New Mark Rehab And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food safety when staff failed to dispose of expired food items, failed to properly label and seal opened food items, failed to wear hairnets and failed to maintain cleanliness in the refrigerators, freezer, and storerooms. This affected all residents by putting them at risk for food borne illness. The facility census was 162. Review of facility policy, Cleaning Schedule Dietary Services, revised 10/24/22, showed: - The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager; - The cleaning schedule includes tasks assigned to specific positions within the dietary department; - Dietary staff will initial next to the assigned task once it is completed; - The Dietary Manager monitors the cleaning schedule to ensure compliance; Review of facility policy, 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 interview, and record review, the facility failed to, provide supportive services, or develop a care plan that directed interventions for facility staff to utilize to protect the resident and prevent trauma from recurring for one resident who was identified as having a past traumatic life event (Resident #26), out of 32 sampled residents. The facility census was 162. Review of the facility's Care and Services Policy, revised 10/24/22, showed: -Care and services are provided a in manner that consistently enhances self esteem and self worth; -Behavior health encompasses and residence whole emotional and mental well-being which includes the identification of needed care and services; -A resident who is diagnosed with mental disorder or psychosocial adjustment difficulty will receive appropriate treatment in accordance with assessed behavioral needs. The facility did not provide a Trauma Informed Care Policy. 1. Review of Resident #26's Quarterly Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/22/25, showed: -Moderate cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide an appropriate discharge when staff failed to provide written notice of discharge that included the date and location the resident would be discharge to, statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) to one sampled resident (Reisdent #1). The facility's census was 161. Review of facility policy regarding Transfer and Discharge, revised 10/24/22, showed: - The facility may not transfer or discharge a resident while the appeal to the notice of transfer/discharge is pending, unless it is documented that failure to transfer or discharge the resident would endanger the health or safety of the resident or other individuals; - In cases in which 30 days' notice is not possible, the notice of transfer or discharge should be provided to the resident or resident representative as soon as practicable; - Documentation of written…

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 facility policy review, the facility failed to ensure air vents were clean, stored food was dated after opening and sealed from contamination, and staff wore hair restraints while in the kitchen. This had the potential to affect 98 of 99 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: 1. During an initial tour of the kitchen on 04/08/24 at 8:40 AM, with the Dietary Director (DD), the following observations were made: Walk-in Freezer and kitchen: a. One large clear bag, containing pork sausage links, was observed open and undated. b. One bag of pepperoni with saran wraps around the outside was observed open and undated. c. One large bag of frozen cheese raviolis was observed undated. d. One large box of turkey breakfast sausage was observed open and exposed to the air. e. Two large clear bags of French toast were observed undated. f. One large clear bag of tater tots was observed undated. g. One large clear bag of shredded hash brown, was observed undated. Walk-in Refrigerator and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident and/or representative of five residents (Resident (R) 78) reviewed for unnecessary medications, out of a total sample of 25 residents, was informed of the risk and benefits of a physician ordered antipsychotic medication. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of medications. Finding included. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R78 was admitted to the facility on [DATE] with Alzheimer's disease and major depressive disorder. Review of an 08/02/23 Physician Order located in the Orders tab of the EMR revealed, Abilify [an antipsychotic medication used as an add-on treatment for adults with major depressive disorder] 5 mg [milligrams] at bedtime. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/29/23 revealed R78 had 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 maintain a clean and comfortable environment for one of 25 sample residents (Resident (R) 67). Findings include: Review of R67's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R67 was initially admitted on [DATE] with diagnoses that included Gillain-Barre syndrome, chronic congestive heart failure, chronic obstructive pulmonary disease, major depression, anxiety disorder, and delusional disorder. Review of R67's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/16/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R67 was cognitively intact. During an observation and interview on 04/08/24 at 11:10 AM, R67 was observed in bed. The sliding door track was observed to have a heavy build-up of dirt and grime and there were four small black ants roaming from the door to under the bed. The head of the bed was observed to be raised at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one resident of four residents (Resident (R) 51) reviewed for abuse out of a sample of 25 residents. R96 bit R51's arm after R51 reached for a blanket R96 was using. Findings include: Review of R96's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed R96 admitted to the facility on [DATE] with diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder. Review of R96's quarterly ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 01/19/24 revealed a ''Brief Interview for Mental Status (BIMS)'' was unable to be completed due to R96 rarely being understood. Review of R96's care plan, located under the ''Care Plan'' tab of the EMR and dated 05/19/23, revealed ''The resident has socially inappropriate/disruptive and aggressive behaviors.''…

