Bayside Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to:- provide written information on the facility's bed hold policy for five Residents (#27, #15, #2, #3, and #7).- provide written transfer notifications to the resident, and resident's representative for four Residents (#15, #2. #3 and #7).of five residents reviewed for transfers out of the facility. Findings include: Resident #27 (R27) was transferred to the hospital Emergency Department (ED) on 7/26/25. There was no documentation in the Electronic Medical Record (EMR) indicating the resident/responsible party was provided a bed hold notice. During an interview on 9/4/25 at 2:25 p.m., the Nursing Home Administrator (NHA) reported, the facility had not been giving bed hold information to the resident/responsible party when discharged to the hospital. Review of policy titled Transfer and Discharge date implemented 4/11/25, read in part .Emergency transfers to acute care.the facility will.provide orientation for transfer or discharge to minimize anxiety…

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 ensure one medication cart of three medication carts reviewed were attended and or locked and all resident medications were secured and or consumed for one Resident (#27) of fifteen residents reviewed for medication storage. Findings include: On 9/4/25 at 12:11 PM, an interview was conducted with Registered Nurse (RN) A who was asked about medication pass and where she was in the process and replied, I have a couple more to do. I have to go check on a resident for feeding assistance. RN A walked away from her medication cart and left it unlocked/unattended and walked into an adjacent resident room [ROOM NUMBER]. On 9/4/25 at 2:30 PM, an observation was made of the 300-hall medication cart that was located at the entrance of the 300-hall unlocked and unattended. This Surveyor walked over to the 300-hall medication cart and opened several drawers which were in a resident common area. RN A was sitting at the nurses' station and was asked how…

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 attempt a gradual dose reduction for one resident (Resident #37) out of five residents reviewed for psychotropic drug use. Findings include:Resident #37 (R37)Review of R37's minimum data set (MDS) assessment, dated 9/9/25, revealed medical diagnoses of hypertension, diabetes mellitus, dementia, depression, and aphasia (a condition where a person finds that they have slight or serious difficulty with either their language or their speech). Review of R37's MDS, section E: Behaviors lacked any documentation of having behaviors. On 9/9/25 at 10:40 AM, an observation was made of R37 resting in his wheelchair in the day room with his eyes closed. Review of R37's physician order, dated 8/21/24, revealed quetiapine (an antipsychotic medication) 25 milligrams (mg) twice daily for dementia without behavioral disturbances and escitalopram (antidepressant medication) 10 mg once daily. On 9/10/25 at 11:15, an observation was made of R37 resting with his eyes closed in the day room sitting in his wheelchair. R37 was asked how he 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 interview and record review the facility failed to ensure the PASARR (Preadmission Screening/Annual Resident Review) level I ([one] (DCH-3877) was obtained annually for one Resident (#6) of two residents reviewed for PASARR requirements . Findings include:Review of R6's electronic medical record (EMR) revealed an initial admission to the facility on 3/25/2022 with diagnoses including depression, unspecified hallucinations, unspecified psychotic disorder with delusions due to known physiological condition, anxiety disorder, and Alzheimer's disease. A review of R6's Minimum Data Set (MDS) quarterly assessment, dated 7/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 2 of 15 indicating severe cognitive impairment. Section E under Behavioral Symptoms revealed R6 was coded as having physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring every 1 to 3 days.A review of the active physician's orders for R6 included an antipsychotic drug quetiapine, prescribed on 7/21/2024, as…

