Pomeroy Living Rochester Skilled Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to order laboratory tests as directed by the Physician/Nurse Practitioner, ensure timely/efficient laboratory services, ensure promptly notify the Physician of abnormal results and failed to develop a policy and/or procedure for ordering laboratory test, obtaining & reporting abnormal values to the Physician for one (R202) of three residents reviewed for a change in condition. Findings include: A review of the medical record revealed R202 was admitted to the facility on [DATE], with a diagnosis of dementia. The resident was documented to have severely impaired cognition and required staff assistance for all activities of daily living.A review of a nursing note dated 8/12/25 at 2:54 PM, documented in part . Writer noted cloudy and discoloration to urine, increased confusion and resident presented with back pain. NP (nurse practitioner) in house and ordered for urine dip and if positive to send out. Writer…

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 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 from the kitchen. Findings include: On 2/25/25 between 8:35 AM-9:15 AM, during an initial observation of the kitchen, the following items were observed: In the walk-in cooler, there was dried up milk on the floor underneath the milk crates. The inside bottom shelf of the Victory freezer was soiled with food spills and food debris. On 2/25/25 at 9:00 AM, Corporate Chef Y confirmed the soiled flooring in the walk-in cooler and inside the Victory freezer, and stated they would be cleaned right away. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The ceiling vent located near the ice machine was coated…

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 facility assessment was reviewed and revised in accordance with current regulatory requirements. This has the potential to affect all 117 residents. Findings include: According to the Centers for Medicare & Medicaid Services (CMS) memo: QSO (Quality Safety & Oversight)-24-13-NH, dated 6/18/2024, revised Facility Assessment requirements effective 8/8/2024 included: .In conducting the facility assessment, the facility must ensure .Active involvement of the following participants in the process: (i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing/ and (ii) Direct care staff, including but not limited to, RNs (Registered Nurse), LPNs (Licensed Practical Nurse)/LVNs (Licensed Vocational Nurse), NAs (Nurse Aide), and representatives of the direct care staff, if applicable. (iii) The facility must also solicit and consider input received from residents, resident representatives, and family members .…

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 enhanced barrier precautions (EBP)policies and protocols were followed and maintained for three residents (R48, 53, & and 78), maintain linen carts, as well as a system of surveillance that consistently documented signs and symptoms of infections and consistently tracked and trended infections, this had the ability to affect all 117 residents residing at the facility. Findings include: Review of the facility's Infection Control program revealed the following: The program revealed no consistent documentation of signs and symptoms and laboratory (Lab) data results for residents with infections that were listed for the months of January 2025 and February 2025. On 2/27/25 at 10:25 AM an interview with the facility's infection control preventionist (ICP) and the Director of clinical services was asked about the missing Lab data and signs and symptoms for the line listing for the months for January and February, and who was responsible 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 observation, interview, and record review, the facility failed to ensure medications were stored appropriately for one resident (R367) of one resident reviewed for medication storage as well as properly stored, labeled, and dated in five of five medication carts reviewed. Findings include: R367 On 2/25/25 at 12:06 PM, R367 was observed lying on their back in bed. An interview was conducted with the resident at that time. Observed on their bedside table was a tube of Triad ointment. A review of the medical record revealed no documentation or assessment of R367 to be able to self-administer the Triad ointment. On 2/27/25 at 12:26 PM, the Assistant Director of Nursing (ADON) A (who covered the medical care/questions as the facility's Director of Nursing (DON) was not present for the survey) was interviewed and asked about the Triad ointment observed by R367's bedside and ADON A replied that R367 is unable to apply the ointment to themselves and that the ointment should have been stored in the treatment…

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 water was provided and kept within resident's reach for one resident, (R33) of one resident reviewed for accommodation of needs. Findings include: On 2/25/25 at 9:39 AM, R33 was observed sleeping in their bed. It was further observed R33 had no water for drinking at their bedside. An observation of their bedside table situated parallel to the bed on the left side revealed a typed note taped to the top that read, PLEASE place this tray table above her abdomen so she can reach her drink! .She is often dehydrated as table & water is out of reach . Further review of the room revealed a chalkboard on the bathroom door that read, Keep my water within my limited reach of Rt (right) hand. On 2/25/25 at 2:32 PM, 2/26/25 at 8:48 AM, 10:05 AM, and 2:30 PM, R33 was observed in their bed. The tray table with water for drinking was observed to the left side of the bed, out of reach from their right hand. A review of R33's care plan was conducted and read, .ADL (activities of daily living)-Decreased ability to self…