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 record review, interview, and policy review, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA) and failed to report a resident-to-resident altercation to the Abuse Coordinator and the SSA within two hours for two residents out of four residents (Resident (R) 96 and R51) reviewed for abuse out of a sample of 25. Findings include: 1. Review of R96's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder. Review of R96's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/24 revealed a Brief Interview for Mental Status (BIMS) was unable to be completed due to R96 rarely being understood. Review of the facility's Event Report dated 10/24/23 revealed R96 was in the television (TV) area sitting on sofa when she was noted to have small purplish bruised…

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 record review, interview, and policy review, the facility failed to conduct a thorough investigation for an injury of unknown origin and a resident-to-resident altercation for two residents of four residents (Resident (R) 96 and R51) reviewed for abuse out 25 sampled residents. Failure to thoroughly investigate injuries of unknown origin and resident-to-resident altercations could place vulnerable residents at risk. Findings include: 1. Review of R96's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder. Review of R96's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/24 revealed a Brief Interview for Mental Status (BIMS) was unable to be completed due to R96 rarely being understood. Review of R96's care plan, located under the Care Plan tab of the EMR and dated 05/19/23,…

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 record review, interview, and facility policy, the facility failed to revise the care plan of two of 25 sampled residents (Resident (R) 66 and R55). R66 did not have a revision to the care plan for a diagnosis of Post Traumatic Stress Disorder (PTSD). R55's care plan was not updated to include the use of her specialized wheelchair. This failure created an increased risk for the residents to receive care and services not appropriate for their current clinical condition. Findings include: Review of R66's electronic medical record (EMR) Profile tab, indicated R66 was admitted on [DATE]. R66's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/24 revealed R66's Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated R66 was cognitively intact. Per the MDS, R66 had a diagnosis of PTSD, R66's total severity score for depression during the assessment period equaled a six out of ten score and indicated R66 had little interest or pleasure in doing things seven to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two residents of 25 sampled residents (Resident (R) 55 and R67) received care and treatment in accordance with professional standards of practice. The facility failed to ensure a wheelchair headrest was placed to support R55's head and that the foot pedal was applied to support her left leg. In addition, the facility failed to obtain a dermatology appointment for R67 in a timely manner, due to a skin condition that caused excessive itching. Finding included. 1. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R55 was admitted to the facility on [DATE] with Alzheimer's disease. Review of the annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/09/24 revealed R55 had a staff assessed Brief Interview of Mental Status (BIMS) of three out of 15 which indicated she was severely impaired in cognition. Per the MDS, R55 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.

Based on observation, interview, record review, review of the facility policy, the facility failed to ensure one of four residents (Resident (R) 34) reviewed for range of motion (ROM) limitation out of 25 sample residents received appropriate services to increase her ROM and/or prevent a decrease in her ROM. This failure placed the resident at risk for increased contractures and a diminished quality of life. Findings included. Review of the Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R34 was admitted to the facility 03/11/21 with diagnoses that included a stroke with right-sided hemiplegia (paralysis on one side of the body) and cerebral palsy. Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 03/15/24 revealed R34 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated she was cognitively intact for daily decision-making and did not receive restorative therapy. Per the MDS, R34 had functional limitations in range of motion on one side for both…

