Golden Years Center For Rehab And Healthcare

Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #44) rights remained intact when he/she had to move to a different room out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Resident Rights dated 6/10/25 showed Information about resident rights and responsibilities would be given to the resident both orally and in writing.1. Review of Resident #44's admission Record showed he/she admitted to the facility with diagnoses that included:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance.-Anxiety (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats).Review of the resident's care plan dated 1/7/26 showed:-The resident had…

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 documentation of non-pharmacological behavioral interventions were attempted prior to administering pro re nata (PRN as needed ) antianxiety medication (medication to address the symptoms of anxiety); to document events/triggers preceding behaviors; to ensure the PRN antianxiety medication had a stop date; and failed to include comprehensive symptoms and/or target behaviors and individualized interventions for one sampled resident (Resident #12) who was taking multiple psychotropic medications (drugs which affect psychic function, behavior, or experience) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Behavioral Health Services policy, revised 6/10/25 showed:-The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. -Staff will share concerns with the interdisciplinary team (IDT)…

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 two sampled residents (Resident #44 and #75) physician's orders were followed out of 17 sampled residents. The facility census was 67 residents. A policy related to following physician orders was requested and not received prior to exit on 1/20/26.1. Review of Resident #44's admission Record showed he/she was admitted to the facility with the following diagnoses:-Retention of Urine (the inability to completely empty your bladder), Unspecified.-Neuromuscular Dysfunction of Bladder (occurs when nerve damage disrupts the brain-bladder communication, causing problems with storage or emptying), Unspecified.Review of the resident's Order Summary Report dated December 2025 showed:-The resident had an order for a Urinary Analysis (UA- a test of your urine that checks and screens for diagnoses such as a UTI), ordered on 12/16/25.--The status of the order showed it had been completed.-The resident had an order for a UA to be completed between 12/21/25…

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 record review, the facility failed to ensure one sampled resident's (Resident #13) gastrostomy tube (also known as G-tube, percutaneous endoscopic gastrostomy/PEG tube/feeding tube - a flexible tube inserted through the wall of the abdomen directly into the stomach that is used to give medications, fluids and liquid food) placement was confirmed prior to administration of medication in accordance with facility policy and current professional standards of practice. The facility census was 67 residents. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed:-The placement of an enteral tube is immediately verified after insertion by an X-ray; after X-ray verification, the tube should be marked to indicate the point on the tube where the feeding tube penetrates the abdominal wall; the mark or number on the tube at the entry point should 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.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident #13) tracheostomy (a surgical procedure that creates an opening (stoma) through the neck into the trachea (windpipe), to provide a direct airway) suctioning supplies were stored appropriately and that staff were trained and competent in the correct method of suctioning out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Tracheostomy (trach) Care dated 6/10/25 showed:-The facility would provide necessary respiratory care and services, such as oxygen therapy, treatments, tracheostomy care and/or suction.-Tracheostomy care would be provided according to physician's orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs, as well as suctioning as appropriate.-General considerations included maintaining a suction machine, a supply of suction catheters (a thin, flexible tube used to remove bodily fluids from a resident's…

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

Based on observation, interview and record review, the facility failed to ensure orders were clarified for one sampled resident (Resident #7), who was receiving hemodialysis (a process of cleansing the blood of wastes, toxins and excess fluid by passing it through a special machine - necessary when the kidneys were not able to filter the blood), out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Hemodialysis policy, dated 5/2/25, showed:-The facility will assure each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.-The facility will ensure the physician's orders for dialysis include the location and type of access for dialysis (e.g. graft (uses a surgically implanted tube to connect an artery to a vein for hemodialysis access), arteriovenous shunt (directly connects the patient's artery and vein for hemodialysis access), external catheter (soft…

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

Based on interview and record review, the facility failed to collaborate with one sampled resident (Resident #6) who experienced past trauma, to identify triggers which may re-traumatize the resident and develop care plan interventions to decrease the resident's exposure to triggers and to minimize the effect of the trigger on the resident out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Trauma Informed Care (TIC) policy, dated 6/10/25, showed:-The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as their cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event as well as using screening and assessment tools.-The facility will collaborate with residents, and as appropriate, their family, friends, physician, and other health care and mental health professionals to develop individualized care plan interventions.-In some cases, if the facility has more than one trauma survivor, as appropriate, social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff had appropriate competencies and skills to manage resident behaviors. The facility failed to provide education to employees related to behaviors and de-escalation including handling verbal and physical outbursts/aggression, suicidal ideation, refusal of antipsychotic medications, and destruction of the environment. Staff reported no knowledge of how to properly and safely care for Resident #4, Resident #7, or Resident #3. Staff stated they were fearful and did not feel competent to care for the residents' safely, and felt they could not keep themselves or other residents safe. The facility census was 90.Review of the facility's Nurse Aide Training Program policy, revised [DATE], showed:-The policy ensured that the facility maintained an appropriate and effective nurse aid in service training program for the purpose of ensuring the continuing competencies of nurse aids.-Each nurse aide would be provided with at least 12 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's dignity was respected when a Licensed Practical Nurse (LPN) called one sampled resident (Resident #13) dumb out of 13 sampled residents. The facility census was 90 residents.Review of facility policy entitled Resident Rights, revised 6/10/25, showed: -All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. -The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Training topics will be appropriate to the individual's role. 1. Review of Resident #13's admission record showed the resident admitted to the facility on [DATE]. Review of LPN D's witness statement, dated 10/28/25, showed: -The resident asked…

