Neilson Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to develop and implement care planned interventions to address refusal of cares for 1 of 3 residents (R1) reviewed for deteriorating skin condition. Findings include: R1's Resident Face Sheet indicated he admitted to the facility on [DATE], with diagnosis that included congestive heart failure, hypertension, cellulitis of right lower limb, Esysipelis and mild cognitive impairment. R1's Skin Risk Assessment with Braden Scale dated 11/2/24, indicated he required assistance of a mechanical lift and was frequently incontinent. The assessment identified open lesions on the foot, edema and reduced urinary output. R1's Braden evaluation for risk of skin breakdown indicate he was at risk. R1's care plan dated 11/18/24, identified a self-care deficit due to weakness. The care plan directed staff to encourage participation in grooming and indicated he required substantial assistance for grooming and toileting. The care plan identified incontinence and directed…

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 toileting and hygiene tasks were performed for 1 of 3 (R1) residents reviewed resulting in worsening skin condition that required physician ordered treatment. Findings include: R1's Resident Face Sheet indicated he admitted to the facility on [DATE], with diagnosis that included congestive heart failure, hypertension, cellulitis of right lower limb, Esysipelis and mild cognitive impairment. R1's Skin Risk Assessment with Braden Scale dated 11/2/24, indicated he required assistance of a mechanical lift and was frequently incontinent. The assessment identified open lesions on the foot, edema and reduced urinary output. R1's Braden evaluation for risk of skin breakdown indicate he was at risk. R1's care plan dated 11/18/24, identified a self-care deficit due to weakness. the care plan directed staff to encourage participation in grooming and indicated he required substantial assistance for grooming and toileting. The care plan identified…

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 maintain clean and sanitary conditions of kitchen equipment and ensure hairnets were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 69 out of 69 residents that received food out of the kitchen or kitchenette. Findings include: Mixer: During an initial tour of the main kitchen on 12/3/24 at 7:02 a.m., a large industrial mixer was on the counter. The underside of the mixer head, which sat over the mixing bowl, was coated in a tan colored food debris on the underside. There was a white dust covering the mixing bowl arms. During an observation of the large industrial mixer on 12/5/24 at 11:20 a.m., the underside of the mixer head continued to be coated with a tan colored food debris. DA-B stated, that's bad, really bad and equipment should be thoroughly cleaned after every use to prevent contamination of food. During an interview on 12/5/24 at 4:59 p.m., 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 EBP: R10's significant change MDS dated [DATE], identfiied R10 was cognitively intact and had diagnoses that included quadriplegia, type 2 diabetes, and neuromuscular dysfunction of bladder. R10 had a stage 4 pressure ulcer, a colostomy and an indwelling catheter and was receiving intravenous medications. R10's care plan revised 11/19/24, identified R10 had an infection to a sacral wound (a region located at the base of the spine in the pelvic area) wound and had a need for enhanced barrier precautions due to indwelling urinary catheter and chronic wound. The following interventions were identified: - Post signage on door or wall outside of resident room - PPE available immediately outside of resident room. Staff to wash their hands upon entering and leaving room. PPE to be doffed prior to leaving resident room. - Provide education to resident or representative on the need for and duration of EBP. Encourage resident or representative to discuss feelings reoardino EBP. - Physical and occupational therapy to use…

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 oral care and shaving assistance to 1 of 5 residents (R23) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 was cognitively intact, had a diagnosis that included hemiplegia (one side paralysis or weakness) due to a history of a stroke. R23 had an indwelling catheter and a feeding tube. R23 was dependent on staff for all care activities. R23's care plan revised 12/3/24, identified R23 had a self-care deficit due to left sided hemiparesis related to a history of stroke. Staff were directed to provide assist of one for grooming. The care plan did not direct shaving on certain days or how often and when oral cares would be completed. During an observation on 12/3/24 at 4:31 p.m., R23 was lying in bed with his head of bed elevated 45 degrees. R23 had a sheet covering R23 to his waist and R23 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 interview and document review the facility failed to comprehensively assess and develop interventions to reduce or prevent continued weight loss for 1 of 1 resident (R30) reviewed for nutrition. We should also righ notification to he Dr at F580 . jsut need peices of it the record showing weight losss and interviews they should notify dr. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had severe cognitive impairment and required moderate to maximum assist with all activities of daily living (ADLs). R30's weight was 114 pounds, Diagnoses included Alzheimer's and congestive heart failure. R30's MDS IDT assessment dated [DATE], identified R30 had no difficulty with chewing or swallowing and required one person assist to eat at times. R30's height, weight, weight loss or gain and appetite was not completed on the assessment form. R30's care plan dated 12/2/24, identified R30 had a potential for weight loss. R30 was to receive a regular diet and offer point of service…

