Villas At Bryn Mawr LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to consistently and comprehensively assess a non-pressure skin condition to ensure skin condition changes could be adequately monitored and acted upon promptly to promote healing and reduce the risk of complications (i.e., infection, worsening) for 1 of 2 residents (R22) reviewed who had skin impairments. In addition the facility failed to ensure services were coordinated with the hospice agency of 1 of 1 residents (R10) reviewed who received hospice services. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], indicated R51 had moderately impaired cognition and was diagnosed with dementia and schizophrenia. The MDS indicated R22 was independent with toileting hygiene, required supervision or touching assistance with bathing/showering, and set up or clean up assistance for lower body dressing. R22's Weekly Skin Inspection dated 3/11/26, indicated R22 had ongoing red rashes on the perineal area, that a cream was applied per…

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 failed to ensure medications were stored in a secure manner when staff left a medication cart unattended and unlocked, resulting in unauthorized individuals having potential access to medications, including controlled substances. This had the potential to affect medications accessible in that cart by allowing unauthorized access and creating the potential for medication diversion or resident harm. Findings include:During continuous observation on 6/16/26 from 9:01 a.m. through 9:21 a.m., an unlocked medication cart remained unattended at the nurses' station while the assigned nurse was away from the cart. During the observation, four ambulatory residents walked past the medication cart, staff members came and went from behind the nurses' station, and the nurse manager also walked past the unattended cart. The cart was out of sight of staff intermittently throughout the observation. Because the medication cart remained unlocked, medications, including controlled substances stored within the cart, were no…

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 follow infection control standards of practice for cleaning a urinal for 1 of 1 resident (R2) reviewed for infection control. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated, R2 had severe cognitive impairment, didn't have delusions, didn't refuse cares, was continent of bladder, was independent with activities of daily living, was independent with transfers, and used a wheelchair for mobility. R2's MDS indicated diagnoses of anemia, coronary disease, heart failure, hypertension, and chronic lung disease. R2's care plan indicated he had a risk for alteration in elimination related to impaired mobility. Care plan indicated R2 was continent of bladder, and he kept a plastic urinal on his wheelchair. R2's care plan also indicated the staff had to clean or replace the urinal as needed. During observation and interview on 6/14/26 at 12:32 p.m., R2 was in his room, and on top of his bedside table there were two…

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 emergency call system remained accessible and functional for 4 of 4 residents (R9, R30, R52, and R64) who used the shared bathroom by failing to ensure the bathroom emergency call light pull cord was long enough to be reached by a resident from the floor creating the potential for delayed staff response during an emergency.Findings include:R9's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R9 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, was independent with personal hygiene and toileting, and had experienced one fall with minor injury.R52's quarterly MDS assessment dated [DATE] indicated R52 had severe cognitive impairment with a BIMS score of 4 and was independent with activities of daily living.R30's quarterly MDS assessment dated [DATE] indicated R30 was cognitively intact with a BIMS score of 15, was independent with activities of daily living, and had diagnoses…

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 assess and develop a plan to ensure tube feeding needs were met for 1 of 1 resident (R1) reviewed who had a behavior of disconnecting her feeding and sustained over 13 pounds (lbs.) of weight loss in less than 30 days as a result. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's diagnoses included malnutrition, anxiety disorder and depression and was severely cognitively impaired, usually understood with unclear speech and had no behaviors. The MDS further indicated she required set up to partial assistance with activities of daily living (ADL)'s and was independent with mobility. In addition, the MDS indicated it was unknown if R1 had a weight gain or loss but received a tube feeding with a weight of 165 pounds (lbs.).R1's care plan (CP) dated 2/19/26, indicated R1 self seeks food and fluids while NPO (nothing by mouth), risk versus (vs) benefits completed on 2/19/26, and required reminders and redirection related…