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

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. In addition, the facility failed to provide a Director of Nursing (DON) for 40 hours per week. The facility census was 73 residents. Review of the facility policy titled Director of Nursing Services, with no date, showed:-The nursing services department was under the direct supervision of a Registered Nurse (RN).-The nursing services department was managed by the Director of Nursing services. The Director was a Registered nurse, licensed by the state, and had experience in nursing service administration, rehabilitative and geriatric nursing.-The Director was employed full time, 40 hours per week. Review of the facility policy titled Registered Nurse, with no date, showed:-The facility would employ the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week.-The facility would designate a Registered Nurse to serve as the Director of Nursing (DON) on a full-time…

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 interview, the facility failed to ensure the facility adhered to all the applicable components of the process for discharging a resident which included reassessment and the identification of how the facility could not meet the needs for one sampled resident (Resident #2). The facility census was 73 residents.Review of the facility Transfer or Discharge, Emergency Policy with no date, showed:-Residents would not be transferred unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met at the facility.-Residents would not be transferred unless the transfer or discharge was appropriate because the resident's health improved sufficiently so the resident no longer needed the services provided by the facility.-Residents would not be transferred unless the safety of individuals in the facility was in danger due to the clinical or behavioral status of the resident.-Should it be necessary to make an emergency transfer or discharge to 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.

Based on interview and record review, the facility failed to ensure procedures were in place and followed in order to ensure physician notification was completed and documented regarding missed medications for two sampled residents (Residents #1, #2) out of four sampled residents, and failed to ensure blood pressure monitoring was completed for one resident with a physician's order to administer medication based on the resident's blood pressure (Resident #1). The facility census was 76 residents. Review of the facility Medication Administration Policy dated December 2012 showed: -Medications must be administered in accordance with physician orders. -For residents not in their room or otherwise unavailable to receive medication, the MAR may be flagged (identified for further attention) and the nurse will return to administration of the medication at a later time. -If a medication is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall circle and initial the MAR for that drug and dose. -The individual administering must…

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

Based on observation, interview and record review, the facility failed to ensure and document measurement of the resident's gastrostomy tube (G-tube/PEG tube, a flexible tube inserted into the stomach through a small incision in the abdominal wall that provides a direct route for administering food, fluids, and medications ) to ensure correct placement in the resident's stomach prior to giving fluids, medications and feedings for two sampled residents (Residents #1 and #4) out of four sampled residents. The facility census was 76 residents. A policy for administration of medication via G-tube was requested and not received. Review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ the National Institutes of Health, National Library of Medicine, Enteral (also known as tube feeding) Tube Management, dated 2021 showed: -The placement of an enteral tube is immediately verified after insertion by an X-ray; after X-ray verification, the tube should be marked to indicate the point on the tube where the feeding tube penetrates the abdominal wall; the mark or number on the tube at the entry…

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 and interview, the facility failed to maintain the floors under and behind the ice-machine free of debris; failed to ensure that items which were labeled refrigerate after opening, were refrigerated; failed to wrap a bowl of pureed pineapple in the kitchen reach-in refrigerator; failed to ensure the fan vent cover in the walk-in refrigerator, was free of dust; failed to label items (syrup and vinegar) with what they were in the containers those items were in; failed to ensure three cutting boards were free from stains and numerous grooves which caused those cutting boards to not be easily cleanable; failed to ensure the spatulas were maintained in an easily cleanable condition; failed to maintain the wall behind the dishwasher free of black colored debris; failed to maintain the floor under the six-burner stove free of debris; failed to maintain the cover of the blower over the door across from the coffee maker station, free from a heavy buildup of dust, and failed to maintain the sprinkler heads free from a grease. This practice potentially affected all…

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

Based on interview and record review, the facility failed to provide the required nurse aide in-services that included dementia (progressive loss of intellectual functioning, with impairment of memory, abstract thinking, and personality change, resulting from disease of the brain) and Abuse/Neglect/Exploitation training for three sampled Certified Nursing Assistants (CNA) (CNA B, H and J) from April 2023 through April 2024. The facility census was 67 residents. Review of the facility's In-Service Training Program, Nurse Aide Policy, dated December 2016, showed: -All nurse aide personnel participated in regularly scheduled in-services training classes. -All personnel were required to attend regularly scheduled in-service training classes. -In-service training was based on the outcome of the annual performance reviews, which addressed weaknesses identified in the reviews. -Annual in-services included: --Continued competence of nurse aides. --No less than 12 hours per employee per employment year. --Address the special needs of the residents, as determined by facility staff. --Included…

