for activity participation. (Resident #1). Finding: On 12/1/25 at 9:44 a.m. during a interview, Resident #1 stated It would be nice to have something to keep my mind busy, would be nice. I have nothing. It would be nice to have a fucking paper once in a while. Review of the Resident's Care Plan for Activities initiated on 10/13/25, states the following: resident has little or no activity involvement r/t Disinterest, Physical Limitations. Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Modify daily schedule, treatment plan PRN (as necessary) to accommodate activity participation as requested by the resident and resident needs assistance/escort to activity functions. The care plans lacks interventions to include mental stimulation/activities and/or mental exercises. On 12/2/25 at 8:30…

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 follow a physician order relating to diabetes management for 1 of 1 resident reviewed for insulin. (Resident #38)Findings:Resident #38's medical record reveals he/she was admitted in late November 2025 with a diagnosis of Diabetes Mellitus with Providers orders dated 11/20/25 instructing nursing to administer Lispro insulin 100 units/milliliter, Inject as per sliding scale: if 71 - 199 = 0 no intervention; 200 - 249 = 2 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350 - 399 = 8 units; 400 - 449 = 10 units, subcutaneously after meals for diabetes. Review Resident #38's medication administration record lacked evidence of a blood glucose monitoring for the evening (after dinner) of 11/24/25 and lacks evidence of Lispro insulin 2 units being administered on the evening of 11/26/25 when the residents blood glucose was 208.On 12/3/25 at 9:21 a.m., the above was discussed with the Director of Nursing.

Based on interviews, observation, record review and facility policy review, the facility failed to provide appropriate treatment and services to prevent the risk of complications related to enteral feeding for 1 of 1 resident reviewed for enteral feeding. (Resident #14)Record review of Resident #14's physicians orders dated 10/13/25 required staff to check for Gastric tube (G-Tube) placement and residual prior to administering medication and flush the G tube with 60 cc's of water following medication administration. The physicians' orders also indicated that crushed medications may be administered together via the G-tube. Care plan review for Resident #14 indicated the resident will have no complications related to the feeding tube. The care plan documented that the resident requires total assistance from nursing staff for G-tube feedings and water flushes, including verifying G-tube placement and assessing gastric contents/residuals per facility policy/protocol and record. A review of the facility's policy, Administering Medications Through an Enteral Tube, Steps in the Procedure,…

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 interviews the facility failed to assure that adaptive cups were available for 1 of 1 resident as directed by their care plan and physician orders (Resident #29).Findings:On 12/3/25 at 8:06 a.m. a surveyor observed a tray delivered to Resident #29's room with no sippy cup on their tray, and the resident stated his/her son had [NAME] in some sippy cups, but they have gone missing. On 12/3/25 at 11:03 a.m. the surveyor reviewed a doctor's order dated 11/21/25 for Resident #29 that states, Level 4 Puree texture, Honey consistency, for aspiration precautions, eat with strict supervision/assist a sippy cup, watch for left side pocketing.On 12/3/25 at 12:03 p.m. a surveyor reviewed Resident #29's care plan with a focus of nutritional concerns dated 11/14/25 with an intervention of use sippy cup.On 12/3/25 at approximately 12:20 p.m. a surveyor interviewed the Food Service Director regarding Resident #29's missing sippy cup. The Food Service Director stated, there is no order,…

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

Based on observations and interview, the facility failed to serve and store food in a sanitary manner on 2 of 4 survey days. (12/1/25 and 12/2/25) Findings:On 12/1/25 at 8:15 p.m., during the initial visit to the Kitchen, with the Manager, the following was observed: the refrigerator contained a container of applesauce, a sandwich and a plate of eggs were unlabeled and undated. At this time, the above was confirmed with the Kitchen Manager.On 12/1/25 at approximately 12:30 p.m., two surveyors observed dietary staff with hair nets on but did not encompass the entirety of their hair. This was confirmed with the Dietary Director at that time. On 12/2/25 at 10:00 a.m. during an additional observation of the Kitchen, a moderate amount of dust was on a wall mounted fan. The Dietary manager stated that she had just dusted it yesterday. There was a line above the stove and the vents had a light to moderate amount of dirt and grease build up. The emergency food supply in the basement, contained the following: 6 #10 cans of Beef stew3 Large Cans of Tomato Soup1 Small can of Tomato Soup2 Large…