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 the reasonable suspicion of a crime to law enforcement for 1 of 1 resident (R4) reviewed who made an allegation of sexual abuse. Findings include: R4's facesheet dated 6/24/25, indicated she admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (one-sided paralysis and weakness after a stroke), need for assistance with personal care, adjustment disorder with anxiety, mild cognitive impairment, post-traumatic stress disorder, and moderate intellectual disabilities. R4's care plan dated 6/6/25, identified she was a vulnerable adult related to severe mobility limitation, severe sensory impairment, poor orientation to person place and time, history of physical aggression, ignoring personal safety, and inability to identify the boundaries of others. Nursing Home Incident Report #360521 dated 5/13/25, was submitted to the state agency (SA) and identified an allegation of sexual abuse,…

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 revise the care plan for an elopement-safety related intervention for 1 of 1 resident (R1) reviewed for resident safety. Findings include: R1's Hospital discharge summary provider note dated 3/14/25, identified R1 had orders to reside in a locked unit due to profound cognitive impairment due to severe Traumatic Brain Injury (TBI). Psych evaluated and agreed R1 lacked decision making ability and had a history of an elopement at a hospital in September 2024. Needs 24/7 supervision. R1's Elopement Risk Evaluation dated 3/14/25, indicated R1 was at risk for elopement due to habit/history of wandering or attempts to leave the unit/building, was ambulatory or able to self-propel wheelchair, asking to go home or other specific destinations, had cognitive deficit diagnosis and family had voiced concerns that resident may have a tendency to wander or elope. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was 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 Based on interview and document review, the facility failed to assess a resident to determine the need for additional treatments and services for mental and psychosocial well-being for 1 of 1 resident (R4) reviewed who made an allegation of sexual assault and had a history of post-traumatic stress disorder (PTSD) and psychosocial adjustment difficulty. Findings include: R4's facesheet dated 6/24/25, indicated she admitted to the facility in 2004 and had diagnoses including post-traumatic stress disorder, adjustment disorder with anxiety, unspecified psychosis, mild cognitive impairment, and moderate intellectual disabilities. R4's trauma care plan dated 4/22/24, identified she was at risk for alterations in behavior related to trauma and diagnosis of PTSD. R4 declined when asked about potential triggers, was unable to articulate coping strategies, and reported no trauma on assessment. R4 saw psychology providers. Interventions included staff to consider past trauma when engaging in work with R4, utilize family…

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 medications were available for administration per physician order for 1 of 1 resident (R1) reviewed for resident safety. Findings include: R1's order summary dated 3/14/25, identified an order for Nicotine min mouth/throat lozenge (Nicotine Polacrilex) give 2 mg by mouth every 1 hour as needed for nicotine craving related to nicotine dependence. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], had severe cognitive impairment, was independent with activities of daily living (ADL's) and mobility. Further identified R1 used tobacco. R1 had diagnoses of traumatic brain injury (a brain injury caused by an external force, like a blow to the head or a jolt) and nicotine dependence. R1's medication administration record (MAR) dated June 2025, identified an order for Nicotine min mouth/throat lozenge (Nicotine Polacrilex) give 2 mg by mouth every 1 hour as needed for nicotine craving related 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 implement admission physician's orders of daily weight checks for 1 of 1 resident (R1) who had a diagnosis of malnutrition and was alleged to have a significant weight loss. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, diagnosis of anemia, malnutrition, hip fracture, difficulty swallowing, cavities or missing teeth. R1's admission MDS further indicated a weight of 102 pounds (lbs.), a mechanical soft diet and four pressure ulcers, all present upon admission, with two identified as unstageable with deep tissue injury. R1's Care Plan dated 3/24/25, indicated R1 had actual alteration in nutrition, malnutrition related to acute hospital stay for edema with polysubstance abuse, poor nutrition history, past gastric bypass, and inadequate intakes. The care plan further indicated increased protein needs related to altered skin as evidence by multiple wounds. Staff were directed 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.