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

Based on interview and record review, the facility failed to ensure residents who allowed the facility to manage their resident funds, received interest payments and failed to ensure signed authorization forms were present for three residents (Residents #11, #32 and #1) selected for the resident trust review. The facility census was 67 residents. 1. Review of the reconciled bank statements, dated April 2023 through March 2024, showed the absence of any interest payments on the any of the bank statements. During an interview on 4/18/24 at 10:55 A.M. the Corporate Director of Fiscal Services said: -He/she did not see any interest on the bank statements. -He/she was not aware of any changes made to the account. 2. Review of Resident #11's authorization records showed there was no authorization form to manage funds found for the resident. 3. Review of Resident #32's authorization records showed there was no authorization form to manage funds found for the resident. 4. Review of Resident #1's authorization records showed there was no authorization form to manage funds found for 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 and interview, the facility failed to maintain the water at the handwashing faucet in resident rooms 517, 520 and 523 at a temperature at or above 105 ºF (degrees Fahrenheit); failed to maintain sprinkler heads over the the therapy area, the Main Dining Room (MDR) and the side Dining room without dust; and failed to maintain two stand up lifts without cracks in the base of those lifts. This practice potentially affected at least 30 residents who resided in those areas, used those area or required assistance of the stand-up lifts. The facility census was 67 residents. 1. Observation on 4/16/24 with the Maintenance Director, showed: -At 9:06 A.M., the water temperature at the handwashing sink in resident room [ROOM NUMBER], was 97.2 ºF after the water was allowed to run for two minutes in that room. -At 9:23 A.M., the water temperature at the handwashing sink in resident room [ROOM NUMBER], was 88.8 ºF after the water was allowed to run for two minutes or more. -At 9:25 A.M., the water…

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 the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the resident discharges/transfers for two sampled residents (Residents #48 and #23) and one supplemental resident (Resident #268) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's undated policy titled Transfer and Discharge) showed the policy did not include notification of the ombudsman when residents were transferred or discharged . 1. Review of Resident #48's health status note dated 3/16/24 at 6:56 A.M. showed the resident was sent to the hospital due to seizures. Review of the resident's admission summary showed the resident returned to the facility on 3/23/24. Review of an email dated 4/8/24 from the ombudsman showed the ombudsman reported not receiving transfer/discharge logs from the facility since September 2023. 2. Review of Resident #23's discharge assessment dated…

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 one sampled resident's (Resident #2) care plan (written out plan for the care of the resident) reflected the resident's need to receive Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST); out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's Goals and Objectives, Care Plans policy dated April 2009 showed: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Care plan goals and objectives are defined as the desired outcome for a specific resident problem. -When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: --Are…

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 update residents' care plans with a change of condition and/or needs for five sampled residents (Residents #65, #41, #13, #19, and #52) and to invite a resident to his/her care plan meeting for one sample resident (Resident #37) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's Goals and Objectives, Care Plans policy dated April 2009, showed: -Care plans incorporated goals and objectives that led to the resident's highest obtainable level of independence. -Goals and objectives were entered on the resident's care plan so all disciplines had access to needed information and were able to report if the desired outcomes were being achieved. -Goals and objectives were reviewed and revised when: --The resident had a significant change. --When the outcome was not achieved. --At least quarterly. 1. Review of Resident #65's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have an activity program directed by a qualified Activity Director. The facility census was 67 residents. Review of the facility's undated Activity Director job description showed the following requirements: -High school diploma or General Educational Development (GED). -Two years experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting; or a qualified occupational therapist or occupational therapy assistant; or must have completed a training course approved by the state. 1. During an interview on 4/22/24 8:59 A.M., Activity Director/Human Resources/Medical Records said: -He/She was in school now, getting an associate degree in human resources. -He/She had not had any training in activities. -He/She had not taken the Activity Director class. During an interview on 4/22/24 at 11:34 A.M., the Activity Director/Human Resources/Medical Records said:…

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 Restorative Aide (RA-Assist residents with exercises designed by rehabilitation staff to help improve the use of limbs and body functions) services were provided as ordered to prevent further decline of Range of Motion (ROM - the range on which a joint can move) in accordance with therapy recommendations to for three sampled residents (Resident #2, #61, and #37) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Restorative Nursing Services, dated July 2017 showed: -Residents would have received restorative nursing care as needed to help promote optimal safety and independence. -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. -Residents may have been started on a restorative nursing program upon admission, or during the course of stay or when discharged from rehabilitative care. -Restorative goals 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 record review, the facility failed to ensure oxygen tubing was changed weekly and stored in sanitary condition with the date it was changed written on it for two sampled residents, (Residents #268 and #17); to ensure a nebulizer (machine that converts medications into a mist to be inhaled by a patient) masks/pipes and tubing were cleaned, and stored in a sanitary condition for three sampled residents (Residents #33, #268, and #267) out of 17 sampled residents. The facility census was 67 residents. A policy was requested and not received at the time of exit. 1. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block air flow and make it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 2/17/24 showed: -His/Her Brief Interview…

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

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was providing services at least eight consecutive hours a day, seven days a week. The facility census was 67 residents. The RN Coverage policy was requested and not provided at the time of exit. Review of the facility's Staffing policy, dated April 2007, showed: -The facility maintained adequate staffing for each shift to ensure that resident's needs and services were met. -Licensed RN staff were available to provide and monitor the delivery of resident care services. 1. Review of the Center for Medicare and Medicaid Services (CMS) Staffing Report dated April 1 - June 30, 2023 showed the facility triggered for the following areas: -One Star Staffing Rating. -Excessively Low Weekend Staffing. Review of the CMS Staffing Report dated July 1 - September 30, 2023 showed the facility triggered for One Star Staffing Rating. Review of the CMS Staffing Report dated October 1 - December 31, 2023 showed the facility triggered for One Star Staffing Rating. Review of the facility's undated current…

