Niles Care Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain accurate medical records for 1 resident (Resident #55) of 14 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #55Review of an admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: depression, anxiety and dementia.Review of Resident #55's Care Plan revealed, FOCUS: .history of anxiety and may exhibit signs or symptoms as evidenced by episodes of agitation, restlessness, tearfulness, and worried facial expressions. Date initiated: 3/3/25 FOCUS: history of depression and may exhibit signs and symptoms of depression as evidenced by episodes of crying, fearfulness negative statements, and/or having a sad, pained, or worried facial expression. Date initiated: 3/3/25 . Review of Resident #55's Physician Note dated 1/12/26 revealed, .Chief…

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 citation pertains to Intake #2682078.Based on observation, interview, and record review, the facility failed to follow professional standards of practice by following up on physician ordered medication that wasn't available in 1 resident (Resident #3) of 3 residents reviewed for medication management, resulting in physician ordered pain medication not being administered and resident having uncontrolled pain and unmet needs.Findings include: Resident # 3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including chronic pain, obesity, depression and osteoarthritis left hip (degenerative joint disease where joint cartilage breaks down causing bones to rub, leading to pain in the groin, buttocks and outer thigh; stiffness, swelling and reduced movement). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact (13 to 15 cognitively intact).Review of the…

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

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During the initial tour of the kitchen, at 9:40 AM on 12/3/24, observation of the walk-in cooler found a one-gallon container and a half gallon container both full of cooked roast beef. The roast beef was dated for 12/2 and was found covered with condensation and moisture on the inside tops of the containers. At this time, the surveyor took a temperature of the product with a Thermoworks Rapid Read thermometer and found the half gallon container was 40F and the gallon container was 43F. When asked what we should do to the product, Director of Housekeeping (DOH) F (Filling in for the Dietary Manager on Maternity leave) stated they should be discarded. When asked if there was a cooling log on the items, DOH F was unsure and was going to ask the cook after she was back from rounds. 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: 1. implement infection control practices during resident care for 5 (Resident #2, #4, #12, #11, and #299) of 12 residents reviewed for infection control, 2. maintain an ongoing infection control surveillance program, and 3. have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the increased risk of transmission of pathogenic organisms and cross contamination between residents. Findings include: Review of a facility policy titled Guidelines for Infection Prevention and Control revealed: .The INFECTION PREVNTION and CONTROL PROGRAM is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This will be accomplished through preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, 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 maintain staff documentation of COVID-19 screening, education, offering and current COVID-19 vaccination status of one of one staff reviewed, resulting in increased risk for COVID-19 infections. This deficient practice has the potential to impact all residents within the facility. Findings include: Review of Infection Control Guidance: SARS-CoV-2 published 6/24/24 by the Centers For Disease Control, revealed: 1. Recommended routine infection prevention and control practices .Encourage everyone to remain up to date will all recommended COVID-19 vaccine doses .health care providers .should be offered resources and counseling about the importance of receiving the COVID-19 vaccine . Review of covid vaccination/education for Certified Nursing Assistant (CNA) DD revealed the staff member was last vaccinated for COVID 19 on 11/24/21. At the conclusion of the survey, the facility did not provide further documentation of annual offering of a covid vaccination or education related to the vaccination for this staff member. In 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 and interview the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents. Findings include: During a tour of the nourishment room, at 10:34 AM on 12/3/24, observation under the sink found a large hole in the wall exposing the back of the wall and leaving an opening for pests. Further review found old moisture damage and a black staining-like substance on the back wall inside of the hole. During a tour of the facility, at 11:29 AM on 12/3/24, observation of empty resident room [ROOM NUMBER] found a large brown splash stain in the far right corner of the room. The wall in this corner of the room was bubbling from the ceiling to the floor. During a tour of the 200 hall bath, at 11:35 AM on 12/3/24, it was observed that five towels and six washcloths were stored open and exposed between 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 maintain a medication error rate less than 5% (total error rate of 20%) in 4 residents (Resident #15, Resident #25, Resident #30, Resident #43) of 9 residents reviewed for medication administration resulting in improper injection location, late oral medication administration, missed dose of medication, and the potential for reduced medication effectiveness. Findings include: Resident #15 Review of an admission Record revealed Resident #15 had pertinent diagnoses which included: diabetes mellitus (a disease that results in high blood sugar levels in the blood due to a body's decreased ability to produce insulin). Review of Order Summary for Resident #15 revealed insulin aspart injection solution 100 unit/ML (milliliter) (short acting insulin) inject as pre sliding scale : if 201-250 = 3 units; 251-300 = 5 units; 301-350 = 7 units; 351-400 = 9 units; 401-999 = 11 units, subcutaneously (administered just under the skin into the fatty areas of the abdomen, back of arms, or outer side of the thighs) three times a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, the facility failed to maintain an effective pest control program resulting in presence of live pests (ants), resulting in the potential for food infestation and resident discomfort. Findings include: During an observation on 12/3/24 at 9:43am, seven live ants were noted on the bathroom floor of room [ROOM NUMBER]. During an observation on 12/3/24 at 10:15am, several open food containers with resident food inside were stored on the floor of room [ROOM NUMBER]. During an observation on 12/3/24 at 2:47pm, 2 live ants were noted on the hallway floor outside room [ROOM NUMBER]. In an interview on 12/3/24 at 2:48pm, housekeeping aide (HSK) W confirmed 2 live ants were on the floor outside room [ROOM NUMBER]. During an observation on 12/4/24 at 1:21pm 4 live ants were noted on the floor outside room [ROOM NUMBER]. During an observation on 12/4/24 at 4:18pm, 25 live ants were noted on the floor of the visitor restroom in the 200 hall. In an interview on 12/5/24 at 1:51pm,…

