Cerenity Care Center On Humboldt

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 failed to identify and report medication errors for 2 of 3 (R1, R2) residents reviewed for medication administration. Findings include: R1 R1's Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] with diagnoses including acute pain due to trauma and dorsalgia (pain in the upper back). R1 was on a scheduled pain medication regimen and received as needed (PRN) pain medications. R1's care plan revised 2/6/25, identified R1 experienced pain and discomfort. Interventions included administration of scheduled and PRN pain medication. R1's care plan also identified risk for alteration of skin status. Interventions included ensuring protective skin measures (barrier cream to dry areas and wheelchair cushion) were in place. R1's physician orders included an order for miconazole nitrate 2% topical cream (antifungal cream used 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 provide adaptive eating utensils according to the care plan for 1 of 1 resident (R7) reviewed for nutrition. Findings include R7's face sheet dated 5/16/25, identified diagnosis of rheumatoid arthritis (a chronic inflammatory disorder affecting joints in hands or feet). R7's Minimum Data Set (MDS) dated [DATE], identified R7 was independent in eating and had intact cognition. R7's nutritional status focus care plan dated 5/7/25, identified a potential for altered nutrition related to rheumatoid arthritis, with an intervention of built-up utensils with all meals and culinary to provide. R7's nursing assistant care sheet dated 5/15/25, identified that R7 needed built-up utensils provided by the kitchen. R7's daily meal cards dated 5/15/25, identified R7 was to have built up utensils for all meals. R7's registered dietician progress note dated 3/6/25, identified R7 has continued to need built-up silverware to help with self-feeding 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 maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 2 of 3 residents (R2, R3) reviewed for documentation. Findings include: R2 R2's facesheet indicated he admitted to the facility on [DATE]. R2's electronic health record (EHR) was reviewed on 5/15/25. The EHR lacked any primary care provider (medical doctor, nurse practitioner, or physician assistant) visit notes from R2's current admission starting 12/3/24. During an interview on 5/15/25 at 10:46 a.m., the director of nursing (DON) confirmed there were no primary care provider visit notes in R2's EHR. R2's primary care provider visit notes were retrieved from the primary care provider's external medical records system by facility staff. Visit notes provided to surveyors absent from the facility's EHR included eight total visits from dates: 12/4/24, 12/17/24, 12/24/24, 1/7/25, 2/19/25, 3/25/25, 4/2/25,…

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, interview and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance they needed (R127, R35, R281, R11, R25, R59) for 6 of 7 residents reviewed for staffing needs. This had the potential to affect all 85 residents who reside in the facility. Findings include: The facility's payroll-based journal (PBJ) Staffing Data Report dated 7/1/24 through 9/30/24, identified excessively low weekend staffing as an area of concern. R127's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and abnormalities of gait and mobility. It further indicated R127 was frequently incontinent of bowel, bladder and required assistance with toileting. R127's care plan dated 2/1/24, indicated R127 will have less than 2 episodes of bowel incontinence per day, will be continent of bowel at all times, and will be continent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure expired food items were removed from service, food items were labeled and dated, and food was stored in a manner to prevent cross contamination from resident care items. Furthermore, the facility failed to ensure follow up and maintenance of a leaking refrigerator, routine maintenance of the dishwasher and overall cleanliness of the kitchen was maintained. Findings include: A facility kitchen/kitchenette cleaning log was requested however was not received. An email recieved 1/13/25, at 2:50 p.m., the administrator stated the last work order for the 4th floor refirdgerator was on 7/16/24. A new order was placed and contractors have been notified to remedy the issue. Kitchenettes An observation on 1/13/25 at 8:56 a.m., the 4th floor kitchenette was reviewed. The refrigerator contained a container of opened Molly's Kitchen premade egg salad with a use by date was 1/7/25. An opened bottle of [NAME] prune juice had a best by date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure transmission-based precautions (TBP) were followed for 1 of 1 resident (R38) who required TPB during medication administration and failed to ensure a glucose meter was disinfected per manufacturer's guidelines after resident use for 1 of 1 residents (R31) observed for glucose monitoring. Furthermore, the facility failed to ensure resident clothing was transported in a manner to ensure cleanliness and protect from dust and soil during transport. This had the potential to impact all residents residing on the 3rd floor and who the facility provides laundry services for. Findings include: R31's quarterly MDS dated [DATE], indicated R1 was cognitively intact and had diagnoses of diabetes. R31's provider order dated 12/17/24, indicated R31 required a blood glucose check on Sun, Tue, Thu, Sat, at 5:00 p.m. R38's admission Minimum Data Set (MDS) dated [DATE], indicated R38 was cognitively intact and had diagnoses of cellulitis (skin…