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 end of life wishes for one of one resident (R417) reviewed for advance directives. Findings include: On [DATE] at 1:43 PM, during and interview, R417 was asked about their end of life wishes. R417 reported, they did not want to receive Cardiopulmonary resuscitation (CPR) because R417 did not want their chest to be cracked open and be placed on a breathing tube. R417 was then asked who was responsible for making medical decisions for them, R417 stated that they would be in control of decision making until they were unable to do so. R417 reported, they signed a paper the day before to become a Do Not Resuscitate (DNR). A review of the record revealed that R417 was admitted to the facility on [DATE] with the diagnoses of depression, anxiety and COVID-19. The most recent Minimum Data Set (MDS) indicated a Brief Interview for Mental Status score of 15, which indicated no cognitive impairments. The record also revealed that R417 was 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 #MI00148138. Based on observation, interview and record review, the facility failed to follow nursing professional standards of practice related to medication administration for two (R29 and R368) of two residents reviewed for professional standards. Findings include: R29 Review of the clinical record revealed R29 was admitted into the facility on 7/8/23 and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with diabetic neuropathy. According to the Minimum Data Set (MDS) assessment dated [DATE], R29 had intact cognition, had orders for insulin and received insulin injections for seven of the last seven days. Review of the physician orders identified R29 was to have their blood sugar (BS) level checked at 7:30 AM and parameters were in place to administer insulin depending on what the BS result was. On 2/26/25 at 9:45 AM, review of R29's Medication Administration Record (MAR) revealed the was no documentation (blank) for if this had been completed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to consistently provide assistance for oral care for a dependent resident, one (R58) of three residents reviewed for Activities of Daily Living (ADLs). Findings include: On 2/25/25 at 11:00 AM, R58 was observed in the community room playing a game with their daughter. R58 was asked if they had any concerns with the facility's care. R58's daughter replied that their dad always made sure their hygiene was up to par and they had concerns with the staff not assisting R58 with brushing their teeth. R58's daughter explained that R58 can brush their own teeth if staff set up their tooth brush and tooth paste and handed R58 their toothbrush, however staff were not ensuring the assistance was being provided. R58 was asked if staff assisted with brushing their teeth this morning and R58 replied No. A review in the medical record revealed R58 was admitted to the facility on [DATE], with diagnoses that included: traumatic subdural hemorrhage encounter,…

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 #MI00150390. Based on observations, interviews and record reviews the facility failed to timely implement a fungal rash treatment (R372), timely implement treatment for edema (R85) and failed to obtain a physician ordered blood sugar level (R48), for three of 24 sampled residents reviewed for quality of care. Findings include: R372 On 2/25/25 at 12:47 PM, R372 was observed lying on their back in bed. R372's husband was observed sitting by the bedside. When asked about any concerns R372 had, R372's husband explained that R372 was prescribed an ointment in the hospital for a fungal rash that had started on R372's buttocks. R372's husband stated the hospital noted the cream on R372's discharge paperwork however they believed the facility failed to implement the treatment. R372's husband stated they saw the rash yesterday and it worsened and spread to R372's groin area. R372's husband stated they are in the facility every day and all day, except overnight and they had never seen…

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 monitor documented weights and ensure timely nutritional interventions were implemented to prevent significant weight loss for one resident (R23) of four residents reviewed for nutrition, resulting in a 22.94% weight loss from October 30, 2024 to December 2, 2024. Findings include: On 2/25/25 at approximately 10:27 a.m., R23 was observed in their wheelchair in the common area. R23 was observed to be thin and was queried if they had lost any weight and they reported that they had. On 2/25/25 the medical record for R23 was reviewed and revealed the following: R23 was initially admitted to the facility on [DATE] and had diagnoses including Moderate protein-calorie malnutrition and - Chronic kidney disease, stage 3. A review of R23's MDS (minimum data set) with an ARD (assessment reference date of 1/29/25 revealed R23 needed assistance from facility staff with most of their activities of daily living. R23's BIMS score (brief interview 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.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when three medication errors were made for two residents (R#'s 12 and 50) of four residents reviewed during the medication pass observation, resulting in a medication error rate of 10.34%. Findings include: On 2/25/25 at 10:21 AM, Nurse 'U' was observed preparing medications for administration to R12. Nurse 'U' prepared multiple medications including a 10 mg cetrizine (allergy medication) tablet. They said R12 had a 5 mg (milligram) midorine (medication to treat low blood pressure) tablet due at that time and they were going to hold it because R12's blood pressure and heart rate were too low for administration. They reported R12's blood pressure was 115/58 and their heart rate was 58. Nurse 'U' proceeded to R12's room and administered the prepared medications. Upon completion of the administration, Nurse 'U' signed the medications out in the medication administration record. On 2/25/25 at 3:51 PM, a review of R12's physician's orders and medication administration…