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 maintain an Infection Control Program designed to help prevent the development and spread of infection relating to hand hygiene during 1 of 3 medication passes observed, linen handling and Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for wound management (Resident #38) and 1 of 4 residents reviewed for indwelling foley catheter (Resident #9).Findings: 1. On 12/2/25 at 8:15 a.m., during medication administration observations, the Infection Preventionist (IP) prepared medications for Resident #14 and left the medication cart without sanitizing his hands. The IP proceeded to enter Resident #14's room and stopped to don a gown and gloves. The surveyor inquired whether the facility utilizes EBP signs for residents who require them? The IP stated that they do. However, no EBP sign was posted on Resident #14's door at the time of observation. The IP administered Resident #14's medications via the gastrostomy tube. Upon leaving…

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, review of the facility's Pneumococcal policy, and interviews the facility failed to implement their Pneumococcal policy for 1 of 5 sampled residents (resident #31).Finding:On 12/3/25 at 11:06 a.m. a surveyor reviewed Resident #31's medical records which contained a signed consent to receive the Pneumococcal vaccine dated 7/18/25. The medical records lacked evidence of Resident#31 receiving the Pneumococcal Vaccine.The facilities Pneumococcal Vaccine policy, sub title Policy Interpretation and Implementation section 1 states, Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. On 12/4/25 at 9:50 a.m. a surveyor confirmed these findings with the Infection Preventionist and Director of Nursing.

Based on observations and interviews the facility staff failed to provide access to resident call bell device for 3 of 35 residents (#2, #3, and #4). Findings: On 12/10/24 at 8:15a.m. Resident #2 was asked if he/she had a device to call the staff if he needed them, he/she said, Sometimes. No device was observed at that time. The call device was observed hanging on the wall, approximately 5 feet from the resident's bed. This was pointed out to the Certified Nursing Assistant (CNA) #1 and she moved it to the resident's bed covers. On 12/10/24 at 8:55a.m. Resident #3 was asked if he/she had a device to call the nurses if he/she needed anything, he/she looked around and said, No. No call bell observed. With a search the device was found with the cord behind him/her and the button on the floor between his/her chair and his/her bed. On 12/10/24 at 9:00a.m. Resident #4 was observed in bed with no call bell near him/her. He/She was unable to respond to questions about his/her call bell. Observed that there was no call for this resident. A Registered Nurse was asked if she knew about 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, review of 4-week menu cycle, and interviews, the facility failed to follow the printed menu for 3 of 3 days of the survey, and not complying with regulation 483.60(c)(2) that menus be prepared in advance; and 483.60(c)(3) that menus must be followed. This has the potential to effect all 33 of the residents in the facility. Findings: On 8/12/24 at 8:56 a.m. a surveyor met with a resident who states it feels like we have the same meal every week, the variety is not a lot 0n 8/12/24 at 10:34 a.m. a surveyor met with a resident in his/her room. He/She also said the same things are served all the time and they never know what it's going to be because they don't get a menu. On 08/13/24 at 12:16 p.m. a surveyor met with a resident who stated The variety is lacking. It feels like we get the same thing every week. I get tired of the same food. A surveyor reviewed the notes from the food committee meeting held on Monday August 5, 2024 with the permission of Resident Council president. The activities Director and 5 residents were in attendance. The following 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 observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 2 of 2 units. Findings: On 8/14/24 at 9:30 a.m., during tour of the facility with Director of Nursing and the Maintenance Director, the following were observed and confirmed: First floor: Upper Dining Room - Stained ceiling around speaker in the middle of the room. Hallway connecting Upper Dining Room and Lower Dining Room has stained ceiling tiles. First floor living room has stained and damaged ceiling. First floor resident hallway at North end has stained ceiling tile near external door. There are also stained ceiling tiles across from rooms 102, 104, the Nurses Station, 108, 109, and at the Main entrance. Resident Rooms on the first floor: room [ROOM NUMBER] - The curtains in room are dirty and have brown stains. Bathroom shared by rooms 108/110, Resident sink does not work and has a sign on it that says it is out of order. room [ROOM NUMBER] - There are stained ceiling tiles over bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS) 3.0 was coded accurately in the area of Active Diagnosis for 1 of 3 sampled residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (Resident #9). Finding: On 8/13/24, R9's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The provider's admission progress note dated 4/19/24 states under Problem List/Past Medical History, ongoing: Nightmares, from PTSD. HX of abusive relationship . PTSD, Pt states from horrible divorce, husband abusive mentally and physically suffers nightmares . Pt fears leaving home. States only drives to get groceries. Suffers from PTSD. The admission minimum data set (MDS) 3.0 dated 4/22/24 and the most recent Quarterly MDS dated [DATE] indicates, under Active Diagnosis Section I6100, states that the resident did not have PTSD. The surveyor was unable to find information in the clinical record that indicated what R9's PTSD…