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 required nurse staffing information was consistently posted on a daily basis. This had potential to affect all 72 residents, staff, and visitors who could wish to review this information. Findings include: On 12/3/24, at 6:45 a.m. adjacent to the front doors was a wall-mounted, particle board which had a paper document hung with a thumbtack titled Daily Staffing for Tuesday November 26, 2024 and identified a census of 70. The document listed staff scheduled hours per shift for each nursing job class. However, the posting was dated 11/26/24, seven days prior. When interviewed on 12/5/24, at 2:40 p.m. medical records (MR)-I stated she was responsible for the daily staffing posting. MR-I thought she had posted for the holiday weekend but must not have done so. MR-I was working on system to ensure she did not forget to post staffing daily. It was important to have the posting updated every day so staff, family and state knew how many residents were in the building and that the facility was sufficiently…

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 the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or medical justification of use for 1 of 5 residents (R3) reviewed for unnecessary medication. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and R3 received antipsychotic medication daily. The MDS identified GDR was not attempted and there was no documentation that a GDR was contraindicated from R3's physician. Diagnoses included Alzheimer's, bipolar disorder, drug induced subacute dyskinesia (define), heart disease, and kidney failure. R3's most recent Physician Order Report dated 12/5/24, identified R3's current physician ordered medications. These included olanzapine five milligrams (mg) at bedtime for bipolar disorder with start date 3/31/22. R3's most recent Physician Progress note dated 10/25/24, identified R3 received olanzapine 5 mg daily for a diagnosis of bipolar. 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 document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted and/or medical justification was provided to support ongoing use of an antipsychotic medication for1 of 5 residents (R3) reviewed for unnecessary medication use. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and R3 received antipsychotic medication daily. A gradual dose reduction was not attempted and there was no documentation that a GDR was contraindicated from R3's physician. R3 was dependent with most activities of daily living (ADLs) and maximum assist with mobility. Diagnoses included Alzheimer's, bipolar disorder, drug induced subacute dyskinesia (a movement disorder associated with long term exposure to certain medications) , heart disease and kidney failure. R3's care plan dated 12/2/24, identified a potential problem related to psychotropic medication use with a goal for medication effectiveness…

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 medications were administered in accordance with physician orders and/or manufacturer guidelines for 2 of 6 residents (R23, R54) observed to receive medication during the survey. This resulted in a facility medication administration error rate of 6.9 percent (%). Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 was cognitively intact and included a had diagnosis of hemiplegia (one side paralysis or weakness) due to a history of a stroke. R23 exhibited pain and received scheduled and as needed pain medications. R23's Physician Order Report dated 12/8/23 identified R23 received Voltaren Arthritis Pain (diclofenac sodium) (an anti-inflammatory topical pain medication) gel 1%. Apply 4 gram (g) to affected area 4 times a day for back pain. During an observation on 12/4/24 at 6:52 p.m., registered nurse (RN)-B took R23's tube of Voltaren gel and apply approximately 1 inch to RN-B's gloved hand and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the correct diet texture was served to 1 of 5 residents (R38) reviewed for pressure ulcers; and failed to accommodate dietary preferences of 1 of 1 resident (R58) reviewed for food choices. Findings include: R38 R38's quarterly MDS dated [DATE], identified R38 had severe cognitive impairment and a diagnosis of Alzheimer's disease. R38 was dependent on staff for all care activities. R38's care plan revised 12/26/23, identified R23 required a mechanically altered diet related to chewing and swallowing abilities. Staff were directed to encourage oral intake of food and fluids. R38's dietary order dated 8/23/24, identified R38 required a minced and moist texture (a minced and moist diet consists of soft and moist foods that are easy to chew and swallow. The food was minced or mashed before serving, with no big lumps, and requires little or no biting. Lumps should be no more than 4 millimeter (mm) in size for adults. Foods in this…