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

Based on observation, interview, and record review the facility failed to update a comprehensive care plan for 1 Resident (#23) of 15 residents reviewed for care plans. Findings include:Resident #23 (R23)On 9/2/25 at 2:40 PM, an observation was made of R23 in his room, sitting in his wheelchair. R23 was observed with a bruise with various colors of yellow, green, and purple around his right eye and a scab above his right eyebrow. R23 was asked if he had fallen and how and replied by pointing to the bathroom and nodding yes. R23 was not able to say when he had fallen.Review of R23's incident and accident report, dated 8/18/25 at 3:20 PM, read in part Un-witnessed fall.Incident description: Nursing description: Was told by and aid '[Resident's name] fell and is bleeding from his head.' Upon arriving in room, resident was sitting on the edge of the bed with blood dripping from his forehead (sic). Resident description: Resident stated he fell and hit his head on the floor coming from the bathroom. Resident stated 'I hit my head on the floor when I fell.' 'I was coming from my…

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 obtain physician orders for supplemental oxygen and ensure respiratory equipment was changed, labeled, and appropriately stored for two Residents (#13 & #27) of two residents reviewed for respiratory care and services. Findings include: On 9/2/25 at 2:49 PM, Resident #13 (R13) was observed with a nebulizer (a drug delivery device used to administer medications into the lungs) on the bedside stand. The tubing attached to the nebulizer was unbagged and labeled with the date 7/30/24. The nebulizer tubing was placed directly atop the nebulizer without a barrier beneath the tubing. On 9/2/25 at 2:49 PM, an oxygen concentrator was observed adjacent to R13's bed. The nasal cannula tube (tubing that delivers supplemental oxygen) was unbagged and undated. The nasal cannula tubing was placed directly atop the concentrator without a barrier between the concentrator and the tubing. R13 said she used oxygen when she experienced respiratory difficulty…

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

Based on interview, and record review, the facility failed to ensure physician assessments and visit progress notes, including review of the program of care and resident condition, were available in the medical record of one Resident (#25) of 15 residents reviewed for physician visits. This deficient practice resulted in potential delinquent execution of care, unmet care needs, and lack of coordination of care. Findings include:Resident #25 (R25) was admitted to the facility 12/9/21. Review of the electronic medical record (EMR) disclosed a primary diagnosis of acute embolism and thrombosis of the deep veins of the left lower extremity. During an interview with Registered Nurse (RN) I on 9/10/25 at 11:05 AM, RN I said she contacted the physician of R25 on 7/16/25 to report medication errors that occurred with R25 for eight consecutive days, from 7/8/25 through 7/15/25. When RN I was asked if the physician assessed R25 after the medication errors were reported, RN I said, I don't know.The EMR of R25 was reviewed on 9/10/25. The most recent physician documentation available in the EMR…

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 physician visits were completed timely for two Residents (#7 & #8) of 15 sampled residents reviewed for physician visits. This deficient practice resulted in extended time frames between physician visits and the potential for unaddressed medical needs.Findings include:Resident #7 (R7)Review of R7's admission Record, retrieved 9/9/25 at 12:56 p.m., revealed R7 was admitted to the facility on [DATE] with a primary admitting diagnosis of generalized anxiety disorder. R7 was their own responsible party for decision making.Review of Physician Visit Progress Notes, retrieved on 9/9/25 at 2:01 p.m., revealed R7 had the following physician visits completed by Physician L following R7's admission to the facility:1. 10/21/24 - initial Physician Visit completed, documented as a late entry on 10/24/24. Completed by Physician L.2. 11/19/24 - second Physician Visit was documented by Physician L.3. 1/28/25 - third Physician Visit was documented as a late entry…

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 prevent administration of unnecessary medications for one Resident (#10) of five residents reviewed for unnecessary medication.Findings include:This citation is related to complaint intake #2605430Resident #10 (R10)On 8/29/25 at 8:00 AM, an anonymous complaint was reported to the State Agency (SA), stating R10 was given the wrong medication from a facility nurse. Resident #23's (R23's) blood pressure medication was given to R10 who already had low blood pressure and the complainant was concerned for R10. The anonymous complainant stated that there was no documentation of the incident in R10's electronic medical record.Review of R10's progress note, dated 8/28/25 at 7:41 AM, read in part Resident vitals are 140/73 (blood pressure) - 56 (heart rate).Resident was given the wrong medication on previous shift.Review of R10's progress note, dated 8/28/25 at 2:47 PM, read Vital (sic) were checked from watch od med (medication) error. On 9/5/25 at 9:20 AM, an…