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 develop a care plan for a resident with a current diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 3 sampled residents reviewed (Resident #9). Finding: Resident #9 was admitted to the facility on [DATE]. The provider's admission progress note dated 4/19/24 states under Problem List/Past Medical History, ongoing: Nightmares, from PTSD. HX of abusive relationship . PTSD, Pt states from horrible divorce, husband abusive mentally and physically suffers nightmares . Pt fears leaving home. States only drives to get groceries. Suffers from PTSD. A review of Resident #9's care plan did not include a care area with interventions for the diagnosis of PTSD. On 8/13/24 at10:19 a.m., the above was discussed with the Director of Nursing. The surveyor confirmed that there was no evidence addressing what might trigger the PTSD symptoms and there was no evidence of interventions that indicated what staff should or should not do that may cause…

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 identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #9, and #31). Findings: 1. On 8/13/24, R9's clinical record was reviewed and indicated the resident was admitted to the facility on [DATE]. The provider's admission progress note dated 4/19/24 states under Problem List/Past Medical History, ongoing: Nightmares, from PTSD. HX of abusive relationship . PTSD, Pt states from horrible divorce, husband abusive mentally and physically suffers nightmares .Pt fears leaving home. States only drives to get groceries. Suffers from PTSD. On 8/13/24 at 10:16 a.m., during an interview, the Licensed Social Worker confirmed she does not complete a trauma assessment on residents other than Veterans. On 8/13/24 at 10:19 a.m., the above was discussed with the Director of Nursing. 2. On 08/12/24 at 9:50…

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 serve food that was at an appetizing temperature to residents on 2 of 2 floors. Findings: On 8/12/24 at 8:56 a.m. a surveyor interviewed a resident in the dining room and was told the food is not hot enough and it feels like the same foods are served every week. On 08/12/24 at 09:40 a.m. a surveyor asked a resident in her bed about breakfast and was told Breakfast was not good. It's cold On 8/12/24 at 10:34 a.m. a surveyor met with a resident in [his/her] room who had a piece of French Toast on a plate. [HeShe] held up the French Toast and said it was cold this morning. The food is always cold. [He/She] also said the same things are served all the time and they never know what it's going to be. On 8/13/2024 at 11:00 a.m. a surveyor interviewed the cook in the kitchen and learned that the food is temperature checked as it's plated, a cover is placed over the plate and the tray is moved to the carts for transporting by the designated time for each meal. She often sees the carts sit there 30-40 minutes before the CNAs take…

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 interviews, the facility failed to ensure that a resident's physician and/or representative were notified immediately of a significant change in the resident's medical condition and failed to follow its own policy and procedure for Unwitnessed falls and Head injury protocol for 2 of 4 residents reviewed for falls. (#1, #4) Findings: Coastal Manors Falls Policy and Procedure, revised 6/24 states under, Types of Falls . An unwitnessed fall is one in which a resident has sustained a fall in which no clinical staff directly witnessed the incident. Regardless if a resident is alert and oriented and a good historian, if no clinical staff member was there to witness the incident, it shall be classified as an unwitnessed fall, and Unwitnessed Fall with or without head injury: any type of unwitnessed fall shall be treated under the Head Injury Protocol. Coastal Manors Head injury protocol, revised 9/23 states, If a resident sustains ahead injury while at Coastal [NAME], the charge nurse will…

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, interview, and facility policy review, the facility failed to adequately assess, monitor and/or complete neurological assessments after unwitnessed falls for 4 of 5 resident reviewed for falls (#1, #3, #4 and #5). Findings: Coastal Manors Falls Policy and Procedure, revised 6/24 states under, Types of Falls . An unwitnessed fall is one in which a resident has sustained a fall in which no clinical staff directly witnessed the incident. Regardless if a resident is alert and oriented and a good historian, if no clinical staff member was there to witness the incident, it shall be classified as an unwitnessed fall, and Unwitnessed Fall with or without head injury: any type of unwitnessed fall shall be treated under the Head Injury Protocol. Coastal Manors Head injury protocol, revised 9/23 states, The nursing staff will do a full set of vital signs as well as neurological testing as follows; every 15 minutes for 1 hr., then every 1 hr. x 4 hrs. then every 4 hrs. x 24 hrs.; once a shift up to 72 hrs. The neurological assessment that should be done includes: check…

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 review and update the facility assessment at least annually (between 10/2022 and 04/2024) to determine what resources are necessary to care for its residents competently during day-to-day operations. Finding: On 4/10/24, the Director of Nursing provided the surveyor with the Coastal Manor, Corp. Facility Assessment, reviewed on 10/2022. The surveyor could not locate any further evidence that a review or update of the assessment was completed by 10/2023. On 4/10/24 at 2:15 p.m., the surveyor confirmed in an interview with the Director of Nursing that the review and revision of the facility assessment was not completed since 10/2022.