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 offer and provide risk vs benefits of receiving or declining immunizations per Center for Disease Control and Prevention (CDC) guidance for 1 of 5 residents (R38) reviewed for immunizations. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 was [AGE] years old and had severe cognitive impairment with a diagnosis of malignant neoplasm of the prostate (cancer). R38's immunization record dated 12/8/23, identified the following immunizations were received at an outside care setting, COVID-19 vaccination on 2/23/21 and on 2/2/21; pneumococcal vaccinations on 7/13/16 and 1/1/99, however, did not indentify the type of pneumococcal vaccination received. R38's medical record lacked evidence the following vaccinations were offered/ in conjunction with the medical provider and educated on the risk versus benefits of the vaccination: most recent booser for COVID-19, annual influenza, and pneumococcal vaccinations…

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 develop a comprehensive care plan with person centered interventions for food seeking behaviors for 1 of 3 residents (R1) reviewed for behavioral health needs. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia, and type 2 diabetes mellitus with hyperglycemia. Further, MDS revealed R1 had moderately impaired cognition and did not exhibit any behaviors. R1's Progress Notes revealed the following: -On 6/25/24, R1 was seen by staff taking half gallon of milk from the kitchen. Staff spoke with R1 and R1 returned the gallon while saying this is bullshit. -On 6/21/24, R1 had been restless all night and had been out to nursing station numerous times looking for and requesting food. R1 had also made attempts to enter kitchen to sneak food. R1 was offered snacks and redirected when attempts were made to enter kitchen. -On 6/19/24, R1's care plan was reviewed and updated 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 obtain blood sugar checks and administer insulin timely, as ordered by physician, for 3 of 3 residents (R1, R2,R3) who had a diagnosis of diabetes. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included dementia, and type 2 diabetes mellitus with hyperglycemia. R1's Medication Administration History dated 6/1/24 through 6/27/24, indicated physician ordered blood glucose monitoring four times a day which was administered late 5 days. Further, physician order revealed insulin aspart once a morning which was administered late 8 days and Novolog FlexPen per sliding scale before meals and at bedtime which was administered late 9 days. R2's quarterly MDS dated [DATE], indicated R2 had diagnosis of diabetes mellitus. R2's Medication Administration History dated 6/1/24 through 6/27/24, indicated physician ordered blood glucose monitoring before meals and at bedtime which was administered…

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 operationalize their policy for prompt resolution of grievances for 1 of 1 residents (R3) reviewed who filed a grievance related to care concerns in the facility. Findings include: R3's Physician Orders dated January 2024, were reviewed. The orders did not include an order for Nitroglycerine tablets. A facility document titled Healthcare Safety Zone dated 2/1/24, indicated R3's family member (FM)-A spoke about a medication (Nitroglycerine) they received a bill for. FM-A stated R3 did not have an order for the medication and said R3 told her the medication was in her medication cupboard and a nurse had tried to give her the medication but R3 had refused. FM-A further identified concerns related to supplies and a skin issue and the nurse on duty, when the skin issue was identified, stated she did not have time to look at. During interview on 2/29/24 at 11:08 a.m., FM-A stated the facility had not followed up with her about concerns as she had requested. During interview on 2/29/24 at 11:42 a.m., licensed social worker…