Based on observation, interview, and documentation, the facility failed to ensure opened food items were wrapped, labeled, dated, and disposed of by use by dates. The facility failed to ensure personal staff items were not stored next to resident food items. Further, the facility failed to ensure facial hair restraints were worn during meal service and hair nets were worn in the kitchen. In addition, the facility failed to ensure the kitchen's dish machine reached adequate temperature and pans and utensils were completely dry before storage to prevent bacterial growth. This had potential to affect all 98 residents who resided in the facility, staff, and visitors who consumed food from the main production kitchen, and specifically residents on station two who consumed food from the steam table. Findings include: During the initial kitchen tour on 3/24/25 at 12:26 p.m., a few culinary staff were in the kitchen area without hair nets or facial hair covers. The dry storage area had two jackets which hung on racks with food items. One shelf had an opened container of Hormel nectar…

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 assess and care plan for a resident's social and emotional well-being for 1 of 1 resident (R20) who wished to help in the dining area. Additionally, did not adequately assess for food preferences or find ways to encourage resident to adhere to dietary recommendations, and neglected to follow up with an order for a video swallow study for 1 of 1 residents (R23) reviewed who frequently refused a modified diet and requested regular-textured foods. Additionally, the facility failed to assess, care plan, and implement interventions for 1 of 1 resident (R90) reviewed for skin assessment. The facility also failed to coordinate care for a resident who was consistently out of the building for scheduled appointments and not receiving treatments/medications as ordered for 1 of 1 resident (R52) reviewed for dialysis. Findings include: R20 R20's quarterly Minimum Data Set (MDS) indicated R20 was admitted to the care facility on 6/19/24, had severe…

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 first-floor shower room was maintained in a clean, sanitary manner when the shower ceiling was observed with brown staining. This had the potential to affect 26 residents (including R28, R73, and R304) who resided on the first floor and utilized the shower room on a routine basis. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and resided on the first floor. R73's annual MDS dated [DATE], indicated R73 had intact cognition. R73's banner printed on 3/24/25, indicated R73 resided on the first floor. R304's admission MDS dated [DATE], indicated R304 had intact cognition, was admitted to the facility on [DATE], and resided on the first floor. During an interview on 3/24/25 at 12:48 p.m., R73 stated she believed the facility had black mold growing in the shower room and felt unsafe using the shower related to this and felt it was a serious issue. R73 stated…

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 there was reasonable access to private phone use for 1 of 1 residents (R303) reviewed who utilized the facility phone. Findings include: R303's admission Minimum Data Set (MDS) dated [DATE], indicated R303 had moderately impaired cognition and resided in a room on the first floor. During an interview on 3/24/25 at 1:44 p.m., R303 stated staff let him use the phone at the nursing station but could only use it for a few minutes as staff frequently had to use it and occasionally, staff would not let him use the phone at all as staff would need to use it to make other calls. R303 stated he wished he had a more private phone that he could use on a more consistent basis that was not in a shared area with staff. R303 stated this really limited how often he could speak with his family and what he could speak with his family about and this bothered him. During an interview on 3/25/25 at 2:43 p.m., nursing assistant (NA)-A stated most of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and depressive symptoms were evaluated for 2 of 4 residents (R3, R19) reviewed for MDS accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified the RAI consists of three basic components including the MDS, the Care Area Assessment (CAA) and the utilization guidelines and this process (i.e., use of the entire RAI) was mandated by CMS. The manual outlined a quarterly assessment was a non-comprehensive assessment which was to be completed every 92 days and was used to track a resident' status between comprehensive assessments . to ensure critical indicators of gradual change in a resident's status are monitored. The manual included a section labeled, SECTION C: COGNITIVE PATTERNS, which outlined the section would be…

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 level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R17) reviewed for PAS. Findings include: R17's admission Minimum Data Set (MDS) dated [DATE], indicated R17 had intact cognition. R17's medical diagnoses list dated 2/24/25, indicated R17 was diagnosed with depression, anxiety, and post-traumatic stress disorder. R17's PAS notice dated 2/21/25, indicated a copy of the PAS was included with this notice but the PAS was not final until the lead agency sent a final determination to the nursing home. R17's entire medical record was reviewed and lacked evidence a final determination had been received. During an interview on 3/25/25 at 11:32 a.m., the senior linkage line representative (SLL) stated she had reviewed the PAS that they had on file for R17 dated 2/21/25, and this was not the final PASARR. SLL stated…