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 This deficient practice pertains to Intake 2565663Based on interview and record review, the facility failed to ensure one Resident (R25) of one resident reviewed for significant medication errors received medications at the frequency ordered by the physician. This deficient practice resulted in inaccurate medication dosages and the potential for subtherapeutic drug levels, blood clot formation, and cerebrovascular accident (CVA - stroke). Findings include: Intake 2565663 alleged Resident #25 (R25) was administered Xeljanz (a medication for rheumatoid arthritis - a chronic, inflammatory disease of the joints that may damage other parts of the body including the lungs, heart, and blood vessels) instead of Eliquis (a blood-thinning medication used to treat or prevent blood clots) during the month of [DATE]. The intake alleged the facility was aware of the error but had not implemented interventions to minimize the risk of recurrence of the medication errors.The electronic medical record (EMR) of R25 was reviewed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This deficiency pertains to Complaint Intake #MI00150445. Based on interview and record review, the facility failed to prevent a significant medication error for one Resident (R1) of four residents reviewed for medication errors. This deficient practice resulted in the potential for adverse side effects and required transfer to an acute care hospital emergency department for monitoring. Findings include: Review of Complaint Intake #MI00150445 revealed an allegation that R1 was administered the wrong medications on 2/19/25 and was transferred to a hospital emergency department in the morning because they (facility staff and/or emergency room physician) were worried R1s' blood pressure would drop too low. R1 was allegedly alone at the hospital for eight hours worrying that she might have a reaction to the medications, with no notification to the family. Review of R1's Minimum Data Set (MDS) assessment, dated 12/13/24, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included heart…

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 adequate numbers of staff to meet the needs of four (Residents #47, #7, #15, and #24) of fifty-seven residents sampled for sufficient staffing and three [Resident #C1 (C1), Resident #C4 (C4), and Resident #C7 (C7)] of seven residents from a confidential resident council meeting. This deficient practice resulted in the potential for a decline in resident quality of life and/or quality of care, not receiving medications timely, and unmet care needs for all fifty-seven residents. Findings include: Resident #47 (R47) Review of R47's Minimum Data Set (MDS) assessment dated [DATE] revealed admission to the facility on 3/6/24, with active diagnoses that included: Parkinson's disease, hypertension, anemia, anxiety disorder, and depression. R47 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. During an interview on 7/9/24 at 8:34 a.m., R47 stated I fell last week when I tried to move, and there…

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

Based on interview and record review, the facility failed to ensure three Certified Nurse Aides (CNA) [P, S, and T] had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for Residents. This deficient practice has the potential for staff to lack the necessary training to adequately meet the needs of all 57 residents that reside in the facility. Findings include: A review of facility staff personnel records revealed CNA P was hired 2/25/22. CNA P's personnel record did not demonstrate dated competency skills since date of hire. A review of facility personnel records revealed CNA S was hired 4/13/21. CNA S's personnel record did not demonstrate dated competency skills after date of hire. A review of facility personnel records revealed CNA T as hired 5/27/23. CNA T's personnel record did not demonstrate dated competency skills after date of hire. During an interview on 7/11/24 at 08:24 a.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged there were undated competency skills for staff. The DON…

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 complete performance reviews for three of three Certified Nurse Aides (CNA's) [P, S, and T] at least once every 12 months. This deficient practice resulted in the potential for inadequate care and unmet resident care needs for all 57 residents living in the facility. Findings include: Review of facility personnel records demonstrated that CNA S was hired on 4/13/21 with no annual performance review. CNA T was hired on 5/27/23 with no annual performance review. CNA P was hired on 2/25/22 with no annual performance review. During an interview on 7/10/24 at 12:49 p.m., the Director of Nursing (DON) acknowledged no performance reviews had been completed in the past year. During an interview on 7/10/24 at approximately 1:30 p.m., the Human Resource staff O stated No performance reviews have been completed since 2022. Review of facility policy titled Nurse Aide Training Program implemented on 4/11/24 . read in part, a review of the employee's .records shall be performed at least annually, such as at time of performance review.…