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 the Medication Regimen Review (MRR) was responded to for four sampled residents (Resident #42, #19, #24 and #41) out of 5 residents reviewed for MRR out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Medication Regimen Reviews dated as revised in April 2007 showed: -The Consultant Pharmacist was responsible for performing a MRR for every resident in the facility monthly. -The Consultant Pharmacist would document his/her findings and recommendations on the monthly drug/medication regimen review report. -The Consultant Pharmacist would provide a written report to physicians for each resident with an identified irregularity. -Copies of MRR reports, including physician responses, will be maintained as part of the permanent medical record. Review of the facility's policy titled Medication Utilization and Prescribing - Clinical protocol dated as revised in July 2016 showed the Consultant…

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

Based on observation, interview, and record review, the facility failed to monitor the medication refrigerator temperatures and to remove expired medications which had no open dates from the Rehabilitation Unit medication refrigerator. The facility census was 67 residents. The facility policy titled Administering Medications dated December 2012 showed: -Medications shall be administered in a safe and timely manner, and as prescribed. -The expiration/beyond use date on the medication label must be checked prior to administering. -When opening a multidose container, the date opened shall be recorded on the container. 1. Observation on 4/18/24 at 6:33 A.M., of the Rehabilitation Unit medication refrigerator showed: -A paper refrigerator temperature log was laying on top of the medication refrigerator. -The log was dated 2024. -The log had columns for daily temperatures for each month of the year. -All columns were blank for January through April 18, 2024. 2. Observation on 4/18/24 at 6:33 A.M., of the Rehabilitation Unit medication refrigerator showed two expired medications: -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 four sampled residents, (Resident #37, #268, # 267, and #32) who had broken or missing teeth were seen by a dentist out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Dental Services dated December 2016 showed: -Routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Routine and 24-hour emergency dental services were provided to residents through a contract agreement with a licensed dentist that comes to the facility monthly. -Social services representatives would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. -All dental services provided were to have been recorded in the resident's medical record. 1. Review of Resident #37's face sheet showed a diagnosis of Chronic Obstructive Pulmonary…

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 implement measures to adequately respond to situations raised by two sampled residents (Resident #37 and #33) in the resident council meetings regarding receiving cold food out of 17 sampled residents; failed to ensure hot foods were at or close to 120 ºF (degrees Fahrenheit) and cold foods were served at a temperature of 41 ºF at the time of room tray service on the 500, 300 and the 200 Hall; and failed to ensure hot foods were served at or close to a temperature of 120 ºF who received room trays on the 200 and 300 Hall. The facility census was 67 residents. 1. Review of the resident council minutes dated 3/19/24, showed the residents raised the issue of cold food. Review of the resident council department response form dated 3/19/24 showed the following written response from the Dietary Manager (DM) regarding the resident question about cold food showed: - He/she (the DM) was filling in as a DM temporarily. - He/she did not know anything…

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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for five sampled residents (Resident #33, #48, #60, #61, and #173) out of five sampled residents. The facility census was 67 residents. Review of the facility's Tuberculosis, Screening Residents for, policy, dated July 2013, showed: -The facility screened all residents for TB. -The facility screened referrals for admission and readmission for information regarding exposure to or symptoms of TB. -TB skin tests (TST) completed within the last 12 months were reviewed. -Residents without documentation of a previous TST received a two-step TST upon admission. -If the results of the first TST were negative then a second TST was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to offer pneumococcal (lung inflammation caused by bacterial or viral infection) and/or influenza (flu-a highly contagious viral infection of the respiratory passages causing fever, severe aching, and often occurring in an epidemic) vaccines for five sampled residents (Resident #33 #48, #60, #61 and #173) out of five residents sampled for immunizations. The facility census was 67 residents. Review of the facility's Vaccination of Residents policy, dated August 2017, showed: -All resident were offered vaccines that aided in preventing infections diseases unless the vaccine was medically contraindicated, or the resident had already been vaccinated. -Resident's or resident representatives were provided information and education regarding the benefits and potential side effects of the vaccinations. -Any…

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 maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide the COVID-19 (an acute disease in humans caused by a virus, which caused fever, cough and could progress to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccine for three sampled residents (Resident #60, #61 and #173) out of five residents sampled for immunizations. The facility census was 67 residents. Review of the facility's Vaccination of Residents policy, dated August 2017, showed: -All resident were offered vaccines that aided in preventing infectious diseases unless the vaccine was medically contraindicated, or the resident had already been vaccinated. -Resident's or resident representatives were provided information and education regarding the benefits and potential side effects of the vaccinations. -Any education…