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 implement an effective antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for three (R418, R29 and R97) of three residents. Findings include: R418 A review of R418 record revealed that in the month of January they were started on Keflex (antibiotic) 500 milligrams (mg) twice a day for five days. The physician also ordered labs. There was no documentation of any signs and symptoms for the need for the antibiotic or labs. R418 arrived from the hospital on contact precautions for clostridium difficile (c. diff-an infection of the bowel often caused by the over use of antibiotics) and was prescribed an antibiotic that started 1/6/25 and was supposed to continue for 10 days, however the order was not transcribed correctly upon admission. R29 A review of R29's medical record revealed that in the month of February 2025, they were prescribed ertapenem antibiotic without a start date and that the first dose was not given. R97 A review of R97's medical record revealed…

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 R406 R406 was a long-term resident, originally admitted to the facility on [DATE]. R406's admitting diagnoses included lung cancer, respiratory failure, heart failure, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Based on the current Minimum Data Set (MDS) assessment, R406 had a Brief Interview for Mental Status (BIMS) score 15/15, indicative of intact cognition. An initial observation was completed on 10/15/24 at approximately 10:30 AM. During an interview R406 reported that they had a concern about cold food. R406 added that they preferred to eat in their room and the food was cold on most days. When queried further if that any pattern such as any particular meal or days, R406 reported that it was lunch and dinner that was served cold. R406 added that cold breakfast was also an issue on some days. R406 reported that meat gets overcooked and tough. During the interview R406's spouse was present in the room. They reported that it was an ongoing concern. Later that day at approximately,…

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(s): MI00146420, MI00146542, MI00146558, MI00145342, & MI00147417. Based on interviews and record reviews the facility failed to ensure medications and treatments were administered/applied as prescribed by the physician, failed to ensure the timely administration of medications and failed to treat a change of condition timely for three (R's 401, 402, & 403) of five residents reviewed for medications/treatments. Findings include: R402 A review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to address R402's change of condition timely which resulted the R402 leaving the facility Against Medical Advice (AMA). A review of the medical record revealed R402 was admitted to the facility on [DATE] and discharged against medical advice on 7/22/24. R402 was admitted with diagnoses that included: aftercare following surgery, absence of left leg below the knee A review of the medical record revealed the following progress notes: A Nursing note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s) #'s MI00145342 and MI00146542. Based on interview and record review the facility failed to provide oxygen (O2) services per physician order for two (R401 and R403) out of five residents reviewed for respiratory services resulting in R401's O2 saturation levels dropping to an extremely low level requiring immediate hospitalization. Findings include: R401 A complaint was filed with the State Agency (SA) that alleged on 7/2/24, R401 was sent to an outside medical appointment with their pulmonologist with an empty Oxygen (O2) tank. The resident's 02 saturation level dropped to 80% (a low level requiring immediate medical attention-normal readings are between 90-100%). The physician's office attempted to use an oxygen concentrator to improve the resident's oxygen level however they were unable to do so. The physician's office then sent R401 via EMS (emergency medical services) to the hospital. A review of R401's clinical record revealed the resident was initially admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake Number(s): MI00144974. Based on observation, interview, and record review, the facility failed to complete skin assessments on a consistent basis and thoroughly complete assessments of existing pressure ulcers for one (R702) of two residents reviewed for pressure ulcers. Findings include: A review of a complaint submitted to the State Agency revealed an allegation the facility was not providing adequate and appropriate care to prevent and treat pressure sores. On 6/26/24 at approximately 9:15 AM, R702 was observed in bed eating breakfast with the assistance of a staff member. R702 was lying on their back positioned slightly to their left side. On 6/26/24 at 12:23 PM, R702 was heard making a groaning noise from the hallway. R702 was lying in bed on their back positioned slightly to their left side as they were earlier in that day. When asked if he needed help, R702 groaned and was not able to answer the question. At that time, Licensed Practical Nurse (LPN) 'B' asked R702 if he…