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 assistance and/or equipment to complete personal hygiene cares (i.e., nail care) for 1 of 5 residents (R59) reviewed who needed set-up assistance with nail care. Findings include: R59's annual Minimum Data Set (MDS), dated [DATE], identified R59 had moderate cognitive impairment and demonstrated no rejection of care behavior. R59's care plan, dated 3/26/25, identified R59 had a self-care deficit due to his cognitive impairment and listed a goal, Resident will be accept [sic] assistance with self cares. The care plan directed, Independent with grooming, provide set up as needed. However, the care plan lacked information on what, if any, preference R59 had about his fingernail length preference (i.e., short or longer). On 3/24/25 at 2:35 p.m., R59 was observed seated in his room reading a Bible. R59 was dressed in a winter coat and stated he had received a shower earlier that same day (3/24/25). However, R59 had multiple…

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 the facility failed to provide activities of daily living (ADLs) including nail care and routine bathing to 2 of 3 residents (R19, R31) reviewed for ADLs who were observed to be disheveled with long, dirty fingernails and greasy appearing hair. Findings include: R19 R19's quarterly Minimum Data Set (MDS), dated [DATE], indicated R19 was admitted to the care facility on 2/25/25 and was dependent on staff for most ADLs including toileting, bathing, dressing and personal hygiene (to include nail care). R19's care plan, dated 6/23/23, indicated R19 had a self-care deficit related to a cerebral vascular accident (stroke) with residual left sided weakness and required assist of one staff member with personal hygiene. During observation on 3/24/25 at 2:47 p.m., R19 was laying in bed, asleep, and was observed to have long fingernails approximately ¼ inch in length with dark matter under the nail beds. During interview and observation on 3/26/24 at 7:59 a.m., R19 was laying in…

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 cataract surgery was coordinated with an appointed guardian to facilitate attendance and successful surgery for 1 of 1 resident (R3) reviewed who complained about their poor vision. In addition, the facility failed to act on reports of missing hearing devices and/or seek a replacement for 1 of 1 residents (R28) reviewed who was reported to have had lost their hearing aids. Findings include: R3 R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R3 had impaired vision (sees large print, but not regular print in newspapers/books) and did not use corrective lenses. However, the spaces to record R3's cognition were dashed and not completed (see F638). On 3/24/25 at 12:51 p.m., R3 was observed lying in bed while in her room. R3 did not have any glasses on at this time. R3 stated repeatedly aloud, I have trouble with my eyes. R3 stated she was unable to see fine things and, again, then voiced, I'm having difficulty seeing…

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 long, hard toenails (i.e., dystrophic) were appropriately referred to the onsite contracted podiatry service in a timely manner for 1 of 1 resident (R3) reviewed who needed professional management of their nails due to a medical condition. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R3 had delusional thinking and demonstrated no rejection of care behaviors during the review period. Further, the MDS recorded R3 required supervision or touching assistance to complete personal hygiene. However, the spaces to record R3's cognition were dashed and not completed (see F638). On 3/24/25 at 12:51 p.m., R3 was observed in her room on the locked unit. R3 had on a pair of flip-flop shoes on with no socks, which exposed both of her feet and toes. R3's toenails were all long with the nail plate being several millimeters (mm) in length, and R3 having visible hallux valgus (inward bend of the big toe)…

