The Estates At Twin Rivers LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected seven residents (R144, R92, R27, R5, R192, R21, and R2) who currently resided in these rooms. Findings include: During the entrance conference on 5/19/25 at 11:34 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage. The following double resident rooms did not meet the required minimum square footage per resident: room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (empty). room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident (R144). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R92). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (empty). room [ROOM NUMBER] = 150…

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 document review, the facility failed to ensure medications had both open dates and expiration dates marked on the medications so staff new how long the medications were good for. This had the ability to affect all residents on the transitional care unit (TCU) who received medications. Findings include: On 5/21/25 at 12:21 p.m., a review of the TCU medication care and treatment cart was performed. Three different insulin dial up pens were observed without open dates or expiration dates documented on the pens. Three different inhalers were also observed without open dates or expiration dates. During an interview on 5/21/25 at 12:36 p.m., licensed practical nurse (LPN)-A reviewed the medications and confirmed there were no open dates or expiration dates on the medications. LPN-A could not report when the medications were opened or how long they were good for once the medications were opened. LPN-A did not know how long insulins or inhalers were good for after opened and stated, I need to check with my supervisor. On 5/22/25 attempts to contact 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 observation, interview and document review the facility failed to ensure food served to the residents was palatable, at a pleasing temperature, and in a timely manner for 4 of 4 residents R145, R29, R33, and R93 reviewed for food concerns. Findings include: R145's admission Minimum Data Set (MDS) dated [DATE], indicated R145 was cognitively intact. R145 was independent with all aspects of eating and was independent with mobility. R145's medical diagnoses included gastroesophageal reflux disease (GERD-acid indigestion) and diabetes (a disease which impacts the body's ability to process sugar in the blood). On 5/19/25 at 2:22 p.m., R145 stated the food was never warm. R145 went on to state she would love a hot meal. R145 stated the coffee was cold and the food was inconsistent. R145 did not indicate she had requested an alternate meal/new plate, or fresh coffee. R29's admission MDS dated [DATE], indicated R29 experienced moderate cognitive impairment. The assessment indicated R29 was independent 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 document review the facility failed to implement interventions to maintain a dignified appearance related to the failure to properly secure urinary leg bags for 1 of 1 residents (R28) reviewed for urinary catheter. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADLs) including dressing, grooming, bathing, and transfers. R28 was noted to have an indwelling catheter. R28's medical diagnoses included an artificial opening of the urinary tract (nephrostomy tubes-tubes which drain urine from the kidneys), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland which can lead to various urinary problems in men), renal insufficiency (a condition which the kidneys are not functioning at their full capacity), urinary tract infections, diabetes (a group of diseases which affects how the body uses blood sugar), specialized disorders 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 observation, interview and record review, the facility failed to obtain proper consent for use of psychotropic medications (a drug which affects behavior, mood, thoughts or perception) for 1 of 5 residents (R35) reviewed for unnecessary medications. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 was noted to receive assist with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy (brain disease, damage, or malfunction which encompasses a range of conditions that could cause brain dysfunction, which might manifest as confusion, memory loss, personality changes, or severe symptoms like coma), cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), arthritis (inflammation of joints), dementia, anxiety, depression, visual…

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 document review, the failed to facilitate resident preferences for bathing and meals for 1 of 1 resident (R27) reviewed for choices. Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADLs) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis (MS), malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain…

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 document review, the facility failed to consistently provide clean bed linens for 1 of 1 residents (R27) reviewed for choices and provision of assistance with activities of daily living (ADLs). Findings include: R27's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with ADLs including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). R27's medical diagnoses included multiple sclerosis (MS) and malnutrition (an imbalance of energy and nutrients consumed. R27's care plan dated 5/2/25, identified R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS. On 5/19/25 at 5:58 p.m., R27 expressed…

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 document review, the facility failed to ensure a baseline care plan was developed to ensure all care needs were adequately addressed for 1 of 1 residents (R29) reviewed for range of motion. Findings include: R29's admission Minimum Data Set (MDS) dated [DATE], indicated R29 experienced moderate cognitive impairment. R29 was identified to have functional limitation of range of motion on one side with impairment on one side. R29 required assistance with activities of daily living (ADLs), including dressing, grooming, bathing, and mobility. R29's medical diagnoses included sequalae of cerebral infarction (details of cerebral infarction (stroke-and its effects it can cause to the brain including, but not limited to, change in mobility, loss of movement of one side of the body, vision problems, memory loss and difficulty with problem solving, emotional and behavioral changes, and seizures), heart failure (a condition where the heart is not able to pump enough blood for the body's needs 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 document review, the facility failed to revise resident care plans with updated interventions for 1 of 1 residents (R27) reviewed for choices and activities of daily. Findings include: R27's admission Minimum Data Set (MDS) assessment, dated 5/2/25, indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADL's) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis, malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability 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 observation, interview and document review the facility failed to provide routine bathing assistance for 1 of 1 residents (R27) reviewed for activities of daily living (ADLs). Findings include: Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADL's) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis (MS), malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27…