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 the kitchen and equipment in a sanitary manner, and failed to ensure food items were dated and discarded when expired. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 3/4/24 between 9:10 AM-9:30 AM, during an initial tour of the kitchen with Dietary Manager (DM) I, the following items were observed: In the walk-in cooler, there was a large puddle of spilled milk on the floor, bloody meat juices on a tray where a vacuum sealed, cooked ham was stored, an undated container of sliced deli ham, and a container of cottage cheese with a best-by date of 2/16. DM I confirmed the ham should have been dated and stated the cottage should have been discarded. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such 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 ensure that meals were served at a preferred temperature and in a palatable manner for two (R212 and R213) and multiple anonymous residents who attended the resident council meeting. This deficient practice had the potential to affect residents that received meals. Findings include: On 3/4/24 at approximately 9:43 AM, R212 was observed sitting in their room. A full breakfast tray was on the tray table next to where they were sitting. The resident was alert and able to answer questions. When asked about life in the facility, R212 reported that they had been in the building for over a week and that most things, with the exception of the food, where going ok. R212 stated that they did not eat their breakfast of eggs, hashbrown and toast because it was served cold. R212 further noted that it was not the first time their food was served cold, and, on another occasion, they did not provide utensils at dinner. On 3/4/24 at approximately 10:15 AM, R213 was observed in their room. When asked about care in the facility…

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.

This citation has two deficient practices. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene for six residents (R362, R364, R13, R37, R1, R3) of six observed during medication administration resulting in the potential for the spread of infection. Findings include: Resident 362 and Resident 364 On 3/5/24 at 8:27 AM, Licensed Practical Nurse (LPN) T was observed for medication preparation and administration for R362 and R364. Hand hygiene was not performed pre and post administration to both residents. When questioned to LPN T if hand hygiene was performed, LPN T acknowledged hand hygiene was not completed it and should have been. On 3/6/24 at 02:16 PM, The Director Of Nursing (DON) was informed by this surveyor that hand hygiene was not performed during medication administration between residents. The DON confirmed that staff should be performing hand hygiene before and after resident contact. Review of the facilities Infection Prevention Manual, Hand Hygiene Policy Revised June 2013 stated: .All…

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 size pull-up underwear (facility provided single-use disposable underwear) was provided for two residents (R20 and R218) of two residents reviewed for accommodation of resident needs. Findings include: R20 On 3/04/24 at approximately 9:54 a.m., R20 was observed in their room, laying in their bed. R20 was queried if they had any concerns regarding their care and they indicated that their pullups they were wearing were too tight and that the facility had ran out of XXL and only provided them XL (extra-large) and not XXL. R20 indicated that they are Supposed to have XXL pullups and the XL ones they had been provided were too small. R20's bathroom was observed to contain a package of XL pull-ups with two remaining in the package. R20's closet was observed to contain a sizing sign that indicated R20 was to have XXL pullups. On 3/5/24 at approximately 9:48 a.m., R20 was observed in their room, laying in their bed. R20 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident's rooms were maintained in a clean, comfortable and homelike manner for five (R1, R13, R17, R30, R49) of five residents reviewed for the environment. Findings include: On 3/4/24 at 9:52 AM, R49 was observed lying in bed. The sink in R49's room, located outside of the bathroom was observed to be cracked. The sink was porcelain and was noted to have several cracks with a piece of porcelain missing around the metal drain at the base, causing a sharp edge which created a safety hazard for residents. R13 shares the same room with R49. On 3/4/24 at 9:59 AM, R1 was observed sitting in a wheelchair next to his bed. The sink, located outside of the bathroom was observed to be cracked. The sink had a hard, plastic coating that was cracked including a large crack which created a raised, sharp area on the back side of the basin portion of the sink, which created a safety hazard for residents. R30 shares the same room with R1. On 3/5/24…

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 Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to ensure medications were documented in the medical record accurately per professional standards for two residents (R15 and R362) resulting in the potential for inaccurate medical records and missed care needs. Findings include: R362 Clinical record review revealed R362 was admitted to this facility on 2/16/24 for admitting diagnosis of lung cancer, hypertension (high blood pressure) and peripheral vascular disease. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ten, indicating a moderately impaired cognition. On 3/5/24 at 8:27 AM, Licensed Practical Nurse (LPN) T was observed for medication preparation and administration for R362. During preparation LPN T stated the ordered Metoprolol and Amlodipine (medications used to treat high blood pressure) were not going to be administered for R362 as the blood pressure taken prior registered low at…