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 range of motion (ROM) for 1 of 1 resident (R63) reviewed for ROM who was dependent on staff for all activities of daily living (ADLs). Findings include: R63's annual Minimum Data Set (MDS) dated [DATE], identified R63 had severe cognitive impairment and diagnoses of aphasia (brain disorder which affects how one speaks and understands language), stroke (occurs when blood vessel is blocked or bursts), and hemiplegia or hemiparesis (loss of muscle function on one side of body or partial weakness on one side of body). R63 had impairment on one side of both upper and lower extremities and was dependent on staff for all activities of daily living, such as dressing, bed mobility, and transfers. R63's care plan intervention initiated 2/14/24, directed staff to provide gentle range of motion as tolerated with daily care. R63's Occupational Therapy Evaluation and Plan of Treatment dated 2/20/24, indicated R63 had impaired ROM 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 observation, interview, and document review, the facility failed to comprehensively assess and implement behavioral interventions for 1 of 1 resident (R46) reviewed for behavior of throwing dining ware. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had severe cognitive impairment, hallucinations, delusions, and no other behavioral symptoms or rejection of care. R46 was independent with activities of daily living. R46's Medical Diagnosis list printed 3/27/25, included mild cognitive impairment of uncertain or unknown etiology, hypertension (high blood pressure), and schizophrenia (chronic mental illness characterized by a combination of symptoms which significantly impair a person's thinking, feeling, and behavior). R46's care plan printed 3/27/25, indicated a focus area of potential nutritional problem and identified R46 had a history of throwing plates and breaking china dishes. The care plan indicated an intervention to offer plastic plates prn (as needed) 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 ensure appropriate and accurate psychotropic medication side effect monitoring was completed and recorded to reduce the risk of complication (i.e., orthostasis) and promote continuity of care for 1 of 5 residents (R59) reviewed for unnecessary medication use. Findings include: A Centers for Disease Control (CDC) Measuring Orthostatic Blood Pressure feature, dated 2017, identified a procedure to check orthostatic blood pressures. This directed to have the patient lie down for five minutes, measure the blood pressure and pulse, have the patient stand up and repeat taking the blood pressure readings at various intervals. The feature outlined, A drop in BP [blood pressure] of [equal or greater than] 20 mm Hg, or in diastolic BP of [equal or greater than] 10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal [i.e., potential orthostasis]. R59's annual Minimum Data Set (MDS), dated [DATE], identified R59 had moderate cognitive…

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 appropriate personal protective equipment (PPE) was used for 1 of 1 resident (R63) who received cares and was on enhanced barrier precautions. Findings include: R63's annual Minimum Data Set (MDS) dated [DATE], identified R63 had severe cognitive impairment and diagnoses of aphasia (brain disorder which affects how one speaks and understands language), stroke (occurs when blood vessel is blocked or bursts), and hemiplegia or hemiparesis (loss of muscle function on one side of body or partial weakness on one side of body). R63 had impairment on one side of both upper and lower extremities and was dependent on staff for all activities of daily living, such as dressing, bed mobility, and transfers. R63's care plan printed 3/25/25, indicated R63 was on enhanced barrier precautions (EBP) related to presence of tube feeding. During observation on 3/26/25 at 7:47 a.m., nursing assistant (NA)-C and -G assisted R63 to put on a sweater.…

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 pain medication was re-ordered timely to prevent pain for 1 of 3 residents (R1) reviewed for pharmacy services. Findings include: R1's admission Record dated 1/29/24 indicated R1's diagnoses included diabetic neuropathy, pain in left foot and post-traumatic stress disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had alteration in comfort related to left toe amputation, required pain medication as ordered by the provider, and had intact cognition. R1's care plan dated 1/29/24, indicated R1 had left foot pain due to amputation with staff intervention to provide pain medication as ordered by the provider, document on effectiveness of pain medication and encourage R1 to verbalize discomfort. R1's Provider Order dated 1/29/24 indicated to monitor for pain daily, every shift. R1's Provider Order dated 10/1/24 included Belbuca Buccal Film (Buprenorphine HCL, a strong opioid pain medication used to manage severe and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to monitor 2 of 4 residents (R1, R4) following an unwitnessed fall. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment with diagnoses which included stroke. R1's nursing note dated 1/4/25 indicated R1 fell and hit the right side of his forehead causing a bump. The note lacked size and description of the injury, and any indication of treatment. R1's electronic medical record (EMR) lacked documentation of monitoring of the injury and ongoing monitoring following the fall to include neuro checks and vital signs. R4's quarterly MDS dated [DATE] indicated R4 had intact cognition with diagnoses which included type 2 diabetes mellitus. R4's nursing note dated 1/6/25 indicated R4 was found laying on the floor next to his bed during morning rounds. The note lacked indication of any injury or treatment. R4's EMR lacked documentation of ongoing monitoring for injury and ongoing monitoring following the fall. On 1/13/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a privacy curtain for 3 or 3 residents (R1,R3, R6) who shared a room and were reviewed for a clean home-like environment. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact. R1's Diagnoses List undated, included adjustment disorder with depressed mood, weakness, and unsteadiness on feet. R1's care plan dated 2/6/24, indicated R1 utilized a two-wheeled walker, and required assistance with transfers and to get out of bed. On 8/7/24 at 9:31 a.m., R1's room was observed to have a privacy curtain that was torn and unusable, and shielded R1's roommate from the doorway, but did not provide privacy from R1's view. R1 was sitting on the side of his bed, and stated he had never had a privacy curtain, nor had his roommate, and he had to watch staff help his roommate dress and undress. He did not want to eat in the dining room, but also did not want to watch staff dress and undress his roommate while 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 interview and document review, the facility failed to ensure 3 of 5 staff (nursing assistant [NA]-G, NA-H, NA-I) received annual training on behaviors in Alzheimer's disease or related disorders, problem solving with challenging behaviors, and communication skills. Findings include: Review of NA-G's, NA-H's, and NA-I's training transcripts lacked identification they completed annual training on Alzheimer's Disease, behavioral health, communication skills, or problem solving with challenging behaviors. Review of the Facility Assessment (FA) dated 7/3/24, indicated the facility accepted residents with psychiatric and mood disorders, and with impaired cognition. The FA indicated staff were trained annually on dementia management and how to address the care of the cognitively impaired residents. On 8/12/24 at 1:14 p.m., during interview with registered nurse (RN)-C and the director of nursing (DON), RN-C acknowledged NA-G, NA-H, and NA-I had not received annual annual training for behavioral health. A behavioral health training policy was requested and not provided.