Based on review of the quarterly Quality Performance Improvement Committee meeting attendance sheets and interview, the facility failed to ensure that the Administrator attended 5/5 quarterly meetings. Finding: The Coastal Manor Quality Assurance and Professional Improvement (QAPI) Plan dated 11/16/17, page 2 under C. QAPI Leadership: The QAPI council provides the backbone and structure of QAPI. This council will consist of an executive leadership team including the Administrator, Director of Nursing (DON) Assistant Director of Nursing, Social worker, Minimum Data Set (MDS) Coordinator, Medical Director, Pharmacist and Physician, etc. The QAPI committee will meet on a quarterly basis. A review of the quarterly QAPI committee meeting attendance sheets also indicate that the Administrator did not attend the 6/2/23, 9/18/23, 12/18/23, 1/29/24 and 3/18/24 quarterly meetings. On 4/10/24 at 1:30 p.m , during an interview with the Director of Nursing, the surveyor confirmed the above findings.

Based on record review, observations and interview, the facility failed to implement a care plan in the area of falls for 1 of 17 sampled residents (#19), and failed to develop a care plan in the area of oxygen/respiratory needs for 1 of 3 residents reviewed for respiratory care (#24) Findings: 1. Review of Resident #19's care plan, initiated on 6/4/2018, states the resident is high risk for falls r/t use of antidepressants, history of falls, poor safety awareness, unsteadiness with gait and transfers with interventions instructing nursing to be sure the residents call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 9/19/22 at 10:35 a.m., on 9/20/22 at 10:26 a.m., and on 9/20/22 at 1:29 p.m., Resident #19 was observed in the recliner with the call bell hanging from the wall and resting on the floor behind the recliner, not within reach for the resident. 2. On 9/19/22 at 11:26 a.m., and 9/20/22 at 10:25 a.m., observations were made of Resident #24 utilizing Oxygen therapy at 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.

Based on record review and interviews, the facility failed to revise the care plan to reflect the current needs of a resident in the area of respiratory. (#14) Finding: On 9/19/22 and 9/20/22 Resident #14 was observed using Oxygen 3 Liters Per minute (lpm) via nasal cannula and the O2 tubing with a date of 8/23. A review of Resident #14's physician order dated 1/4/22, instructs nursing to change the O2 tubing weekly on Tuesday's evening shift. Review of the current care plan initiated on 6/10/19 and recently reviewed and revised by an interdisciplinary team on 8/11/22 stated, the resident has altered cardiovascular/respiratory status related to congestive heart failure, hypertension and chronic obstructive pulmonary disease with the intervention of oxygen settings: O2 3 liters per minute via nasal cannula continuous . Change tubing monthly and PRN. As of 9/20/22 the current care plan was not revised to reflect the residents current needs related to the physician orders for changing the O2 tubing weekly. On 9/20/22 at 1:29 p.m., in a discussion with the Director of Nursing, 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, record review and interview, the facility failed to provide respiratory care according to physician orders for 2 of 3 residents (#14 and #20) and failed to obtain physician orders for oxygen therapy for 1 of 3 residents (#24) reviewed for respiratory care. Findings: 1. On 9/19/22 at 10:39 a.m., and 9/20/22 at 10:25 a.m., observations of residents #14's O2 tubing labeled with the date of 8/23. A review of Resident #14's physician order dated 1/4/22, instructs nursing to change the O2 tubing weekly on Tuesday's evening shift. 2. On 9/19/22 at 2:59 p.m., and 9/20/22 at 10:25 a.m., observations of residents #20's O2 tubing labeled with the date of 8/23. A review of Resident #20's physician order dated 12/14/21, instructs nursing to change the O2 tubing weekly on Tuesday's evening shift. 3. On 9/19/22 at 11:26 a.m., and 9/20/22 at 10:25 a.m., observations of resident #24 utilizing Oxygen therapy at 2 liters per minute via nasal cannula with O2 tubing labeled with the date of 8/23. A review of Resident #24's medical record lacked evidence of a physician order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to remove spoiled items from the refrigerator located in the kitchen and failed to discard expired dry goods for 1 of 4 days of survey. On [DATE] at 9:00 a.m., during the initial tour of the kitchen with the Cook, the following was observed: 1. The Kitchen refrigerator contained a head of brown wilted lettuce and 3 cucumbers which were shriveled up on the ends. 2. Dry storage contained a stack of pie shells in saran wrap with no expiration date, 1 Package of hot dog rolls with expiration date of [DATE] and 6 packages of English muffins all with expiration date of [DATE]. At this time, the above concerns were confirmed with the Cook.