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 document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 1 of 1 resident (R35), identified to receive hospice services. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 received assistance with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy, cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), arthritis (inflammation of joints), dementia, anxiety, depression, visual hallucinations (seeing something that is not there), adjustment disorder with anxiety, chronic pain syndrome, fibromyalgia (symptoms of widespread chronic pain, headaches, depression and other symptoms). R35's care plan printed 5/22/25, identified R35…

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 document review, the facility failed to provide routine assistance with range of motion (ROM) to to improve strength, mobility and improve circulation of left arm for 1 of 1 (R29) reviewed for ROM. Findings include: R29's care plan, dated 2/14/25, indicated R29 was a fall risk related to left side(d) weakness, impaired vision. The care plan directed staff to follow PT (physical therapy) and OT (occupational therapy) instructions for mobility function. The care plan additionally identified R29 had self care deficit related to left sided weakness. The care plan directed staff R29 was to receive OT as ordered by provider. Staff were also directed to follow OT instructions. A review of the Interdisciplinary Team (IDT) Conference notes was reviewed and it was noted in the document dated, 2/13/25, R29 was receiving assist with from therapy for ROM with left arm. A review of the subsequent IDT notes of 3/28/25 indicated The IDT note indicated the nurse practitioner had reviewed swelling in left forearm and ordered a compression wrap for his left arm. 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.

Based on observation, interview and document review, the facility failed to assess and analyze a fall with significant injury for 1 of 2 residents (R11) reviewed for falls. Findings include: R11's minimum data set (MDS) completed for significant change dated 3/5/25, was noted to be cognitively intact and able to communicate her thoughts, needs, and wishes. R11 was identified as using a walker and wheelchair for mobility. R11 received assistance to complete her activities of daily living (ADLS), however, actively participated with cares. R11's medical diagnosis included anemia (low levels of healthy red blood cells or hemoglobin), coronary artery disease (a build up in the walls of the blood vessels which supply blood to the heart), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), difficulty in walking/unsteadiness on her feet, muscle weakness, peripheral autonomic neuropathy (nerve damage which affects the system which controls involuntary body functions such blood pressure and heart rate, and weakness. The MDS…

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 monitoring for tardive dyskinesia (TD- a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications) was implemented for 1 of 5 residents (R35) reviewed for unnecessary medications. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 was noted to receive assist with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy (brain disease, damage, or malfunction which encompasses a range of conditions that could cause brain dysfunction, which might manifest as confusion, memory loss, personality changes, or severe symptoms like coma), cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure),…

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 document review, the facility failed to provide an individualized care plan for 1 of 3 residents (R1) reviewed for smoking plans. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a diagnosis of cerebral infarction (stroke). The MDS indicated R1 required assistance with personal care, transfers, and mobility. R1's care plan dated 4/30/25 directed R1 had a history of smoking at the facility, and was noncompliant with the smoking policy. R1's care plan indicated he had been noted to be smoking in his room, and he was educated on the safety risk to himself and others. The care plan listed interventions of resident can smoke outside with family, and was deemed unsafe to store/handle his own smoking materials. The goal listed on R1's care plan was he would not smoke while at the facility. The undated facility care sheet (nursing assistant and nurse care guide) lacked a smoking plan or plan for supervision for R1. R1's Smoking assessment dated [DATE] indicated…

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 document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed for safe smoking, after R1 was discovered smoking in his room on multiple occasions. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a diagnosis of cerebral infarction (stroke). The MDS indicated he required assistance with personal care, transfers, and mobility. R1's care plan dated 4/30/25 directed R1 had a history of smoking at the facility, and was noncompliant with the smoking policy. R1's care plan indicated he had been noted to be smoking in his room, and he was educated on the safety risk to himself and others. The care plan listed interventions of resident can smoke outside with family, and was deemed unsafe to store/handle his own smoking materials. The goal listed on R1's care plan was he would not smoke while at the facility. The undated facility care sheet (nursing assistant and nurse pocket care guide) lacked a smoking…

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 document review the facility failed to notify the physician of a significant medication error for 1 of 3 residents (R3) who did not receive prescribed blood pressure medication for five days. Findings include: R3's admission Record indicated he admitted to the facility 12/3/24. R3's diagnosis included chronic atrial fibrillation (A-fib), pain, chronic kidney disease and weakness. R3's Order Summary Report dated 12/1/24 through 12/31/24, identified the following order: diltiazem hydrochloride (HCl) extended release (ER) coated beads oral capsule extended release 24 Hour 120 milligrams (mg). Give 120 mg by mouth in the morning for A-Fib. R3's Medication Administration Record dated December 2024, displayed the following for R1's diltiazem order: 12/4/24, 9- other/ see nurses notes. 12/5/24, 9- other/ see nurses notes. 12/6/24, 9- other/ see nurses notes. 12/7/24, indicated medication was administered. 12/8/24, 5- Hold/ see nurses notes. R3's Progress Notes identified the following: 12/4/24, Diltiazem HCl ER Coated Beads Oral Capsule Extended Release 24 Hour, 120…