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 dignity was maintained for 2 of 4 residents (R11, R277) reviewed for dignity. Findings include: R11's Optional State Assessment (OSA) dated 1/6/25, indicated intact cognition, and did not have behaviors or reject care. R11's face sheet form in the electronic medical record indicated R11's given name, name A, along with quotations around another name, name B. R11's care plan was reviewed and lacked information R11 had a preferred name. R11's care sheet dated 1/13/25 at 9:08 a.m., included R11's given name A. Name B was listed in quotations. R11's physician progress notes dated 1/7/25, indicated R11 wanted to be called by name B. During interview and observation on 1/13/25 between 9:28 a.m., and 9:48 a.m., R11 had signage on her door that indicated R11's given name A. Name B was listed in quotations. R11 stated the staff were calling her name A and not her preferred name, which was name B. R11 stated it got tiring having to tell them the same thing. During interview on 1/15/25 at 11:35 a.m., nursing…

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 resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R10, R278, R59) reviewed who had medications in their rooms. Findings include: R10's annual Minimum Data Set (MDS) dated [DATE], identified diagnoses of Parkinsonism (neurological condition which makes body movements difficult), mild cognitive impairment, personality disorder, bipolar disorder, depression, and arthritis. High risk medications included antidepressant, antipsychotic, anticoagulant, antibiotic, hypoglycemic and anticonvulsant medications. R10 required supervision with eating meals. R10's Cognition Care Area Assessment (CAA) dated 10/22/24, was triggered and identified staff were to monitor for changes in cognition and assist with decisions. R10's Care Plan dated 10/22/24, identified she was a vulnerable adult and needed assistance to remain safe within the community.…