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 one sampled resident's (Resident #61) code status was changed from a full code (if a person's heart stopped beating and or or they stopped breathing, all resuscitation procedures would be provided to keep them alive) to a Do Not Resuscitate (DNR - a legal document that means a person has decided not to have cardiopulmonary resuscitation attempted on them if their heart stops or they stop breathing) status, out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Advance Directives, dated December 2016 showed: -Upon admission, the resident would have been provided with written information concerning the right to refuse or accept medical treatment and to formulate an advance directive if he or she choose to do so. -If a resident was incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may have been provided to the resident's legal…

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 provide the resident with a written summary of a baseline care plan that included instructions needed to provide the resident with care until the comprehensive care plan was developed for two sampled residents (Resident #41 and #60) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Care Plans - Baseline dated as revised December 2016 showed: -A baseline care plan would be developed within the first 48 hours of the resident's admission. -The interdisciplinary team would implement a baseline care plan to meet the resident's immediate care needs. -The baseline care plan would be used until the staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. -The resident and their representative will be provided a summary of the baseline care plan that includes but it not limited to: --The initial goals of the resident. --A summary of the resident's…

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 accurately document the administration of pain medication for one sampled resident (Resident #41) and failed to ensure one sampled resident (Resident #33) had taken his/her prescribed medications out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Administering Pain Medication dated as revised October 2010 showed the policy did not address where to document the administration of opioids (pain medications used to treat severe pain). Review of the facility's policy, Administering Medications, dated December 2012 showed: -The Director of Nursing Services would supervise and direct all nursing personnel who administer medication. -Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's undated policy,…

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 bathing/showers were completed at least once weekly and at the resident's preference for two sampled residents (Resident #13, and #54) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's shower policy dated October 2010 showed: -No indication of how often a shower/bath should be offered or given. -The purposes of the procedure. -General guidelines. -Equipment and supplies. -Steps in the procedure. -Information recorded on the residents' Activity of Daily Living (ADL) record and/or the residents medical record as: --The date and time the shower was performed. --The name and title of individual who assisted the resident with the shower. --All assessment data pertaining to the resident's skin condition obtained during the shower. --The reason why and the intervention taken if the resident refused the shower. --The signature and title of the person recording the data. -Notify the supervisor if 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 ensure physician ordered weekly weights were completed for one sampled resident (Resident #61) who had lost weight and was receiving tube feeding out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy, Weighing and Measuring the Resident, dated March 2011 showed: -The purposes of the procedure were to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status of the resident. -Weight was usually measured upon admission and monthly. -The following information should have been recorded in the resident's medical record: --The date and time the procedure was preformed. --The name and title of the individual who had performed the procedure. --The height and weight of the resident. 1. Review of Resident #61's face sheet showed he/she was admitted to the facility on [DATE] with the following 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.

Based on interview and record review, the facility failed to have ongoing communication and collaboration with the dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) center regarding dialysis care and services for one sampled resident (Resident #18) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Care of a resident with end-stage renal (kidney) disease dated as revised September 2020 showed the policy did not address communication between the facility and the dialysis center. 1. Review of Resident #18's care plan dated 3/7/23 showed the resident received dialysis. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 3/13/24 showed the following staff assessment of the resident: -Cognitively intact. -Had a diagnosis of end-stage kidney disease. -Received dialysis. Review of the resident's Physician's Order Sheet (POS)…

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 psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications were administered for a specific condition and as needed orders were limited to 14 days without review at 14 days and without documented physician rationale for one sampled resident (Resident #41); and to ensure the resident received a gradual dose reduction (GDR) for psychotropic medications after it was recommended by a pharmacist in a Medication Regimen Review (MRR) for one sampled resident (Resident #24) out of 17 sampled residents. The facility census was 67 residents. Review of the facility's policy titled Medication Utilization and Prescribing - Clinical Protocol dated as revised in July 2016 showed: -The physician and the staff would identify the indications for a prescribed medication. -An attempt at determining the likely cause of symptoms should be made. -The physician and staff would review the rationale for existing…

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 and interview, the facility failed to ensure the lids of the dumpster were closed after facility staff place trash the dumpsters. This practice affected one outdoor area. The facility census was 67 residents. 1. Observation on 4/15/24 at 9:59 A.M. and 11:21 A.M., showed both outdoor dumpsters were left open. 2. Observation on 4/16/24 at 2:20 P.M, showed two lids of one dumpster were left open. 3. Observation on 4/17/24 at 12:36 P.M,, showed the lids of both dumpsters were left open. During an interview on 4/17/24 at 12:38 P.M., the Dietary Manager (DM) said he/she expected all departments within the facility who used the dumpsters to place items in to keep the dumpsters closed and keep the raccoons out.