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 report a fall from a mechanical stand that resulted in a broken clavicle (collarbone) to the state agency (SA) for 1 of 3 residents (R2) reviewed for falls. Findings include: R2's care plan dated 1/26/24, identified a risk for falls and directed staff to offer assistance with activities of daily living and transfers. R2's Progress Note dated 2/5/24, indicated staff was assisting R2 to the bathroom using a mechanical stand. R2 let go of the handles and began to slide out of the stand. Staff was able to help guide R2 to the floor. R2 complained of right shoulder pain. R2 agreed to go to the emergency department after dialysis. During interview on 2/27/24 at 3:08 p.m., the director of nursing (DON) stated R2 sustained a skin tear and a broken clavicle. The DON stated the incident was not reported to the SA because staff had identified a decline in condition that contributed to his falls. During interview on 2/27/24 at approximately 3:30 p.m., the administrator stated R2's fall from the lift was not reported to the SA because…

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 investigate a fall from a mechanical stand that resulted in a broken clavicle (collarbone) for 1 of 3 residents (R2) reviewed for falls. Findings include: R2's care plan dated 1/26/24, identified a risk for falls and directed staff to offer assistance with activities of daily living and transfers. R2's Progress Note dated 2/5/24, indicated staff was assisting R2 to the bathroom using a mechanical stand. R2 let go of the handles and began to slide out of the stand. Staff was able to help guide R2 to the floor. R2 complained of right shoulder pain. R2 agreed to go to the emergency department after dialysis. During interview on 2/27/24 at 3:08 p.m., the director of nursing (DON) stated R2 sustained a skin tear and a broken clavicle when he fell from the mechanical stand. The DON stated the fall had not been investigated. During interview on 2/27/24 at approximately 3:30 p.m., the administrator stated a formal investigation into the fall had not been completed. During interview on 2/27/24 at approximately 3:45 p.m., licensed…

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 develop and implement interventions to prevent sexual abuse for 1 of 2 residents (R1) who was being sexually abused by another resident (R4). Findings include: A report to the state agency dated 11/1/23, indicated on 10/29/23, Staff reported that they saw R4 touching R1's face, legs, thighs and head then tried putting his hands down her pants. The report indicated staff stepped in and stopped R4 and told him he needed to go to his room. An undated, untitled document provided by the facility in response to request for the investigation of the allegation indicated the incident was isolated. The document indicated three residents were interviewed by the facility with no identified concerns. Summary of interviews with witnesses indicated: It was reported on 11/1/23, that on 10/29/23, staff member had seen R4 touching R1 on her legs and face and also tried to put his hands down her brief. The document however, lacked evidence of interviews with 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 document review the facility failed to timely report an allegation of sexual abuse to the state agency for 1 of 1 residents (R1) reviewed who was allegedly being abused by another resident (R4) in the facility. Findings include: A report to the state agency dated 11/1/23, indicated on 10/29/23, Staff reported that they saw R4 touching R1's face, legs, thighs and head then tried putting his hands down her pants. The report indicated staff stepped in and stopped R4 and told him he needed to go to his room R4 Progress Notes identified the following: 10/24/23, R4 was making sexual comments to another resident (R1). R4 asked R1, Do you want me to come into your room tonight? 10/25/23, R4 was witnessed attempting to expose himself to another resident (R1) in the dining room. Report from the dietary aid was that R4 approached R1 in the dining room and looked around then stood up and began to unzip his pants. He attempted this two times and was redirected each time. R4's response to redirection was I am just trying to make her happy. 10/26/23, Writer was contacted…

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 thoroughly investigate an allegation of resident to resident sexual abuse for 1 of 1 residents (R1) who was being abused by another resident (R4). Findings include: A report to the state agency dated 11/1/23, indicated on 10/29/23, Staff reported that they saw R4 touching R1's face, legs, thighs and head then tried putting his hands down her pants. The report indicated staff stepped in and stopped R4 and told him he needed to go to his room. R4 Progress Notes identified the following: 10/24/23, R4 was making sexual comments to another resident (R1). R4 asked R1, Do you want me to come into your room tonight? 10/25/23, R4 was witnessed attempting to expose himself to another resident (R1) in the dining room. Report from the dietary aid was that R4 approached R1 in the dining room and looked around then stood up and began to unzip his pants. He attempted this two times and was redirected each time. R4's response to redirection was I am just trying to make her happy. 10/26/23, Writer was contacted from unit staff reporting…