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 of two residents (Resident (R) 44) reviewed for respiratory care out of 25 sampled residents received care consistent with professional standards of practice. The facility failed to ensure R44's nebulizer tubing and pipe were placed into a covered bag to minimize spread of pathogens. This failure placed R44 at risk for infection. Findings included. Review of the Face Sheet located in the Face Sheet tab in the electronic medical record (EMR) revealed R44 was admitted to the facility on [DATE] with diagnoses that included heart failure and chronic obstructive pulmonary disease (COPD). Review of a 10/19/23 Physician Order located in the Orders tab of the EMR revealed, Ipratropium-albuterol [DuoNeb-a medication used to aid in shortness of breath] 0.5mg [milligrams]-3mg (3 ml) per nebulized inhalation four times a day. Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference 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 interview, record review, and review of facility policy, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS-a test that rates involuntary muscle movements on residents who are administered antipsychotic medications) assessment for one resident (Resident (R) 78) and failed to have a stop date and diagnosis for use of an as needed (PRN) psychotropic medication for one resident (R59) out of five residents reviewed for unnecessary medications in a total sample of 25 residents. This failure placed residents at risk for unrecognized side effects and a diminished quality of life. Findings included. 1. Review of the Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed, R78 was admitted to the facility on [DATE] with Alzheimer's disease, dementia, and major depressive disorder. Review of an 08/02/23 Physician Order located in the Orders tab of the EMR revealed, Abilify [an antipsychotic medication used as an augmentation with an antidepressant…

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, record review, and review of facility policy, the facility failed to ensure an insulin pen was removed from one medication cart after 28 days for one of 18 Kwik pens (Resident (R) 46) that were observed for open date and expiration date on three of three nurse medications. This failure to ensure insulin pens were removed from the medication cart timely, placed the resident at risk for receiving ineffective medication and health complications. Findings included: During an observation with Registered Nurse (RN) 3 on [DATE] at 3:08 PM, the 200 Hall nurse medication cart revealed three Kwik pens. Review of R46's Kwik pen revealed an open date of 2-24, and the expiration date was smudged as not to be legible. RN3 was asked when was the last time R46 had received insulin from this Kwik pen. RN3 stated, On [DATE] when his blood sugar was 375. RN3 confirmed the Kwik pen was expired. Review of the Physician Orders located in the Orders tab of the electronic medical record (EMR) revealed…

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 staff interview, the facility failed to ensure the reach-in refrigerator was properly maintained. This had the potential to affect 98 of the 99 residents who consume food from the kitchen. Findings include: 1. Observations during the tour of the kitchen on 4/08/24 at 8:40 AM revealed the reach-in refrigerator had a leak that resulted in about an inch of water holding at the bottom of the refrigerator. There was a cookie sheet with several condiments on it on the bottom shelf, the water was almost to the rim of the cookie sheet. There were several boxes of Jello that were visibly wet from the leak. The water was extending onto the floor when the doors were opened. 2. Observations during the tour of the kitchen on 04/09/24 at 10:54 AM revealed the reach-in refrigerator continued with the water build-up on the bottom shelf, one thick slice of cheese wrapped in saran wrap observed submerged in the water. Dietary Staff (DS) 2 was immediately interviewed. DS2 said that the reach-in freezer had been leaking for at least 6 months, and that the water would sometimes…