Based on observation and interview, the facility failed to maintain the siding located on the outside of the former dementia unit and the siding on the outside wall behind the kitchen in good repair, which created openings that pests could get into. This practice potentially affected an unknown number of residents. The facility census was 67 residents. 1. Observation on 4/15/24 at 8:36 A.M., showed the siding on the outside wall of the dementia unit with a bird that went into one of the gaps in the missing siding. 2. Observation on 4/16/24 at 2:17 P.M., with the Maintenance Director showed an approximately 6 feet (ft.) wide by 2 ft. high section of siding behind the air conditioning unit outside the kitchen that was damaged with the insulation that was under the siding visible. During an interview on 4/16/24 at 2:19 P.M., the Maintenance Director said the siding was damaged before he/she started his/her tenure and the water from the damaged downspout contributed to the damage in that area. 3. Observation on 4/16/24 at 2:23 P.M., with the Maintenance Director, showed an approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) with a facility acquired pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) that became infected requiring antibiotic therapy had weekly assessments of his/her skin and to ensure assessment, staging and measurements and description of the wound bed and drainage, and that the resident's care plan was revised to address his/her coccyx (tailbone) pressure and his/her pressure ulcer infection, and failed to ensure weekly licensed nurse skin assessments and weekly wound documentation for one sampled resident (Resident #8) admitted to the facility with two unstageable (not stageable due to coverage of the wound bed with slough - tan/yellow dead tissue or eschar - dry, black hard dead tissue) pressure ulcers, out of eight sampled residents. The facility census was 71 residents. Review of the facility Wound…

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

Based on observation, interview and record review, dietary staff failed to follow the recipe directions for Egg Salad Sandwich to maintain the temperature at or below 41 degrees Fahrenheit (ºF) in the kitchen before the time of service. This practice potentially affected 63 residents who ate food from the kitchen. The facility census was 67 residents. 1. Record review of the directions for the Egg Salad Sandwich showed: - Chill all ingredients prior to use. - Boil boil eggs till hard, then refrigerate at 41 ºF for several hours. - Peel eggs and chop. - Combine all remaining ingredients (relish, mayonnaise, mustard, red peppers) in a bowl and mix well. Observation on 8/21/22 from 3:37 P.M. through 6:21 P.M. showed: - Eggs were placed in boiling water. - Dietary [NAME] (DC) B placed the eggs in ice to cool them off cooling off eggs. - Between 5:17 P.M. and 5:42 P.M., the additional ingredients were mixed with eggs to make the egg salad. - The dietary staff did not chill all ingredients prior to use. - The pan which contained the egg salad mix was placed on ice in a well on the steam…

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

Based on observation, interview and record review, the facility failed to ensure paper towels were available at the handwashing sink next to the food preparation table; to ensure the handwashing sink next to the food preparation table was not blocked by boxes; to ensure the handwashing sink next to the automated dishwasher was not obstructed by a food cart and a red washing bucket; to discard 12 containers of half and half dairy product was discarded by the use by date; to discard two gallons of milk by the use by date; to remove an area of mildew or mold form the upper part of the ice machine; to maintain the gasket (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects), to store one bag of onions off the floor; to ensure light fixtures, sprinkler heads and door frames, were free of a dust buildup in the kitchen area; to ensure a cup of coffee at the food preparation table was covered; to ensure there was not debris in one of the utensil drawers; to remove debris from the floor under the ice…

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

Based on observation, interview and record review, the facility failed to ensure that items stored in the resident use refrigerator were labeled with a date they were placed in the fridge, a resident's name to identify who the items belonged to; to remove items that had expired according to the date on the package;and to maintain the resident use refrigerator free of food stains within the refrigerator and along the gasket which went around the inside part of the refrigerator. This practice potentially affected an unknown number of residents whose food was stored in that refrigerator. The facility census was 67 residents. Record review of the Policy entitled Foods Brought by Family/Visitors revised in 2/14, showed: - Family members should inform nursing staff of their desire to bring foods into the facility. - The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. - Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. - Containers will be labeled with 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 include the following in their Water Management Plan: diagrams from hot water heaters and the destinations of water from those hot water heaters, corrective actions that the facility would implement as a result of changes in municipal or facility water quality and members of the water management team; to ensure documentation of the most previous backflow testing (using valves on the backflow testing device, known as backflow preventers to ensure they're working properly to prevent contaminated water from going back into the building) was conducted. The facility also failed to follow appropriate infection control practices during wound care for one sampled resident (Resident #27); and to ensure infection control measures were performed to prevent cross contamination during incontinence care for two sampled residents (Resident #23 and #42) out of 18 sampled residents. The facility census was 67 residents. Record review of page 3 of Centers…

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 and interview, the facility failed to maintain the kitchen steam table in working order; to maintain two washers and two clothes' dryers in the laundry in working order; and to have a system to indicate that the clothes' dryers were not working. The facility census was 67 residents. 1. During an interview on 8/21/22 at 5:48 P.M., Dietary [NAME] (DC) B said: - No pans could be placed in the middle well of the steam table because it would not shut off. - The dietary staff were going to serve meals that needed to be kept cold that day. - There have been four maintenance persons that have tried to fix the steam table, but were unsuccessful. Observation on 8/21/22 at 5:50 P.M. showed the absence of a switch from the middle well of the steam table. During an interview on 8/21/22 at 7:32 P.M., the Administrator said he/she was not notified by maintenance regarding the steam table. 2. Observation with the Housekeeping Supervisor on 8/23/22 from 2:18 P.M. through 2:23 P.M. showed: - Two clothes' dryers in the laundry which were not working without any signs or warnings…