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 maintain an on-going infection control program, which included comprehensive surveillance of resident infections to identify and analyze possible patterns of infection in the facility, including identification of any patterns in residents, locations or pathogens in real time to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 69 residents who resided in the facility. Findings include: Review of the facility's infection control surveillance program was conducted on 10/25/23 at 11:18 a.m., with licensed practical nurse infection preventionist (IP)-A. The infection logs lacked the following columns: resident name, room number, admit date , type of infection, surveillance definition met, symptoms, onset date, antibiotic name, class, dose, route, frequency provider, antibiotic start date, antibiotic end date, transmission on based precautions required, and date symptoms resolved. The infection logs lacked necessary documentation for adequate surveillance 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 food was served at a palatable and appetizing temperature for 1 of 1 resident (R7) who had food concerns. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and was independent with mobility and eating. R7's care area assessment (CAA) dated 11/14/22 triggered for nutritional status. During an observation on 10/24/23 a 4:48 p.m., R7 was seated at the table with three other residents. R7 indicated the meat sauce and noodles were on the chilly side. R15 agreed with R7 and stated, It is always like this. R7 pushed her plate in front of her and indicated she could not eat the dinner. R7 indicated her son had brought her some snacks that she would eat later in her room. During an observation on 10/25/23 at 8:16 a.m., R7 was seated at the dining room table for breakfast with four other residents and indicated the sausage links were not really warm and expressed they never were. R7…

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 dignity was maintained for 1 of 1 residents (R18) who utilized an indwelling catheter. Findings include: R18's annual Minimum Data Set (MDS) dated [DATE], identified R18 had intact cognition and had diagnosis which included: anxiety disorder, asthma, and Neurogenic bladder (condition in which a person lack's bladder control). Identified R18 required staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R18's annual Care Area Assessment (CAA) dated 8/11/23, identified R18 required assistance with toileting. Indicated R18 had an indwelling catheter related to a neurogenic bladder. R18's care plan reviewed 8/21/23, identified R18 had an indwelling catheter due to neurogenic bladder. Care plan instructed staff to position catheter bag below level of the bladder. Care plan lacked direction on covering the catheter bag. Care plan indicated R18 required extensive staff assistance…

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 resident current wishes for resuscitation status were accurately documented in the medical record for 2 of 27 residents (R8 and R25) reviewed for advanced directives. Findings include: R8 R 8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had mild cognitive impairment and had diagnosis which included end stage renal disease, hyperlipidemia (elevated cholesterol) and hypertension (elevated blood pressure). Identified R8 was independent with activities of daily living (ADL's) which included bed mobility, toileting, and transfers. During an interview on [DATE] at 10:00 a.m., R8 stated he had decided a few months ago that he did not wish to be resuscitated. R8's current care plan revised [DATE], identified R8's advance directives were for full resuscitation (full code) status. Review of R8's paper health record identified the following: -R8's Resuscitation status form dated [DATE], identified R8 requested to change his code 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 on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R7) with visual and hearing impairments reviewed for activities. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and was independent with transfers, mobility and activities of daily living (ADLs). R7's face sheet identified diagnoses of Nonexudative age-related macular degeneration, bilateral (dry eye disease in both eyes) and sensorineural hearing loss, bilateral (nerve related hearing loss in both ears). R7's Activity assessment dated [DATE], indicated R7 preferred day/activity room and independent activities in her room. R7's preferred program style was small groups and independent at times. Indicated R7's preferences were crafts/arts, music, spiritual/religious, watching TV, talking or conversing, and helping others. R7's focus of programing was creative/expressive, independent, relaxation, religious, social…