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 document review the facility failed to ensure prescribed blood pressure medication and oxygen was administered for 2 of 3 residents (R3 and R1) reviewed. R3 had an in increase in blood pressure and R1 had an empty oxygen tank and was sent to the emergency room. Findings include: R3's admission Record indicated he admitted to the facility 12/3/24. R3's diagnosis included chronic atrial fibrillation (A-fib), pain, chronic kidney disease and weakness. R3's Order Summary Report dated 12/1/24 through 12/31/24, identified the following order: diltiazem hydrochloride (HCl) extended release (ER) 24 Hour, 120 milligrams (mg). Give 120 mg by mouth in the morning for A-Fib. R3's Medication Administration Record dated December 2024, displayed the following for R1's diltiazem order: 12/4/24, 9- other/ see nurses notes. 12/5/24, 9- other/ see nurses notes. 12/6/24, 9- other/ see nurses notes. 12/7/24, indicated medication was administered. 12/8/24, 5- Hold/ see nurses notes. R3's Progress Notes…

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 document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R3) reviewed for quality of care. Findings include: R3's admission Record dated 12/28/24 indicated R3's diagnoses included and type two diabetes mellitus. R3's annual Minimum Data Set (MDS) dated [DATE] indicated R3 had moderate cognitive impairment. R3's care plan dated 1/2/25, indicated R3 had type two diabetes mellitus, with staff interventions to monitor blood sugars, and keep the provider informed per resident orders. R3's Provider Order dated 12/28/24 indicated blood glucose checks before meals and bedtime. Call the provider if blood sugars less than 75 or greater than 400. R3's orders dated 12/28/24 included insulin Aspart subcutaneous solution pen-injector 100 unit/milliliter (ml). Inject 20 units subcutaneously with meals and 10 units as needed for diabetes mellitus. May take additional 10 units for higher carb meal daily, up to 70 units total in 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 Based on observation, interview and document review, the facility failed to provide 1:1 supervision during meals to ensure a resident who was identified as a choking risk was supervised while eating for 1 of 3 residents (R2) reviewed for 1:1 supervision during meals. Findings include: R2's admission Record dated 4/24/24 indicated R2's diagnoses included muscle weakness, dysphagia, and oropharyngeal phase. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had mechanical altered diet, required change in texture of food, and required staff supervision for all meals and drinks. R2's care plan dated 8/21/24, indicated R2 had potential alteration in nutrition related to dysphagia, oropharyngeal phase, and needed 1:1 supervision with meals with reminders to swallow foods and liquids. R2' Provider Orders dated 8/21/24 indicated regular diet mechanical soft texture, regular (thin) consistency fluids, 1:1 feeding and drinking, remind to swallow. No straws per speech therapist. On 1/7/25 at 12:53 p.m. R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with no behaviors identified. R3 required substantial to maximal assistance with personal hygiene, dressing, roll left and right, and dependent on staff for toileting hygiene, shower/bath, all transfers, and mobility in a manual wheelchair. R3 was always incontinent of bowel and bladder. R3's active diagnoses included: CVA (cerebrovascular accident) (stroke), hemiplegia (one sided paralysis/weakness), diabetes mellitus (DM), and at risk for pressure ulcers. R3's care plan dated 10/16/24, identified self-care deficit and decreased mobility, instructed staff to check and change and reposition every two to three hours and 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 review the facility failed to ensure staff implemented the care plan for 1 of 3 residents (R3) when staff failed to reposition and check and change incontinent brief for R3 who required assistance with activities of daily living (ADLs). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with no behaviors identified. R3 required substantial to maximal assistance with personal hygiene, dressing, roll left and right, and dependent on staff for toileting hygiene, shower/bath, all transfers, and mobility in a manual wheelchair. R3 was always incontinent of bowel and bladder. R3's active diagnoses included: CVA (cerebrovascular accident) (stroke), hemiplegia (one sided paralysis/weakness), diabetes mellitus (DM), and at risk for pressure ulcers. R3's care plan dated 10/16/24, identified self-care deficit and decreased mobility and instructed staff to check and change and reposition every two to three hours and 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 observation, interview and document review, facility failed to practice competent, safe, and sterile technique when administering intravenous (IV) medication via peripherally inserted central catheter (PICC) (enters a peripheral vein and extends to the supervisor vena cava of the heart) 1 of 1 resident (R6) reviewed for medication administration. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 was admitted to facility from hospital. R6 was admitted with an IV access and had diagnoses of a multidrug resistant organism (microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents), and paraplegia (paralysis that affected the lower half of the body and ability to walk). R6's orders included: Flush pulsating before medications with 10 cubic centimeters (cc) saline, PICC line per nurse. Start date 10/2/24. Meropenem 1 gram (gm) /100 milligram (mg) normal saline (NS) 100 milliliters (ml) infuse over 30 minutes at 200 ml /per hour. PICC…