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 timely assistance with toileting for 2 of 2 (R50, R127) residents. Findings include: R50 R50's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, chronic pain, muscle weakness, reduced mobility, and a need for assistance with personal care. It further indicated R50 required substantial assistance with toileting was dependent on staff with mobility, and was frequently incontinent of bowel and bladder. R50's care plan dated 11/25/24, indicated R50 experienced bladder and bowel incontinence due to diagnoses of cerebral vascular accident, dysphagia, hemiplegia/hemiparesis, seizures, hypertension, atrial fibrillation and history of human immunodeficiency virus (HIV). It further indicated the following interventions: -check and change brief 2-3 times per shift and as needed. -keep call light 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 interview, observation, and document review, the facility failed to ensure symptoms of loose stools was acted upon and assessed to determine what, if any interventions were needed to promote appropriate bowel management. Findings include: R11's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have behaviors, and did not reject cares. Further, R11 required substantial to maximal assistance with toileting hygiene, and transfers, did not have a catheter or ostomy, was frequently incontinent of urine and bowel and a toileting program trial had not been attempted. Additionally, R11 had diagnoses of noninfective gastroenteritis and colitis, nausea and vomiting, The MDS indicated R11 was at risk for developing pressure ulcers and application of ointments and medications were completed other than to feet. R11's Facesheet form undated, indicated the following diagnoses: noninfective gastroenteritis and colitis, diarrhea, and other sites of candidiasis (a fungal infection) 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 observation, interview, and document review, the facility failed to implement interventions necessary to maintain continence for 1 of 1 resident (R72) reviewed for bowel and bladder. Findings include: R72's Facesheet form identified the following diagnoses: brachial plexus disorders carpal tunnel (a small passageway in the wrist that contains the median nerve and tendons that control the thumb and fingers), encounter for surgical aftercare following surgery on the nervous system carpal tunnel release (a surgical procedure where a ligament is cut to relieve pressure on the median nerve), sepsis (a condition where the body responds improperly to an infection), severe sepsis without septic shock, malignant neoplasm of the prostate, autistic disorder ( a condition related to brain development that impacts how a person perceives and socializes with others), rhabdomyolysis (a condition where muscle cells break down and release their contents into the bloodstream), legal blindness, wrist drop (paralysis of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure pain medications were administered timely in accordance with physician's orders and care plan for 1 of 1 residents (R25) reviewed for pain management. Findings Include: R25's minimum data set (MDS) dated [DATE], indicated R25 had a brief interview for mental status (BIMS) of 15, showing intact cognition. R25 had a diagnosis of hypertension, diabetes, arthritis, and chronic obstructive pulmonary disease (COPD). R25 receives both scheduled and as needed pain medication related diagnosis of chronic pain syndrome and non-displaced oblique fracture of the shaft of the right fibula. R25's care area assessment (CAA) dated 1/15/25 at 12:16 p.m., indicated pain made it hard for R25 to sleep at night, day-to-day activities were limited because of pain, pain was described as moderate to very severe and occurred frequently or almost constantly daily. R25's care plan dated 11/29/24, indicated scheduled pain medications to be administered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to assess trauma history and identify potential triggers for 1 of 1 resident (R54) who had a diagnosis of post traumatic stress disorder (PTSD). Findings include: R54's quarterly Minimum Data Set, dated [DATE], identified intact cognition and diagnoses of anxiety, depression, mild cognitive impairment and PTSD. Daily medications included an antispychotic. R54's annual Care Area Assessment (CAA) dated 6/20/24, triggered for psychosocial needs; indicating little interest or pleasure in doing things on the PHQ-9 (depression screen). R54 was seen by a therapist and care plan was established to minimize risks. R54's Behavioral Symptoms Care Plan dated 12/30/24, lacked identification of potential triggers related to PTSD. R54's LTC (long term care) Social services assessments dated 3/22/24, 6/19/24, 9/17/24 and 12/16/24 lacked assessment of PTSD and triggers. R54's Associated Clinic of Psychiatry notes dated 11/21/24, 10/24/24, 9/19/24 8/16/24, 7/11/24, 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 call lights were accessible for 1 of 1 resident (R9) reviewed. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, repeated falls, chronic pain, unspecified displaced fracture of sixth cervical vertebra, need for assistance with personal care, dependence on wheelchair, and history of a traumatic brain injury (TBI). It further indicated R9 had an impairment on one side of his upper and lower extremites and required substantial/maximal assistance with all activities of daily living (ADL) and mobility except eating and oral hygiene. R9's care plan last reviewed on 12/16/2024, indicated R9 was at risk for falls due to Basal Ganglia stroke resulting in left hemiparesis, history of TBI, subdural hematoma, and mild degenerative retrolisthesis of C3- C4, with an intervention of call light…