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 comprehensively assess, monitor, and provide necessary care 1 of 1 residents (R62) with a port-a-cath (an implanted device in the chest with direct access to a vein. It is used to administer medication or fluids that are unable to be taken by mouth or would harm a smaller peripheral vein, obtain blood tests, and measure central venous pressure) in the facility. R62 was at risk for injury or an infection. Findings include: R62's admission Minimum Data Set (MDS) assessment dated [DATE], identified R62 had independent decision making skills for activities of daily living and had no memory impairment. Indicated R62 had diagnoses of anemia, coronary artery disease, diabetes mellitus, and depression. R62's care plan dated 9/22/23, indicated R62 had a self-care deficit due to deconditioned status. R62's care plan listed various interventions with included assist of one to two to ambulate with walker, assist of one for bathing and dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure menus and individual resident food plans met the nutritional needs and preferences for 2 of 2 residents (R4 and R7) reviewed for food. Findings include: R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had intact cognition and had diagnosis which included diabetes mellitus (DM) , chronic kidney disease, and heart failure. Identified R4 required staff assistance with activities of daily living (ADL'S) which included bed mobility, toileting and transfers. A nutritional assessment dated [DATE],indicated R4 preferred lettuce salads and disliked salmon. R4's care plan revised 7/18/23, instructed staff to encourage protein at breakfast (eggs, yogurt, cottage cheese). During an interview on 10/23/23 at 2:59 p.m., R4 stated her preferences were fried eggs for breakfast and a lettuce salad at lunch. R4 stated that up until a few months ago, she had received a fried egg and lettuce salad however is no longer able 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 document review the facility failed to report an allegation of neglect to the state agency (SA) which had the potential to affect all residents who resided on the Elderberry unit of the facility. Findings include: A report to the SA dated 7/17/23, indicated on 7/15/23, a nursing assistant (NA) was sent to the Elderberry unit of the facility at 1:30 a.m. to relieve licensed practical nurse (LPN)-A for a break. Upon arriving to the unit LPN-A was nowhere to be seen, the NA checked every room and bathrooms and was still unable to find LPN-A. At 3:00 a.m. LPN-A still had not returned to the unit. The on call nurse instructed staff to check the parking lot to see if LPN-A was asleep in her car. A second nurse went to the second floor to assist with the search and found LPN-A asleep in the sunroom. The report indicated there was only one staff on each unit on the overnight shift so staff were not to leave the unit unattended. During interview on 10/18/23, at 3:58 p.m. registered nurse (RN)-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 interview and document review the facility failed to thoroughly investigate and allegation of neglect of care which had the potential to affect all residents who resided on the Elderberry unit of the facility. Findings include: A report to the SA dated 7/17/23, indicated on 7/15/23, a nursing assistant (NA) was sent to the Elderberry unit of the facility at 1:30 a.m. to relieve licensed practical nurse (LPN)-A for a break. Upon arriving to the unit LPN-A was nowhere to be seen, the NA checked every room and bathrooms and was still unable to find LPN-A. At 3:00 a.m. LPN-A still had not returned to the unit. The on call nurse instructed staff to check the parking lot to see if LPN-A was asleep in her car. A second nurse went to the second floor to assist with the search and found LPN-A asleep in the sunroom. The report indicated there was only one staff on each unit of the overnight shift so staff were not to leave the unit unattended. During interview on 10/18/23, at 3:58 p.m. registered nurse (RN)-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 observation, interview and document review the facility failed to perform root cause analysis and failed to provide staff education to reduce the risk for burns after 1 of 1 residents (R9) reviewed sustained a burn from a hot plate. Findings include: R9's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition. R9's care plan dated 10/3/23, identified a Self Care deficit due to quadriplegia and indicated he had some function in upper extremities. The care plan directed staff to set up R9's food and cut up food as needed. R9's Resident Progress Note dated 9/28/23, indicated R9 was eating breakfast in his room and had placed plate on bare abdomen. When plate was removed it was found that R9 had a 4 centimeter (cm) x 5 cm red area and 1 cm x 2 cm blistered burn from the plate. Provider was notified and orders received for treatment. Dietary was talked too about this and thought that the new plaid clothing protectors would be appropriate coverage for abdomen. A supply was placed in residents…

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.