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 document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 30 residents who reside at the facility. Review of the facility staffing schedules dated 10/1/23 through 12/31/23, identified there was not eight consecutive hours of RN coverage for 10/1/23, 10/8/23, 10/14/23 and 10/15/23. When interviewed 4/24/24 at 8:09 a.m., trained medication aide (TMA)-A stated there were only two licensed nurses employed with the facility which resulted in having to utilize agency licensed nurses. TMA-A stated she was unaware of any day or date when a registered nurse was unavailable for eight consecutive hours and verified a licensed nurse was always on duty. TMA-A stated she was unaware of any situation in which a resident needed cares from an RN and had not received them. When interviewed on 4/24/24 at 8:45 a.m., the administrator verified there was no RN on for eight consecutive hours on 10/1/23, 10/8/23, 10/14/23 and 10/15/23. The administrator…

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 document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected nine residents (R1, R187, R12, R16, R5, R23, R18, R6 and R27) who currently resided in these rooms. Findings include: During the entrance conference on 4/22/24 at 11:42 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage. The following double resident rooms did not meet the required minimum square footage per resident: room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (R12). room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident (R187). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R18). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R23). room [ROOM NUMBER] = 150…

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 document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R21), reviewed and observed for self-administration of medications. Findings include: R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and was independent with all activities of daily living (ADLs). R21's diagnoses included stroke, hemiplegia (left side), depression, asthma, muscle wasting and atrophy, muscle weakness, cellulitis, and long-term use of anticoagulants. During record review on 4/24/24, R21's electronic health record (EHR) indicated a signed orders completed by certified nurse practitioner (CNP)-A on 4/12/24 directinh staff to leave melatonin and trazadone at bedside when giving R21 medications and R21 would take medications when ready for bed. Order lacked parameters of time when medications could be left. R21's EHR lacked assessment for self-administration 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 observation, interview and document review, the facility failed to ensure reasonable accommodation of need related to repositioning device for 1 of 1 resident (R21) reviewed for bed rails. Findings include: R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and was independent with all activities of daily living (ADLs). R21's diagnoses included stroke, hemiplegia (left side), depression, asthma, muscle wasting and atrophy, muscle weakness, cellulitis, and long-term use of anticoagulants. During observation and interview on 4/22/24 at 6:17 p.m., R21 did not have bed rails on bed. R21 stated he had chronic right shoulder pain, used to have bed rails in room one and have asked several times for bed rails to be put on bed in room two to assist him with repositioning and/or getting in and out of bed due to pain. During observation on 4/23/24 at 9:30 a.m., R21's bed did not have bed rails on bed. During observation on 4/24/24 at 8:29 a.m., R21's bed did not have…

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 document review, the facility failed to ensure room temperature and refrigerated food items were properly stored, labeled, and dated when the original packaging was opened. This deficient practice had the potential to affect all 36 residents who ate food prepared in the kitchen. Findings include: During a kitchen observation on 3/15/24 at 8:45 a.m. with the culinary director (CD)-A, the following items were observed in the food preparation sink: - Two packages of sealed frozen pork sausage in a clear plastic container filled with water. - [NAME] onions floating in water in a clear plastic container, balanced on top of the container with the frozen pork. - A bucket of soapy water with soiled utensils, to the left of the two stacked containers. The following items were opened without any dates in the dry storage area: - One package of Crispy Onions - One bag of Stovetop stuffing The following items were opened without any dates in the refrigerator: - Two bowls containing yogurt and berries. - One package of imitation crab meat was opened. - One…

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 document review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 36 residents who ate food prepared in the kitchen. Findings include: On 3/15/24 at 8:45 a.m., during a tour of the kitchen with the culinary director (CD)-A, a thick brown substance was observed on the base boards of the kitchen and under the counters, refrigerators, freezers, dry storage shelves, oven, and dishwashing area. The microwave, the toaster, and lower shelves were also covered in the thick brown substance. The vent between the dry storage area and the food preparation area of the kitchen, located approximately 8 feet high, located above the food preparation sink had a dark gray fuzz matter. The ceiling vent, over the counter where food dishes were prepared had a dark brown fuzz matter covering the vent and extending approximately 3 feet in all directions beyond the vent across the ceiling. The ceiling material was peeling back and angled downward toward the floor in an approximate 6 inch by 6 inch area. The ceiling…

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.