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 notify family and physician regarding a resident change in condition for one of one resident (R1) reviewed when R1's venous ulcer wound worsened requiring hospitalization. Findings include: R1's medical record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of venous insufficiency. R1's additional diagnoses included non-pressure chronic ulcer of other part of right lower leg with fat layer exposed on right shin, methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere- wound culture, pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere-wound culture, chronic kidney disease stage 3, pressure ulcer of right heel (unstageable), pressure ulcer of sacral region (unspecified stage), morbid obesity due to excess calories, non-pressure chronic ulcer of other part of right foot with unspecified severity on right toe, non-pressure chronic ulcer 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 observations, interviews, and record review the facility failed to reduce the risk of harm for one of one resident (R2) reviewed accidents and hazards. R2 required the use of an EZ Stand and facility staff were using a large sized harness. The EZ Stand manufacturer guidelines state a large harness fit a person between one hundred ninety pounds to three hundred twenty pounds. R2 exceeded the weight limit. Findings include: The facility provided the EZ Way Smart Stand operator's instructions that stated a large sling was to be used on a resident between forty to fifty-six inches in circumference around the resident's torso and weighed between one hundred ninety to three hundred twenty pounds. During an observation on 8/26/24 at 9:20 a.m., there was a EZ Stand outside R2's door with a large harness on the back of it. The EZ Stand stated it had a four-hundred-pound capacity. During an observation on 8/26/24 at 9:34 a.m., the occupational therapy assistant (OTA) was getting R2 up from her wheelchair for 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 record review, the facility failed to ensure an EZ Stand was maintained in accordance with manufacturer guidelines for one of one resident (R2) reviewed for EZ Stands. It is unknown when R2's EZ Stand was last maintained due to no record of it being maintained. Findings include: The facility provided an operator's instructions for EZ Stand with the serial number 907725. The operator's instructions states the manufacturer suggests that components and operating points be scheduled for inspection at intervals not greater than six months. R2's medical records indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis. R2's additional dizziness and daffiness, morbid obesity, and muscle weakness. During an observation on 8/26/24 at 9:20 a.m., there is a EZ Stand outside R2's room that had a sticker stating the next maintenance check was due in May 2024. The EZ Stand is called an EZ Way Smart Stand. The EZ Stand's serial number was 907725. 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 record review the facility failed to provide a safe, clean, and home like environment for 10 of 25 residents (R12, R13, R4, R5, R6, R7, R8, R9, R10, R11) reviewed and all independently mobile residents on the 3rd floor when concerns related to resident bathrooms and flooring, cleaning practices and cleaning product storage were observed. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition. R5's annual MDS dated [DATE], identified moderately impaired cognition. R6's annual MDS dated [DATE], identified moderately impaired cognition. R7's quarterly MDS dated [DATE], identified severely impaired cognition. R8's annual MDS dated [DATE], identified severely impaired cognition. R9's quarterly MDS dated [DATE], identified severely impaired cognition. R10's quarterly MDS dated [DATE], identified severely impaired cognition. R11's annual MDS dated [DATE], identified severely impaired cognition. R12's quarterly MDS dated [DATE], 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 interview and record review the facility failed to accurately assess 1 of 3 residents (R1) reviewed upon admission to the facility. R1 was admitted with two pressure ulcers, a deep tissue injury and a shearing wound that the facility did not assess or create inventions for during his stay at the facility. R1's hospital discharge orders dated 6/25/24 indicated R1 had: -A Stage 3 (an injury that extends through the skin into deeper skin and fat but does not reach muscle tendon or bone) pressure ulcer on the dorsum (upper surface) of his second right toe. R1 had this pressure injury since 1/6/23. -A dermatologic condition of his right foot since 1/6/23 -Incision on the anterior portion of his right knee since 6/20/24 -A Stage 4 (an injury that extends to the muscle, tendon, and bone) pressure injury on the dorsum of his third right toe since 6/21/24. -A dermatologic condition of generalized rash and pruritis since 6/21/24 -A Shearing wound to his buttocks bilaterally from friction and adhesive from sacral…

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 serve food at a palatable temperature to 4 of 4 residents (R4, R9, R11, R10) reviewed for dietary and nutrition. Findings include: On 5/21/24 at 12:57 p.m., during an interview social worker (SW)-B stated residents expressed the food was cold, and it remained a, Prevalent concern. On 5/21/24 at 1:30 p.m., during an interview SW-C stated, Cold food is a big complaint, and had been for years. R4's quarterly minimum data set (MDS) dated [DATE], indicated R4 was cognitively intact. On 5/21/24 at 4:56 p.m., during an interview R4 stated the hot food was usually served cold. On 5/22/24 at 8:50 a.m., during an observation and interview the director of culinary services (DCS) performed temperature checks on R9's food prior to staff serving the food to R9. The meal came in a hot box (cart designed to hold food trays at an appropriate temperature before service) from the building next door, and sat on a cart to be distributed to the resident rooms…