Based on record review, observation and interview the facility failed to ensure the Treatment Administration Record (TAR) was accurately documented for Oxygen (O2) tubing replacement for 2 of 3 residents observed for respiratory care. (#14, #20) Finding: 1. A review of Resident #14's physicians order dated 1/4/22, instructs nursing to change the O2 tubing weekly on Tuesday's evening shift. The TAR indicated, by nursing documentation, the evening shifts on 8/30/22, 9/6/22 and 9/13/22 the O2 tubing was changed. On 9/19/22 at 10:39 a.m., and 9/20/22 at 10:25 a.m., observations of Residents #14's O2 tubing labeled with the date of 8/23. 2. A review of Resident #20's physician order dated 12/14/21, instructs nursing to change the O2 tubing weekly on Tuesday's evening shift. The TAR indicated, by nursing documentation, the evening shifts on 8/30/22, 9/6/22 and 9/13/22 the O2 tubing was changed. On 9/19/22 at 2:59 p.m., and 9/20/22 at 10:25 a.m., observations of residents #20's O2 tubing labeled with the date of 8/23. On 9/20/22 at 1:29 p.m., in an interview 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 record review and interview, the facility failed to ensure its infection prevention and control program (IPCP) included standards, policies and procedures that that were based on its facility assessment and reviewed at least annually. Findings: A review of the facility's policies and procedures for its IPCP noted the following policies were not reviewed at least annually: *Surveillance for Infections, last revised July, 2017; *Antibiotic Stewardship, last revised December, 2016; *Pneumococcal Vaccine, last revised August 2016; and *Influenza Vaccine, last revised August, 2016. In addition, a review of the Facility Assessment noted the last review and revision was November, 2019. On 9/21/22 at 12:00 p.m., the facility's former director of nursing confirmed that IPCP policies and procedures, as well as the Facility Assessment, had not been reviewed on an annual basis.

Based on facility policy reviews, interviews, and observations, the facility failed to ensure that Coronovirus (Covid-19) policies and procedures were implemented based on Centers for Medicare and Medicaid Services (CMS) guidance for unvaccinated staff. Findings: On 12/28/21, CMS's memo Quality Safety & Oversight (QSO)-22-07-ALL, Attachment A, Long-Term Care and Skilled Nursing Facility directed facilities to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Page 1, states: (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the [Centers for Disease Control] CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first…

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 a call bell was accessible to 1 of 17 sampled residents observed for 2 of 4 days of survey (#19). Findings: On 9/19/22 at 10:35 a.m., Resident #19 was observed sitting in the recliner with elevated feet. The call bell was hanging from the wall and resting on the floor behind the recliner, not within reach for the resident. On 9/20/22 at 10:26 a.m., Resident #19 was observed sleeping in the recliner. The call bell was hanging from the wall and resting on the floor behind the recliner, not within reach for the resident. On 9/20/22 at 1:29 p.m., the surveyor, Director of Nursing (DON) and the Registered Nurse (RN) observed Resident #19 sleeping in the recliner with the call bell hanging from the wall and resting on the floor behind the recliner, not within reach for the resident. At this time the surveyor discussed the above findings with both the DON and the RN.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 1 medication rooms and failed to ensure that medications were stored properly by having an unlocked, unattended treatment/medication cart allowing residents and unauthorized persons access to Treatments/medications, on 1 of 3 days of survey. Findings: 1. On 9/21/22 at 8:20 a.m., a surveyor observed in the medication room, a refrigerator containing an opened box of Bisacodyl suppositories with an expiration date of 6/2022. At this time, the surveyor confirmed the above finding with the Certified Medication Technician. 2. On 9/20/22 at 12:10 p.m., a surveyor observed an unlocked, unattended treatment/medication cart (in the first floor nurses station located near the front entrance with no staff around the cart or in the nurses station). The gate entering the nurses station was open, allowing access to the nurses station from the hallway. On 9/20/22 12:17 p.m. a surveyor opened 2 drawers of the treatment cart and observed over the counter…

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.