Based on observation, interview, and document review, the facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of cross-contamination and/or foodborne illness. This had the potential to affect all 88 residents residing in the facility at the time of the survey. Findings include: During observation and interview during the initial kitchen tour with dietary manager (DD) on 4/29/24 at 12:07 p.m., DD demonstrated the low temp machine use and chlorine testing for sanitization for the Ecolab ES-2000 low temperature commercial dishwasher. DD pointed to a container with chlorine test strips and a three ring binder on a shelf in the dishwasher area and stated the kitchen staff were required to document the wash temperature using a mechanical temperature indicator and obtain a chlorine measurement result following every meal each day when operating the machine. Observation of dishmachine testing by the DD indicated a temperature of 118 degrees Fahrenheit which the DD stated, It must be at least 120 degrees. Also, the chlorine sanitizing strips result 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 document review, the facility failed to ensure transmission-based precautions (TBP) were assessed for and implemented for 1 of 1 residents (R11) with symptoms of a respiratory illness with the potential to affect 23 residents residing on the unit. In addition, the facility failed to ensure resident education was provided and smoking infection control practices were followed for 2 of 2 residents (R22, R61) assessed for smoking. Findings include: TBP The Centers for Disease Control and Prevention (CDC) guideline titled Transmission-Based Precautions dated 1/7/16, indicated droplet precautions should be used for residents with known or suspected infections of pathogens transmitted by respiratory droplets that are generated by coughing, sneezing, or talking. The guideline indicated the resident should wear a mask, put in a single room if possible and a staff should wear a mask when entering the resident room or are in the resident space. The facility should limit 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 a self-administration of medications (SAM) assessment was completed to allow a resident to safely self administer medications for 1 of 1 (R5) resident reviewed who stored medication at their bedside. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE] indicated R5 was independent with making her own decisions, didn't have signs or symptoms of delirium or hallucinations or refused personal cares and medications. R5's Clinical Diagnosis record printed 5/2/24, indicated diagnoses of delusional disorders(one or more firmly held false beliefs that persist for at least one month), epilepsy (brain disorder that causes recurring, unprovoked involuntary movement) , major depressive disorder, mild intellectual disabilities, insomnia, somatization disorder (characterized by an extreme focus on physical symptoms such as pain or fatigue that causes major emotional distress and problems functioning), bradycardia (slow heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure maintenance services were provided in a timely manner to address broken window blinds to help provide a private, homelike living space for 2 of 2 residents (R65, R85) reviewed whose window blinds had broken exposing their room to outside public view. Findings include: R65's quarterly Minimum Data Set (MDS), dated [DATE], identified R65 had intact cognition. R85's admission MDS, dated [DATE], identified R85 had intact cognition. On 4/29/24 at 3:38 p.m., R65 was observed lying in bed while in his room. R65's bed was positioned closest to the doorway entering the room and, on the other side of a half-pulled privacy curtain, was R85's bed positioned against the outside wall with a large picture window immediately above it. However, below the window and, in part, underneath R85's bed was a long, white-colored roll-up style curtain on the floor. R65 stated the window shade had been in disrepair for several months and staff still had not…