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

Based on observation, interview and record review, the facility failed to ensure that openings that could let pests in, the attic area above the dry goods storage area and the Memory Care Unit hot water heater room, were maintained in good repair; and to clean up dead insect carcasses in the 300 Hall soiled utility room, the 400 Hall medication room, and the 200 Hall climate control unit room. This practice potentially affected at least 40 residents who resided in or used those areas. The facility census was 67 residents. 1. Observations of the attic area over the kitchen dry goods storage room, with the Maintenance Director on 8/22/22 at 10:27 A.M. and 11:22 A.M., showed the presence of wasps which flew around in the attic, bird and mouse droppings, dried vegetation, and a dead carcass of an animal that was not identifiable. During an interview on 8/22/22 at 10:34 A.M. the Maintenance Director said he/she needed to spray the wasps. Observation of the outside of the attic area on 8/22/222 at 10:36 A.M., showed a 2.5 inch (in.) opening that was not sealed, that wasps used, to fly…

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 provide documentation that change was returned to two sampled residents (Residents #23 and #24), after money was spent on their behalf during a shopping trip. The facility also failed to provide records pertaining to the following areas within resident trust: reconciled bank statements for [DATE], [DATE], [DATE] and [DATE]; a listing of the residents' transactions over the past few months ([DATE] through [DATE] at least); a list of residents who were discharged with resident funds; a list of residents who were deceased with resident funds; and quarterly statements from [DATE] through [DATE]. This practice affected 29 residents who allowed the facility to manage their funds. The facility census was 67 residents. 1. Record review of a receipt dated [DATE], showed $50.00 was spent for an item for Resident #23 with change of $20.39. There was no documentation to show that the change was returned to the resident. 2. Record review of a receipt dated [DATE]…

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 maintain bed sheets free from stains and to change those sheets for five days of the survey for one sampled resident (Resident #40) out of 17 sampled residents. The facility also failed to maintain ceiling fans in the Golden Meadows dining room, the Memory Care Unit and the Social Worker's Office, free of a heavy buildup of dust; to maintain the floors of the resident rooms 110, 105, 310, 208, 201, free of a grime buildup; to maintain a stand up lift used on 400 Hall, without grime and food crumbs on its base; and to maintain a shower chair in the Memory Care Unit shower room in good repair. This practice potentially affected at least 40 residents who resided in or use these areas. The facility census as 67 residents. A request for the bed linen policy was made to the Corporate Liaison on 8/26/22; the policy was not received. 1. Record review of Resident #40's Face Sheet showed he/she was admitted [DATE] with diagnoses of Chronic…

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 the dinner meal was served in a timely manner according to the listed meal schedule, on 8/21/22. This practice potentially affected 63 residents who ate food from the kitchen. The facility census was 67 residents. 1. Record review of the undated document which stated the facility meal times, showed dinner was supposed to be served at 5:00 P.M. Record review of the resident council minutes dated 5/12/22 showed late meals was one of the concerns raised during that meeting. Record review of Resident Council minutes dated 6/9/22, showed there was not any written followup to the concerns raised in the meeting on 5/12/22. During an interview on 8/21/22 at 3:25 P.M., Dietary Aide (DA) A said the turkey burgers did not come in on the most recent food and ingredient delivery to the facility, so they would change to making egg salad. Observations on 8/21/22 showed - At 4:46 P.M., Dietary [NAME] (DC) placed the eggs in ice to cool them off…

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

Based on observation, interview and record review, the facility failed to ensure all the necessary items were available for the dinner meal on 8/21/22; to notify the Registered Dietitian (RD) when the dietary department changed from one entrée to another entrée on 8/21/22; and to ensure the recipe for super cereal was available for dietary staff to use while making the super cereal, for one observed resident (Resident #42). This practice potentially affected 62 residents who ate food from the facility kitchen. The facility census was 67 residents. 1. Record review of the weekly menu entitled Week at a Glance for General/Regular Week 1, dated 3/7/2022 showed the meal that was to be served on 8/21/22 was Philly style turkey burger, seasoned green beans, strawberries and whipped topping hamburger bun, 2% milk, and hot beverage. Record review of the order sheet dated 8/15/22, showed the turkey burgers were not ordered at the time for the meal on 8/21/22. During an interview on 8/21/22 at 3:32 P.M., Dietary [NAME] (DC) A said: - Turkey burgers did not come in on the truck with the food…

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 and interview, the facility failed to ensure the hot foods (sausage and eggs) of breakfast meal was at or close to 120 degrees Fahrenheit (ºF) at the time of service to residents on the Memory Care Unit on 8/25/22. This practice potentially affected 12 residents who resided on the Memory Care Unit. The facility census was 67 residents. 1. Observation of the breakfast food at the steam table on 8/25/22 at 7:52 A.M., showed the temperatures for the food served was scrambled eggs were 156.4 ºF, oatmeal cereal was 183 ºF, sausage was 142 ºF, and hot cereal was 175.3 ºF. Observation on 8/25/22 at 8:28 A.M., showed the food cart was delivered to the Memory Care Unit. Observation on 8/25/22 from 8:29 A.M. through 8:32 A.M., showed Certified Medication Technician (CMT) A provided assistance to Resident #21, in getting that resident dressed. Further observation showed (CMT) A was the only staff on the Memory Care Unit at the time During an interview on 8/25/22 at 8:33 A.M., CMT A said he/she was the only one from nursing staff who worked on the unit at the time.…