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 proper assessment for self-administration of medication was completed for 1 (Resident #300) of 1 resident reviewed for self-administration of medications resulting in the potential for a resident to not receive medications as ordered. Finding included: Resident #300 Review of an admission Record revealed Resident #300 had pertinent diagnoses which included: complications of amputation stump, weakness, and noncompliance with other medical treatments and regimens. Review of a Minimum Data Set (MDS) assessment for Resident #300, with a reference date of 12/31/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #300 was cognitively intact (BIMS score of 12-15 indicates cognitively intact). On 2/10/25 at 3:57 PM, Registered Nurse (RN) F was observed entering Resident #300's room with a medication cup with pills in it and a second medication cup with vanilla pudding and a spoon in it. RN F placed the two medication cups on a dresser top in the room and exited 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 professional standards of nursing were maintained during administration of an enteral feeding (also known as a tube feeding- the delivery of nutrients through a feeding tube directly into the stomach) for 1 (Resident #4) of 1 resident reviewed for professional nursing standards, resulting in an inaccurate administration of daily nutrition. Findings include: Resident #4 Review of an admission Record revealed Resident #4 had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (feeding tube inserted directly into the stomach used to provide nutrients directly into the stomach). Review of Order Summary for Resident #4 revealed NPO (nothing by mouth) diet. Enteral Feed Order every shift Vital 1.5 (formula brand) @ (at) 75cc/hr (cubic centimeters (milliliters) per hour) x (for) 20 hours, on at 1500 (3:00 pm) off at 1100 (11:00 am) with a start date of 11/15/2024. During an observation on 12/3/24 at 9:47 AM., Resident #4 was in 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 observation, interview and record review, the facility failed to ensure assistance with activities of daily living (ADL) were provided for 3 residents (Residents #46, Residents #27, Resident #38) of 4 residents reviewed for ADL care potentially resulting in dissatisfaction with care and hygiene concerns. Findings include: Resident #46 (R46) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R46 admitted to the facility on [DATE] with diagnoses including type 2 diabetes, cellulitis (bacterial skin infection) and need for assistance with personal care. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R46 was cognitively intact (13 to 15 cognitively intact). During an interview on 12/03/2024 at 11:17 AM, R46 sat in his room watching television. R46 stated that he only had a couple of showers since he was admitted to the facility. R46 stated that his preference was to have showers instead of bed baths and he wanted to receive 2 showers a…