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 nail care for 1 of 1 residents (R28) who required assistance with personal hygiene. Findings include: R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 had intact cognition and needed extensive assistance with toilet use, personal hygiene, and dressing. R28's diagnostic report dated 8/8/22, indicated R28 was diagnosed with a stroke with resulting right-sided weakness, diabetes, and muscle weakness. R28's care plan dated 4/5/23, indicated R28 required physical assistance with activities of daily living as R28 had limited physical mobility and weakness resulting from the stroke. R28's Weekly Skin Inspections dated 3/1/24- 4/26/24, indicated it was not necessary for R28 to receive fingernail trimming during this period, leaving the box marked refused unchecked. R28's order summary report dated 4/2/24, did not address nail care. During an observation and interview on 4/29/24 at 2:09 p.m., R28 was observed sitting in…

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 staff provided cares according to standard of practice for gastrostomy tube (stomach insertion feeding tube) care for 2 of 2 residents (R19, R67) reviewed for tube feedings. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 dependent on helper (staff) for toileting and maximal assistance of staff for transfers, personal hygiene, upper body dressing, lower body dressing, and shower/bath. In addition, R19 diagnoses included hemiplegia/hemiparesis (partial paralysis) affecting left non-dominant side, stroke (cell death to portions of the brain causing loss of functioning), dysphagia (inability to swallow), malnutrition (body not getting enough nutrients), hypertension (high blood pressure), muscle weakness, and had a gastrostomy tube (feeding tube to stomach) for portion of caloric and fluid intake. R19's care plan (CP), printed 5/2/24, identified R19 requires tube feeding r/t [related 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 observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 3 of 3 (R18, R34 and R74) residents reviewed who's diagnoses included post-traumatic stress disorder (PTSD). Findings include: R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 admitted to facility on 10/16/20 with impaired cognition, limited mobility due to left below knee amputation, and diagnoses of diabetes, seizure disorder, anxiety, depression, schizophrenia, and post traumatic stress disorder (PTSD). R18's assessment titled Trauma Questionaire dated 7/22/23 indicated, The goal of the questionnaire is to provide each resident with the best person-centered care & customer service while in our facility. We?d [sic] like to ask some questions related to your personal history to obtain awareness of any specific practices or preferences you may have, as well as any past experiences that may cause distress…

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 offer or provide the recommended pneumococcal vaccine to 1 of 5 residents (R74) reviewed for immunizations. Finding include: The National Center for Immunization and Respiratory Diseases feature, dated 9/22/23, indicated adults 19 through [AGE] years old with certain risk conditions including i.e., chronic heart disease, congestive heart failure and cardiomyopathies should receive the pneumococcal vaccine. Individuals who had never received any pneumococcal vaccine, regardless of risk condition the recommendation is to give 1 dose of PCV15 or PCV20. When PCV15 is used, it should be followed by a dose of PPSV23 at least 1 year later. The minimum interval (8 weeks) can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. Their vaccines will be then complete. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete. R74's quarterly Minimum Data Set…

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 document their weekly skin assessments for 2 of 4 residents (R1 and R3) reviewed for pressure ulcers. Findings include: R1's care plan dated 11/15/23, indicated he had a risk for developing skin breakdown related to bowel and bladder incontinence, and impaired mobility. R1's last weekly skin inspection dated 12/15/23, indicated he did not have any skin impairment. R1's treatment administration record (TAR) dated 2/1/24 through 2/23/24, indicated a nurse would complete a weekly skin assessment on the resident's bath day. They would then document their findings on a weekly skin inspection note located in the electronic medical record. On 2/2/24 the staff documented he was in the hospital when the skin evaluation was due. On 2/9/24 and 2/16/24, the nursing staff documented a check mark and their initials that the skin assessment was complete. The documentation did not indicate what their findings were. R1's significant change Minimum Data Set (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.