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 clean, safe and home-like environment for 3 of 3 residents (R1, R4, R11) reviewed for a clean environment on the 4th floor and [NAME] end. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and admitted on 4/2024. R1's progress note dated 4/16/24, indicated R1 wanted to move to another facility due to housekeeping and other concerns. On 5/21/24 at 12:38 p.m., during an interview family member (FM)-A stated R1 was concerned the facility was not clean and didn't have sufficient staff to clean. On 5/21/24 at 12:57 p.m., during an interview social worker (SW)-B stated R1 expressed general concerns to her about cleanliness of her room and said her room was dirty. On 5/21/24 at 1:30 p.m., during an interview SW-C stated R1 complained about a dirty tray table and had other isolated complaints about facility cleanliness, and facility maintenance. On 5/21/24 at 4:14 p.m., during an observation 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, observation, and document review the facility failed to ensure baths were given as ordered for 2 of 3 residents (R4, R10) who needed assistance with activities of daily living (ADLs). Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact, and was fully dependent upon staff to bathe. R4's care plan dated 4/17/24, indicated a self-care deficit for bathing, assistance of one staff for weekly bath dated 10/17/23, and offer a second shower weekly dated 10/17/23. R4's physician orders dated 2/5/24 indicated R4 was to bathe twice weekly on Thursday and Sunday. R4's Point of Care (POC) nursing assistant (NA) bath documentation in the electronic health record (EHR) indicated from 4/1/24 to 5/22/24, R4 missed baths on 4/7/24, 4/18/24, 5/2/24, 5/5/24, 5/16/24, and 5/19/24. R4's record did not identify the reason why these baths were missed. The POC documentation further identified R4 required maximum assistance of staff to bathe. On 5/21/24 at 4:56…

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 medications were appropriately transcribed into the electronic health record (EHR), ordered timely and correct medication dosages were administered in accordance with physician orders for 1 of 1 residents (R3), reviewed for missed medication errors. Findings include: R3's face sheet printed 5/22/24, indicated R3 admitted to the facility with diagnoses of enterocolitis due to clostridium difficile, cirrhosis of the liver, acute gastric ulcer with hemorrhage, ascites, and reflux disease. R3's admission Minimum Data Set (MDS) dated [DATE], was not complete as R3 was in the facility less than 24 hours. R3's medication orders dated 5/2/23, were as follows: -cholestyramine-aspartame powder in packet (medication to lower cholesterol), 4 grams by mouth with meals twice daily at 8:00 a.m., and 4:00 p.m. (start date 5/2/24). -pantoprazole tablet delayed release (medication for gatroesophageal reflux (heart burn)) 40 milligrams (mg) twice daily by mouth…

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 3 of 3 kitchenettes were cleaned,including the cleaning of the kitchenette refrigerators and also failed to monitor refrigerator temperatures daily to maintain food safety. This had the potential to affect all residents who resided at the facility. Findings Include: During observation and record review on 11/30/23 at 9:34 a.m., the second-floor kitchenette countertop was noted with debris and dust buildup. The refrigerator freezer had spilled brownish matter frozen to the bottom lining of the freezer. The refrigerator had brown buildup and dark brownish stains in the refrigerator shelving and door compartments. During record review, the refrigerator temp log on the door of the refrigerator was dated 5/23 and was missing several days of documented temperature checks for May 2023. Only the following temperatures were documented: -5/2/23-temperature was recorded as 36 degrees Celsius -5/8/23-temperature was recorded as 36 degrees Celsius -5/16/23-temperature was recorded as 36 degrees Celsius…

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 catheter drainage bags were properly cleaned and stored in accordance with professional standards of practice for 1 of 1 resident (R38) reviewed for catheters. Findings include: The Center for Disease Control (CDC) Catheter-Associated Urinary Tract Infections (CAUTI) guideline dated 11/5/2015, identified after aseptic insertion of the urinary catheter, a closed drainage system should be maintained. If the aseptic technique was broken, disconnected, or if leakage occurred, the catheter and collecting system should be replaced with aseptic technique and sterile equipment used. R38's annual Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition and diagnoses of chronic kidney disease and urinary retention. R38 had an indwelling catheter and required extensive assist with toileting. R38's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 9/11/23, identified the CAA triggered due 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 monitor a resident (R59) with involuntary muscle movements who was taking antipsychotic medications. R59's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of alzheimer's disease (early onset), dementia with other behavioral disturbance and adjustment disorder with anxiety. It further indicated R59 required total dependence with transfers, required extensive assistance with all other activities of daily living (ADL), and received an antipsychotic 7 out of 7 days in the look back period. R59's physician's orders dated 11/03/22, indicated quetiapine tablet 50 milligrams by mouth, three times a day (8:00 a.m., 12:00 p.m., 7:00 p.m.) for agitation. R59's care plan dated 9/29/22 indicated R59 received a psychotropic medication with interventions to administer medication per medical doctors order, monitor for target behaviors daily, monthly medication record review by pharmacist, and observe…

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.