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

During the breakfast meal on 7/9/24 at 7:57 a.m., Staff U was observed removing a baseball-style cap from their head and scratching their scalp before placing the cap back on their head. Staff U began scratching their facial hair before touching the condiments, tableware, and food on a tray next to the serving station. Staff U did not perform hand hygiene after touching their scalp and facial hair and beginning to touch items used or consumed by residents. On 7/9/24 at 8:15 a.m., Staff U began assisting with preparing resident meal trays without performing hand hygiene. At 8:28 a.m., Staff U was observed to be touching the front of their shirt, running their hand from their chest down to their abdomen. Staff U did not perform hand hygiene after touching their shirt and commencing with meal tray set-up. On 7/9/24 at 8:42 a.m., KM D confirmed Staff U was an employee of the Dietary department. KM D said Staff U was a dietary aide. On 7/10/24 at 12:26 p.m., The dining room observation was conveyed to the Administrator (NHA) and Director of Nursing (DON). The NHA and DON were told 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 interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 57 residents in the facility. Findings include: On 7/11/2024 at 7:11 a.m., a review of the available attendance documentation for the QAPI meetings with the Nursing Home Administrator (NHA) revealed the following: Meeting held on 4/30/2024: The Medical Director or designee did not attend. Meeting held on 1/10/2024: No attendance record found. Meeting held on 7/13/24: The Medical Director or designee did not attend. Meeting held on 8/10/23: The Medical Director or designee did not attend. November 2023: No meeting held. No attendance record found. December 2023: No meeting held. No attendance record found. Meeting held on 1/19/24: The Medical Director or designee, and Director of Nursing (DON) did not attend. Meeting held on 2/2/24: The Medical Director or designee did not attend. Meeting held 3/21/24: The Medical Director or…

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

Based on interview and record review, the facility failed to ensure nurse aide training of no less than 12 hours per year, for three Certified Nursing Assistants (CNA) P, S, and T of five CNA's reviewed for nurse aide training hours. This deficient practice resulted in the potential for unmet resident care needs for all 57 residents in the facility. Findings include: During an interview on 7/10/24 at 11:19 a.m., Human Resource Staff O revealed the 12 hours of annual CNA training is based on the CNA's hire date. On 7/10/24 at approximately 1:30 p.m., a review of CNA P training log revealed P was hired on 2/25/22 and had only 9.5 hours of in-service training. A review of CNA S training log revealed S was hired 4/13/21 and had only 5 hours of in-service training. A review of CNA T training log revealed T was hired on 5/27/23 and had only 10.25 hours of in-service training. Review of facility policy titled Nurse Aide Training Program implementation date . 4/11/24 read in part, each nurses aide shall be provided at least 12 hours of in-service training annually, based on his/her…

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

Based on interview and record review, the facility failed to ensure training on behavioral health care was provided for two of three staff reviewed for required behavioral health care training. This deficient practice had the potential to result in unmet behavioral health care needs for residents, with the potential to affect all 57 residents in the facility. Findings include: Review of [Vendor] computer training logs on 7/10/24 at approximately 4:00 p.m., revealed the following staff had no behavioral health care training: Certified Nurse Aide (CNA) T was hired on 5/27/23 and CNA S was hired on 4/13/21. Review of policy titled Nurse Aide Training Program implementation date of 4/11/24 read in part, In-service training will be provided by qualified personnel and will be based on the special needs of the residents in the facility. Minimum training will include: . behavioral health . or other behavioral health conditions. Review of Facility Assessment (FA) did not include a requirement for the provision of behavioral health training for staff. During an interview on 7/11/24 at 8:37…