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 necessary labs were completed for a resident with an observed change in condition for one (R219) of three residents reviewed for pain/catheter care/laboratory services. Findings include: On 3/4/24 at approximately 9:54 AM, R219 was observed lying in bed. The resident was moaning and had their hand on their stomach and appeared thin. A full breakfast tray containing an egg, hashbrown patty, toast and a bowl of oatmeal was on the table next to the resident. When asked about care provided in the facility, the resident was not able to provide a verbal response. A review of R219's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: need for assistance with personal care, unspecified protein-calorie malnutrition and dysphagia following a cerebral infarction. A review of the resident Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score 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 This citation has two deficient practices Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure interventions to prevent injury from falling were provided for one resident (R93) of one residents reviewed for accidents/hazards. Findings include: On 3/4/24 at approximately 1:45 p.m., R93 was observed in their room, laying in their bed. R93's family member (guardian) was present during observation and was queried if R93 had any falls in the facility and they indicated that they have fallen out of the bed. At that time, no mat preventing injury from falling out of the bed was observed next to R93's bed. On 3/5/24 at approximately 8:48 a.m., R93 was observed in their room, laying in their bed. R93 was observed to be in a lower bed. R93 reported they had urinated in their bed and were waiting for some help. R93 was observed not to have a fall mat ( a floor mat utilized to prevent injury from falling) next to their bed. On 3/5/24 at approximately 3:09 p.m., R93 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate urology services was provided for one resident (R98) reviewed for urinary catheters, resulting in the increased likelihood of a urinary tract infection. Findings include: A review of the clinical record revealed R98 was originally admitted to the facility on [DATE], with admitting diagnosis of a neurogenic bladder (chronic suprapubic catheter), schizophrenia, congestive heart failure, and diabetes. Review of the Minimum Data (MDS) dated [DATE] revealed Brief Interview for Mental status (BIMS) score as unable to determine. On 3/4/24 at 10:00 AM, R98 was observed lying in bed asleep. A urinary catheter bag was hanging from the lower left bed frame. The urinary drainage bag had approximately 400 milliliter (ml) straw colored urine. Inside the drainage tubing was considerable amounts of thick pus-like, white, cloudy sediment. On 3/4/24 at 2:04 PM, A second observation was made to R98 and revealed the urinary catheter bag…

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 a resident with a history of protein-calorie malnutrition received weekly weights and 1:1 feeding as ordered for one (R219) of two residents reviewed for nutrition/hydration. Findings include: On 3/4/24 at approximately 9:54 AM, R219 was observed lying in bed. The resident was moaning and had their hand on their stomach and appeared thin. A full breakfast tray containing an egg, hashbrown patty, toast and a bowl of oatmeal was on the table next to the resident. When asked about the full plate of food as well as care provided in the facility, R219 was not able to answer. A review of R219's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: need for assistance with personal care, unspecified protein-calorie malnutrition and dysphagia following a cerebral infarction. A review of the resident Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status…

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 interview and record review, the facility failed to consistently ensure the physicians review, action and rationale of identified medication irregularities documented by the Pharmacy monthly medication reviews were documented and maintained in the resident's medical record for one (R55) of five residents reviewed for unnecessary medications. Findings include: On 3/4/24 the medical record for R55 was reviewed and revealed the following: R55 was initially admitted on [DATE] and had diagnoses including: depression and high cholesterol. A review of R55's MDS (minimum data set), dated 1/22/24 revealed R55 had a BIMS score (brief interview of mental status) of 5, indicating a severely impaired cognition. A review of the monthly medication regimens reviewed for R55 revealed the following dates in which irregularities were noted by the pharmacist during their monthly review: 11/15/23, 12/21/23, 1/3/24, 2/24/24. Further review of the medical record revealed no documentation that the physician had acknowledged the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a laboratory diagnostic was completed in a timely manner per Physician's order for one resident (R20) of one residents reviewed for laboratory diagnostics. Findings include: On 3/4/24 the medical record for R20 was reviewed and revealed the following: R20 was initially admitted to the facility on [DATE] and last admitted on [DATE] and had diagnoses including Overactive bladder and Irritable bowel syndrome. A review of R20' MDS (Minimum data Set) with an ARD (assessment reference date) of 1/25/24 revealed R20 had a BIMS score (brief interview for mental status) of 12 indicating moderately impaired cognition. A Physicians order dated 12/6/23 revealed the following: Check UA (urine analysis) with culture A second Physician's order dated 12/28/2023 revealed the following: Check UA with culture A Physician's evaluation dated 12/6/23 revealed the following: History of Present Illness: Patient is a [R20 demographics] here for long-term care. No chest…

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.