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

Based on observation, interview, and record review the facility failed to ensure that enteral feeding (also known as a tube feeding- the delivery of nutrients through a feeding tube directly into the stomach) was administered as ordered to 1 (Resident #4) of 1 resident reviewed for enteral feeding, resulting in the potential for weight loss, dehydration, and/or an overall deterioration of wellbeing. Findings include: Resident #4 Review of an admission Record revealed Resident #4 had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (also known as G-tube) a feeding tube inserted directly into the stomach used to provide nutrients directly into the stomach). On 12/3/24 at 9:47 AM., Resident #4 was in bed and her tube feeding pump, located next to her bed in her room, was noted to be powered off. A bottle and tubing set with approximately 200 ml (milliliters) of noted formula was hanging from the pole with the tubing inserted into the pump for feeding administration. The feeding tubing was not connected…

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

Based on interview and record review the facility failed to ensure that gradual dose reductions (GDRs) for the ongoing use of psychotropic medications were completed for 1 (Resident #12) of 5 residents reviewed for unnecessary medications. Findings include: Resident #12 Review of an admission Record revealed Resident #12 had pertinent diagnoses which included: major depressive disorder. Review of Order Summary for Resident #12 revealed Duloxetine (antidepressent) 60 mg HCL powder give 60 mg (milligrams) enterally (via g tube) one time a day related to major depressive disorder. Review of Psychotropic and Sedative/Hypnotic Utilization by resident dated 3/1/2024 to 3/6/2024, provided by Director of Nursing (DON) B revealed Resident #12 recommended next eval (evaluation) date (s) for the use of Duloxetine was March of 2024. In an interview on 12/5/24 at 12:32 PM., DON B reported that Resident #12's dosage for Duloxetine had remained the same for over a year. DON B reported Resident #12 had not had an attempted gradual dose reduction of her ordered Duloxetine at any time during 2024. By…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00147456 & MI00146518 Based on observation, interview and record review the facility failed to: 1. minimize the risk of scalding and burns by allowing hot water to exceed 120 degrees F (degrees Fahrenheit) and not monitoring hot water temperatures consistently resulting in an increased risk of injury among residents who reside in the facility, and 2. prevent an elopement for 1 resident (Resident #101) of 5 residents reviewed for elopement, resulting in Resident #101 exiting from the facility without staff knowledge and the potential for injury. Findings include: During an interview on 10/22/2024 at 1:51 PM, FF stated the facility has only one boiler that is currently working and the other one needs to be replaced. FF said it is difficult to keep the water temperatures below 120 degrees F in some resident rooms. During a tour of resident rooms with Maintenance Director (MD) AA on 10/23/2024 at 10:20 AM, hot water was checked in several resident rooms and shower rooms with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number MI00147372 Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (Resident #104) reviewed for abuse, resulting in Resident #104 experiencing physical abuse from Resident #103. Findings include: Resident #104: Review of an admission Record revealed Resident #104 was a male with pertinent diagnoses which included Alzheimer's disease, weakness, cervical disc degeneration (condition affecting the neck's spinal discs causing pain and discomfort), cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language) and back pain. Review of current Care Plan for Resident #104, revised on 9/19/24, revealed the focus, .(Resident #104) has severe barriers related to poor memory, cognition, and comprehension. He has a history of Alzheimer's . with the intervention .Nursing staff to provide reminders, support, and simple logical communication to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (Resident #102) of five residents reviewed for abuse. Findings include: Resident #102 (R102) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R102's original admit date was 2/11/2021 with diagnoses including schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), anxiety, depression, dementia (thinking and social symptoms that interferes with daily functioning) and aphasia (language disorder that affects the ability to communicate). Brief Interview for Mental Status (BIMS) was not completed since R102 was not understood. During an interview on 10/23/2024 at 9:40 AM, Certified Nursing Assistant (CNA) Y stated on 8/17/2024 she was in R102's room changing her brief with CNA EE. CNA Y stated that R102 was standing up…