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 revise care plans after multiple falls for four Residents (#17, #26, #36, and #47) of fourteen residents reviewed for care planning. This deficient practice resulted in the potential for further falls and the potential for injury. Findings include: Resident #17 (R17) Review of R17's Minimum Data Set (MDS) assessment, dated 4/21/24, revealed admission to the facility on [DATE], with active diagnoses that included: unsteadiness on feet, schizophrenia, down syndrome, anxiety disorder, and depression. R17 scored a 99 on the Brief Interview for Mental Status (BIMS) reflective of an incomplete interview due to R17 not participating in the assessment or giving a nonsensical response. Review of the facility fall reports revealed R17 had two falls in January on 1/23/24 and 1/24/24, one fall in February on 2/16/24, and one fall in March on 3/2/24. The care plan for R17 was not revised after each fall. During an interview on 7/11/24 at 8:37 a.m., the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician visits accurately reviewed the total program of care for four Residents (R24, R26, R36, & R38) of four residents reviewed for physician visits. This deficient practice resulted in the potential for lack of comprehensive and supervised medical care. Findings include: Resident #24 (R24) Review of R24's admission Record revealed R24 was admitted to the facility on [DATE] with diagnoses that included the following, in part: Alzheimer's disease, diabetes, hallucinations, psychotic disorder with delusions, depression and generalized anxiety disorder. Review of R24's Physician Order Summary, retrieved 7/11/2024, revealed R24 was prescribed the following, in part: melatonin 3 mg (milligrams) at bedtime and memantine HCL (hydrochloride) 10 mg related to Alzheimer's disease, quetiapine fumarate 25 mg related to psychotic disorder with delusions, and sertraline HCL 75 mg related to depression, Review a comprehensive list of R24's medications…

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

Based on observation, interview, and record review, the facility failed to ensure inhalers and eye drops were labeled with dates when opened according to facility policy for two medication carts of two medication carts reviewed for medication storage and labeling. This deficient practice resulted in the potential for administration of expired medications to nine residents receiving inhalers and five resident receiving eye drops. Findings include: The 100-hall medication cart was audited on 7/9/24 at 1:33 p.m. with Registered Nurse B (RN B). The cart was observed to contain five bottles of opened eye drops for four different residents. The bottles were not labeled with a date when opened. The cart contained three opened inhalers for two different residents. The inhalers were not labeled with a date when opened. One of the inhalers was inside a clear plastic bag that contained a pharmacy label indicating the pharmacy dispensed the inhaler on 5/30/24. RN B said, They're (inhalers) good for six weeks so that one is expired. The Director of Nursing (DON) was interviewed on 7/9/24 at 1:42…

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 ensure appropriate assessments, physician orders, risk education, medical justification, and care plans for restraints were in place for one Resident (R36) of one resident reviewed for restraints. Findings include: Resident #36 (R36) On 7/10/24 at 3:30 p.m., R36 was observed sitting in a wheelchair with a tray table in front of her. The tray table was attached to both sides of the wheelchair. The tray table extended across the width of the wheelchair, securing R36 in the wheelchair. R36 was unable to remove the tray table from the wheelchair. During the observation, R36 was also observed sitting on a pommel cushion (a cushion with a raised, center protuberance on the front of the cushion). The medical record revealed R36 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. A quarterly Minimum Data Set (MDS) Assessment completed on 5/7/24 documented R36 as having short-term and long-term memory impairment…