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 staff failed to sit next to residents while assisting them to eat, rather than standing over them for two sampled residents (Resident #68 and #52), honor resident preferred choices in meal preferences for one sampled resident (Resident #19), and failed to provide meals to all residents at a table at the same time for three residents (Resident #58. #68 and #72); failed to provide oral care for one resident (Resident #30) and failed to provide one resident a table to sit at during meals (Resident #52) . The facility failed to ensure one of 22 sampled residents. The facility census was 110. Review of the facility's policy for resident choices and preferences, revised 1/21, showed, in part: - The residents have the right to make choices about aspects of their lives that are significant to them; - When a resident dislikes the meal choices, they are offered substitutions or choices as appropriate and in accordance with his/her preferences, with consideration for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of needs when they did not provide ease of access for three residents (Resident's #42, Resident #5 and Resident #96) out of the 22 sampled residents, to enter in and exit out of the facility's courtyard area independently. The facility census was 110. Review of the facility's Resident's Rights policy revised January 2021 showed: - It is the facility's responsibility to accommodate individual needs, and preferences of and abide by the resident's right of choice and self -determination will be balanced against protecting the resident. The responsibility to respect a residents choice is balanced by considering the potential impact of these choices on other individuals and on the the facility's obligation to protect the residents from harm. Activities are an important right for a resident to have choices to participate in preferred activities. The facility's physical environment and staff behaviors will 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 record review and interview, the facility failed to ensure they kept resident's money separated from the facility's operating account. This effected six additionally sampled residents. The facility census was 110. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, dated 12/18/18, included the following: - This facility will establish and maintain a system that assures full, complete and separate accountings of each resident ' s personal funds entrusted to the facility on the resident ' s behalf. A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; - The facility will deposit all funds of the resident in an interest-bearing account that is separate from any of the facility operating accounts and all interest will be credited monthly to the resident fund account with a separate accounting for each resident's share; - Written receipts will be issued for cash received. 1. Review of the facility's aging report (a report used to determine 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 record review and interviews, the facility failed to follow acceptable standards of practice for two sampled residents (Resident #51 and #37), when the staff failed to administer medications per the physician's order; and failed to obtain an order for bed cane rails for four residents (Resident #30, #69, #103 and #79) out of 22 sampled residents. The facility census was 110. Review of the facility's medication administration policy, updated on 1/2021 showed: -It is the policy of the facility to retain, store, administer, and document compliance with Federal and State regulations and in accordance with current standards of practice and guidelines for medication management. -Physician's medication orders must be reviewed and renewed. -Orders must be signed and dated when ordered and maintained in chronological order. -The resident has the right to receive services in the facility with reasonable accommodation. -The resident has the right to be informed of changes in care. -This facility endeavors to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the safety of residents that use U-rails (rails installed at the head of the bed on one or both sides of the bed that is in the shape of an upside-down U), failed to do an entrapment assessment when the rails where initiated, failed to review the risks and benefits of the rails and obtain consent for the use of the rails, for four of 22 sampled residents, (Resident #30, #69, #79, and #103). The facility census was 110. The facility did not provide a policy for cane bed rails. 1. Review of Resident #30's significant change in status Minimum Data Set, (MDS) a federally mandated assessment instrument completed by facility staff, dated 7/8/22 showed: - Cognitive skills severely impaired; - Physical behavior directed at others occurred one to three days; - Rejected care occurred one to three days; - Wandering occurred one to three days; - Dependent on the assistance of two staff for bed mobility, dressing and toilet use; - Required…

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 observations, interviews, and record review, the facility failed to assure staff served food that is of a safe and acceptable temperature to the residents. The facility census was 110. Review of the facility's Food Temperatures policy, dated May 2015, showed: -The Dietary Services Manager or designee is responsible for seeing that all food is the proper serving temperature(s) before trays are assembled. -Hot food should be at least 120 degrees Fahrenheit when served to the resident. Observation of the lunch meal preparations on 9/28/2022 showed: -11:19 A.M.: Dietary Staff B began preparing the plates for the residents on Unit 1. Plates were placed into the portable heated transport rack uncovered. -11:31 A.M.: The test tray is completed and placed into the portable heated transport rack. -11:36 A.M.: The portable heated transport rack arrives on Unit 1. The dietary staff member left the portable heated transport rack in the hall outside the Unit 1 dining room, unplugged. -11:54 A.M.: Nursing staff moved the portable heated transport rack to the Unit 1 dining room 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.

Based on observation, interviews and record review, the facility failed to store food in a safe sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all facility residents who receive food from the facility kitchen. The facility census was 110. Review of the facility's Safe Food Handling policy, dated May 2015, showed: -All food should be tightly sealed with an identifying label and date. Observation of the kitchen on 9/26/2022 at 11:26 A.M., showed: -Walk-in Refrigerator: -Large pan of meatballs, covered with plastic wrap, no label or date. -Two aerosol cans of whipped cream, no date. -One open bag of shredded mozzarella cheese, no date. -Two door Fridge: -Open package of sliced cheese, no label or date. -Walk-in Freezer -Twelve cookies, individually bagged, no label or date. -Two bags chopped chicken, no label to identify the food or date of when opened. -One blue plastic bag, open, of corn on the cob, no label or date. -One open bag of potato patties, no label or date. -Icicles hanging from the cooling unit in the back of the…