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 develop and implement a baseline care plan related to skin integrity for one resident (Resident #1) of three residents reviewed for admission, transfer, and discharges resulting in ineffective skin care to be provided to the resident. Findings include: Resident #1(R1) R1 was admitted to the facility on [DATE] under Hospice care for a 5-day respite stay with diagnoses of heart failure, dementia, and depression. She was discharged back to her daughter's residence on 6/25/2024. Review of the Admission/re-admission Screener dated 6/20/2024 revealed that R1 had a rash under her right breast. The screener also indicated that R1 had a history of skin integrity issues prior to admission. Review of the Baseline Care Plan assessment dated [DATE] on page 6 revealed that the section for skin risk which included current skin integrity issues and history of skin integrity issues was left blank. Review of R1's Care Plan which was initiated on 6/21/2024 revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to conduct a thorough assessment upon admission, follow-up on a skin concern and communicate findings to Hospice for one resident (Resident #1) of three residents reviewed for admission, transfer, and discharges, resulting in a rash under the breast not being treated for 4 days, worsening to occur and a lapse in the continuity of care. Findings include: Resident #1(R1) R1 was admitted to the facility on [DATE] under Hospice care for a 5-day respite stay with diagnoses of heart failure, dementia, and depression. She was discharged back to her daughter's residence on 6/25/2024. During an interview on 7/2/2024 at 9:48 AM, Family Member (FM) C stated that the Hospice Nurse found an area under R1's breast on 6/24/2024 that wasn't there upon admission. FM C said that she could smell the yeast from the infection when she visited her. During an interview on 7/2/2024 at 12:30 PM, Hospice Social Worker (HSW) E stated that R1 developed a yeast infection under 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances for one (resident #1) of three residents reviewed for grievance resolution, resulting in unresolved concerns and unmet needs. Findings include: Resident #1(R1) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with diagnoses of diabetes, hypertension (high blood pressure) and cognitive communication deficit. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R1's cognition was moderately impaired (8-12 is moderately impaired). The I Would Like to Know Form is the facility process for resident's and resident's representatives to file a concern/grievance. Review of R1's form dated 4/12/2024 showed it was filled out by Social Service Director (SSD) I on behalf of R1. The form revealed R1's question related to Indv(individual) stated on Thursday April 11th (night shift) CNAs (Certified Nursing Assistants) left…

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, staff failed to report an allegation timely to the Nursing Home Administrator and as a result to the State Agency, to law enforcement, and failed to report a concern/allegation to the State Agency for one resident (Resident #1) of three residents reviewed for abuse resulting in delayed reporting, an incomplete investigation and the resident not being protected from abusive individuals. Findings include: Resident #1(R1) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 admitted to the facility on [DATE] with diagnoses of diabetes, hypertension (high blood pressure) and cognitive communication deficit. Brief Interview for Mental Status (BIMS) reflected a score of 10 out of 15 which indicated R1's cognition was moderately impaired (8-12 is moderately impaired). During an interview on 6/18/2024 at 3:30 PM, R1 stated that on 3/5/2024, Certified Nursing Assistant (CNA J) was trying to change her and the nurse {Licensed Practical Nurse (LPN) D}was helping…

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 assure that a Registered Nurse was on duty for eight consecutive hours a day seven days a week resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcomes affecting all 38 residents in the facility. Findings include: Review of Fundamentals of Nursing, [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Tenth Edition-E-Book (Kindle Location 1265 of 76897) revealed .There is a positive correlation between direct patient care provided by an RN (Registered Nurse) and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status .Research also correlates poor staffing with missed nursing assessments and missed nursing care . Review of a Payroll Based Journal Data Report dated 4/1-6/30/23 revealed the facility reported 9 incidences of no Registered Nurse coverage during the third quarter of 2023. Review of a Job…