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 collaboration and communication between the facility and hospice provider for one Resident (R56) of one resident reviewed for hospice services. Findings include: Resident #56 (R56) A family member of R56 was interviewed on 7/8/24 at 2:39 p.m. The family member said R56 was originally admitted to the facility for skilled therapy but was now in the facility for long-term care. The family member said R56 had a severe decline in health and was now receiving hospice services. R56 was admitted to the facility on [DATE]. A review of R56's physician orders did not reveal an order for hospice, and the care plans for R56 did not contain a care plan for hospice. Hospice visit notes and hospice documentation were not located in R56's medical record. A progress note on 6/28/24 read, in part: .(resident's family member) and resident have been discussing hospice services. contacted hospice. There were no other progress notes that mentioned hospice. A hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate medically related social services to one Resident #15 (R15) of one resident reviewed for social services care. This deficient practice resulted in a lack of supportive visits, delayed referral to a behavioral care provider, and psychosocial decline. Findings include: Resident #15 (R15) Review of R15's Minimum Data Set (MDS) assessment, dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: depression, heart failure, hypertension, and diabetes mellitus. R15 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. During an interview on [DATE] at 2:35 p.m., R15 stated sometimes I miss my son . he passed away and I get depressed. He had cerebral palsy and I took care of him for most of his life . I couldn't be with him when he died. R15 was teary eyed and stated he passed away this past October .but the staff or social worker does not talk with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the timely reorder and acquisition of pressure ulcer wound treatment medication for one Resident (R51) of one resident reviewed for pressure ulcer treatment medication availability. This deficient practice resulted in the lack of prescribed medication and the potential for worsening of pressure ulcers for R51. Findings include: Review of R51's admission Record, acquired 7/8/24 at 3:23 p.m., revealed R51 was admitted to the facility on [DATE], with a readmission on [DATE]. Diagnoses included the following, in part: Partial traumatic amputation of right great toe, present on admission. Review of R51's Electronic Medical Record (EMR) on 7/9/24 at 8:23 a.m., revealed the following physician orders that required Santyl for the prescribed wound dressing medication in the Treatment Administration Record (TAR). 1. #23 Left Heel: Clean wound bed with Dial soap and pat dry. Apply nickel thick Santyl to wound bed and cover with Tegaderm High…

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 This deficient practice has two parts: A and B. Part A: Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for one Resident (R24) of five residents reviewed for medication regimen reviews. This deficient practice resulted in the potential for the administration of unnecessary medication or a medication dosage in excess of what was required to treat the resident symptoms. Findings include: Resident R24 Review of R24's admission Record revealed R24 was admitted to the facility on [DATE] with diagnoses that included the following, in part: Alzheimer's disease, diabetes, hallucinations, psychotic disorder with delusions, depression and generalized anxiety disorder. Review of R24's Physician Order Summary, retrieved 7/11/2024, revealed R24 was prescribed the following psychotropic medications: quetiapine fumarate 25 mg related to psychotic disorder with delusions, and sertraline HCL 75 mg related to depression, Review of R24's [Company Name] Psychological 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 observation, interview, and record review, the facility failed to ensure adequate supervision to prevent an elopement for one Resident (R1) out of three residents reviewed for elopement. This deficient practice resulted in an unsupervised exit from the facility and unsafe ambulation and wandering off facility property for a cognitively impaired Resident. Findings include: Resident #1 (R1) Review of the facility Incident Investigation of R1's elopement from the nursing home on 4/7/24 at 6:06 p.m., revealed the following information: Visitor entered building and allowed [R1] to exit. R1 was back in the building by 6:15 p.m.; with staff at 6:13 p.m. Staff were alerted to a possible resident outside of the facility . R1 was off facility property . (Elopement verified) . Administrator (NHA), had a discussion with the wife of the visitor who opened the door . She verified it was her husband who opened the door and stated that he doesn't visit regularly and isn't as familiar with the residents as she is (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 interview and record review, the facility failed to ensure adequate monitoring and documentation of psychotropic medications for 4 residents (Resident #56, #36 #50 and #51) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with the increased potential for serious side effects and adverse reactions, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #56 (R56) Review of an admission Record revealed R56 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: altered mental status, generalized anxiety disorder, and depression. Review of R56's Order Summary revealed, RisperiDONE Tablet 0.25 MG Give 0.25 mg by mouth two times a day related to ALTERED MENTAL STATUS, UNSPECIFIED. Review of the FDA prescribing information revealed Risperdal indications for use: RISPERDAL is an atypical antipsychotic agent…