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 update the authorization to manage resident funds for one sampled resident (Resident #23) by failing to obtain a signature of authorization from the resident's legal guardian, when the status of that resident was changed from having self determination to needing a guardian. The facility census was 67 residents. 1. Record review of Resident #23's paperwork showed: - The resident signed to allow the facility to manage his/her funds when he/she was admitted on [DATE]. - The resident became a ward (a person, usually a minor or of unsound mind, for whom a guardian has been appointed by a court or one who has become directly subject to the authority of that court) of the County Public Administrator on 9/23/19. During an interview on 8/24/22 at 9:56 A.M., the Business Office Manager (BOM) said: - The facility did not get his/her authorization updated at that time. - That resident's status was changed before his/her tenure at the facility which started on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a current copy of each resident's Advanced Directive (legal document which allows you to plan and make your own end-of-life wishes known in the event you are unable to communicate) for one sampled resident (Resident #61) out of 17 sampled residents. The facility census was 67 residents. Record review of Revisor.mo.gov's article Title XII Public Health and Welfare-Chapter 190 dated [DATE] showed: -An Outside the Hospital Do-Not-Resuscitate Order (OHDNR) requires a written physician's order signed by the patient and the attending physician, or the patient's representative and the attending physician, in a form promulgated by rule of the department which authorizes emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from the patient in the event of cardiac or respiratory arrest. Record review of the facility's policy Advanced Directives dated [DATE] showed: -Prior to or upon admission, the Social Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain and follow a complete detailed physician's order for type, care and monitoring of a Suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis); and to follow infection control practices by ensuring a Suprapubic catheter drainage bag (a bag that holds drained urine) was kept off the floor for one sampled resident (Resident #18) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system); out of 17 sampled residents. The facility census was 67 residents. Record review of Missouri Certified Nursing Assistant (CNA) Manual Nursing Assistant in Long term Care Facility Student Reference, Revised 2010 showed: -Indwelling catheter (is a catheter tube passed through the urethra into the bladder to drain urine) care should be provided at least every shift and if soiled. -The catheter drainage tubing and bag must be maintained below the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician orders were detailed for a colostomy (ostomy, an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen stoma) care to include the type of appliances, skin barriers and skin care; to obtain physician orders for self-care of colostomy; to complete a self-care assessment for the residents ability to perform own care; and to document a detailed skin assessment of the colostomy site for one sampled resident (Resident #1) out of 17 sampled residents. The facility census of 67 residents. The facility colostomy care policy was requested and was not received at the time of exit. 1. Record review of Resident #1's face-sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of having a colostomy and history of stroke. Record review of the resident's Weekly Skin Assessment Sheets dated 3/8/22 showed no documentation related 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 record review, the facility failed to ensure physician's dietary orders were transcribed to the Medication Administration Record (MAR) monthly, to ensure physician's dietary supplement orders were followed, and to ensure dietary interventions were being monitored and documented to prevent gradual weight loss that became significant for one sampled resident (Resident #42) out of 17 sampled residents. The facility census was 67 residents. Record review of the Facility's Nutrition/Unplanned Weight Loss policy and procedure dated 9/2012, showed the facility will monitor and document the weight and dietary intake of the residents which permits readily available comparisons over time. The threshold for significant unplanned weight loss/undesired weight loss included a 10 percent weight loss within six months was considered significant. Weight loss greater than 10 percent was considered severe. The procedure showed: -The physician will assess the possible causes of weight loss with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure physician's orders were complete for the resident's tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called enteral feeding or tube feeding) to show how the facility was going to monitor the tube to ensure patency, to check Gastric Residual Volume (GRV) and flushing the gastrostomy tube (also called G-tube or percutaneous endoscopic gastrostomy (PEG) tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) before, during and after medication administration and bolus (the administration of a limited volume of enteral formula over brief periods of time) feedings, and to have detailed documentation of the tube feeding process for two sampled residents (Resident#10 and #18) out of 17…

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 properly store the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose) and nebulizer mask/tubing (used for aerosol breathing treatments) in a manner to prevent the spread of infection for two sampled residents (Resident #70 and #40) out of 17 sampled residents. The facility census was 67 residents. Record review of the facility's policy titled Oxygen Administration dated October 2010 showed facility staff were to document in the resident's electronic chart when tubing was changed. Record review of the facility's policy titled Administering Medications through a Small Volume Nebulizer dated October 2010 showed: -Facility staff were to store the nebulizer mask and tubing in a plastic bag with the resident's name and the date the mask/tubing was opened. -Facility staff were to change the mask/tubing every seven days. 1. Record review of Resident #40's Face Sheet showed he/she was admitted on [DATE] with 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 obtain and transcribe detailed physician orders for dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) care and monitoring of dialysis line (port) or dialysis shunt monitoring and care; to obtain diet order, transcribe and follow-up on recommended dialysis nutrition orders; to document ongoing observations and monitoring for the resident before, and after dialysis treatments; and to provide ongoing management of nutritional and fluid intake including documentation of weights, resident compliance with food and fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered for one sampled resident (Resident #1) out of 17 sampled residents. The facility census was 67 residents. The facility did not provide a Dialysis policy at time of exit. 1. Record review of Resident #1's…

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.