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 effectively clean and maintain the food production kitchen physical plant effecting 38 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 10/23/23 at 10:20 A.M., an initial tour of the food service was conducted with Dietary Manager M. The following items were noted: The Dry Storage Room vinyl tile flooring surface was observed (cracked, chipped, missing). Numerous vinyl flooring tiles were also observed severely worn and stained. The Janitor Closet vinyl tile flooring surface was observed (cracked, stained, chipped). Dietary Manager M indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-201.11 states: Except as specified under § 6-201.14 and except for anti-slip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are…

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 effectively clean and maintain the physical plant effecting 38 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 10/24/23 at 09:00 A.M., A common area environmental tour was conducted with Maintenance Director H and Environmental Services Director U. The following items were noted: Main Dining Room: Three acoustical ceiling tiles were observed stained from previous moisture exposure. The return-air exhaust ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits. The courtyard entrance/exit door, located adjacent to the Activity Room, was observed missing the threshold door sweep creating an air gap. The air gap between the metal threshold plate and lower door slab surface measured approximately 1-2 inches high by 42 inches wide. Activity Room: The return-air ventilation grill was observed heavily soiled with…

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

Based on observation, interview, and record review, the facility failed to effectively maintain domestic hot water temperatures between 105 - 120 degrees Fahrenheit in 9 (207, 209, 211, 212, 215, 216, 303, 304, 307) of 12 sampled resident restrooms effecting 38 residents, resulting in the increased likelihood for resident discomfort and/or personal injury. Findings include: On 10/24/23 at 10:20 A.M., An environmental tour of sampled resident rooms was conducted with Maintenance Director H and Environmental Services Director U. Domestic hot water temperatures were monitored at the restroom hand sink basin utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following temperature values were noted: 207: 125.0 degrees Fahrenheit* 209: 126.3 degrees Fahrenheit* 211: 130.8 degrees Fahrenheit* 212: 121.8 degrees Fahrenheit* 215: 131.8 degrees Fahrenheit* 216: 126.5 degrees Fahrenheit* 303: 130.5 degrees Fahrenheit* 304: 127.3 degrees Fahrenheit* 307: 130.5 degrees Fahrenheit* (*) Note: Domestic hot water temperatures are required to be maintained between…

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 adaptive dining equipment was provided per physician order in 1 (Resident #30) of 1 sampled resident reviewed for nutrition, resulting in the potential for difficulty with self-feeding and continued weight loss. Findings include: Review of an admission Record revealed Resident #30 was a male, with pertinent diagnoses which included: dysphagia (swallowing difficulty), unspecified lack of coordination, and unspecified severe protein-calorie malnutrition. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 9/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated Resident #30 was cognitively impaired. Review of Resident #30's current Order Summary Report revealed, Client use of built up utensils and use of divider plate meals as needed .Order Status Active .Order Date 6/27/23 During an observation on 10/24/23 at 1:40 PM, Resident #30 was seated in his wheelchair in the hall just outside of the dining…

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 follow standards of infection control practices related to ensuring resident shared equipment was sanitized between uses, resulting in the potential for the transmission/transfer of pathogenic organisms and cross contamination for vulnerable residents. Findings include: During an observation on 10/23/23 at 11:27 AM., noted a hoyer and sit to stand lift outside room [ROOM NUMBER]. The sit to stand lifts foot base (where residents plant their feet while being raised up) was heavily soiled with dust, debris and food crumbs. The black knee pad on the sit to stand lift (which stabilizes residents shins to stand) was noted to be soiled with dried crusted substances, the handles on the lift were noted to be soiled with grime. During an observation on 10/23/23 at 1:40 PM., noted a hoyer and sit to stand lift outside room [ROOM NUMBER]. The sit to stand lifts foot base was heavily soiled with dust, debris and food crumbs. The black knee pad 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.