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 notify the physician of abnormal vital sign results for 2 residents (Resident #1 and #56) reviewed for notification of changes, resulting in the lack of assessment and monitoring, and the potential for the worsening of a medical condition and delay in treatment. Findings include: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R1's Physician Order dated [DATE] revealed, Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day (blood pressure medication that can cause decreased heart rate). Review of R1's Nursing Progress Note dated [DATE] revealed, During Sp02 (oxygen saturation) check noted to record a HR (heart rate) of 37 bpm (beats per minute). Checked apical HR and found to be 48 . Review of R1's Electronic Health Record (EHR) revealed no documentation that R1's provider was notified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance for two residents (Resident #48 and Resident #18) who depend on staff assistance to complete activities of daily living, resulting in the potential for skin break down and feeling forgotten for Resident #48 and the potential for dental caries for Resident #18. Findings: Resident #48 (R48) Review of an admission Record revealed R48 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of Muscular Dystrophy. R48 required extensive assistance from staff for transfers and going to the bathroom. During an interview on 07/16/23 at 10:01 AM, R48 reported she was on a bed pan and would use the call light shortly to alert staff when she needed assistance getting off the bed pan. During an observation on 07/16/23 at 10:13 AM, R48 activated the call light system, staff immediately responded to the room, the call light was turned off, and staff left R48's room within 10 seconds. During an…

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 ensure an in-use oxygen tank was full and functional for 1 resident (Resident #1) reviewed for oxygen/respiratory care, resulting in the potential for respiratory distress. Findings: Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension. Review of R1's Physician Order dated 10/12/21 revealed, May use O2 as needed to maintain oxygen saturation >=89% (greater than 89%) as needed for Emergency use per Standing orders. During an observation on 07/16/23 at 10:35 AM, R1's was in the dining room, wearing nasal cannula oxygen tubing, which was connected to an oxygen tank. The needle gauge was pointing to the red indicating the tank needed to be refilled/changed. During an observation on 07/16/23 at 10:58 AM, Licensed Practical Nurse (LPN) D assisted R1 with her dentures and did not assess R1's oxygen tank. During…

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

Based on observation, interview and record review, the facility failed to ensure systems were implemented to accurately account for controlled substances when licensed nurses were not signing out controlled substances from narcotic sheets prior to administration of the controlled substances, resulting in the potential for drug diversion. Findings: Review of a facility policy Medication Storage, undated, reflected It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, light, ventilation, moisture control, segregation and security. During an observation on 7/17/23 at 9:06 AM, a narcotic count was conducted of the 300 Hall medication cart with Licensed Practical Nurse (LPN) A. Discrepancies were discovered on the narcotic sheets for Resident #47's prescribed Gabapentin, R22's Lorazepam and R31's Gabapentin. When asked, LPN A reported she had forgotten to sign the narcotic sheet when she pulled the medication from the…

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

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #45) was free from significant medication errors when a medication was not administered according to the physician orders. Findings: Resident #45 (R45) Review of an admission Record reflected R45 was admitted to the facility with diagnoses that included schizophrenia, dementia, major depressive disorder and weakness. During an observation on 7/17/23 at 8:35 a.m., Licensed Practical Nurse (LPN) A prepared medications to be administered to R45. LPN A placed 1 tablet of Midodrine HCl 5 MG into a separate medication cup from the other medications R45 was to take that at that time. R45 explained that the midodrine was kept separate because she needed to check his BP prior to administration. LPN A took R45's BP which was 116/70. LPN A said that R45's blood pressure was not within the parameters ordered by the physician and the drug needed to be held. LPN A did not administer the midodrine to R45 and was witnessed wasting the drug in the sharps container on the medication cart. Review 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.