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

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when the facility failed to implement their policy regarding employee tuberculosis testing when they did not provide a second step of the test timely. The facility census was 110. Review of the facility's undated policy titled Tuberculosis (TB) Control included the following: - All employees will be screened for TB; - Once the decision has been made to employ an individual, the individual will be asked for documentation of a prior purified protein derivative (PPD) TB Test: o If the employee does not have documentation of a prior PPD; the first step PPD will be administered by the nursing department, documented on the employee immunization record, and must be read prior to or no later than start date; o If the employee has documented evidence of prior two step PPD, the decision tree for employee accepts position will be followed; o If the employee has had a documented…

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, facility staff failed to complete entrapment assessments for four residents with side rails (Residents #30, #69, #103 and #79) to ensure the environment remained safe and free of accident hazards. The facility census was 110. Facility did not have a policy regarding bed canes. 1. Review of Resident #69's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 8/5/22 showed: -Brief Interview for Mental Status (BIMS, an interview conducted by staff to determine the residents ability to answer questions appropriately and make decisions) of 4; the resident is unable to make decisions and answer questions appropriately; -Extensive assistance of one staff member for transfers and bed mobility; -Diagnoses of Alzheimer's disease (is a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die.), Depression (is a mood disorder that causes a persistent feeling of sadness and loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for residents. The facility census was 110. 1. Observation on 9/28/22 beginning at 7:45 A.M. showed the following: - room [ROOM NUMBER]- Three broken tiles by the bed; - room [ROOM NUMBER]- Large scratches and gouges on the wall behind the bed; - ¾ inch () by four inch crack on the wall by the exit to from unit 1; - #303- large area of the wall behind door damaged, the from the door opener at the top. - room [ROOM NUMBER]- large gouges in about a thee foot by four foot area behind the bed; - 316 - a 2 to 3 hole in the bathroom door; - 317 - area of the laminate floor missing by the toilet approximate size of a baseball; - Unit 3 shower room- 2 by 4 area on the ceiling where the ceiling texture was peeling; - room [ROOM NUMBER]- 8 crack in the floor in front of the toilet, 301 A bed frame is dirty - privacy curtain with a dark substance around the bottom and edges of the curtain. Split food and fluid down…

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 issue written notice of transfer for one residents (Resident #86). The facility census was 110. Review of the facility Bed-hold Notice and Return/readmission policy, dated January 2022, showed: -It is the policy of this facility to to provide written bed hold policy when a resident is admitted and upon transfer to a hospital or goes on therapeutic leave. -These bed hold policies apply to all residents and require that two notices are issued relation to the bed-hold policies: -The first notice of bed-hold policy is given well in advance of any transfer, usually at admission. -The second notice, which specifies the duration of the bed-hold policy, will be issued at the time of transfer. In cases of emergency transfer, the bed-hold notice either accompanies the resident or is provided to the family, surrogate, or representative within 24 hours of the transfer. 1. Review of Resident #86's MDS entry and discharge information on 9/27/2022, showed: -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.

Based on observations, interviews, and record review, the facility failed to maintain medication storage when loose pills were found in the medication cart and expired medication was found in the medication room; failed to date an opened vial of insulin and ensure staff were able to read the opened and expiration date on a vial of insulin for one (Resident #9) of 22 sampled residents, The facility census was 110. Review of the facility's undated policy for storage of medications, showed, in part: - Medications must be stored in the container in which they were received; - No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. 1. Observation and interview on 9/28/22 at 11:11 A.M., in the medication room for Unit 1 showed: - 50 bisacodyl suppositories expired 6/2022; - Resident #9 had an opened vial of Lantus (long acting) insulin which staff had dated when it was opened but was unable to read the date or read the expiration 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.

Based on observations and interview, the facility failed to ensure the pureed food was prepared to a smooth and appropriate consistency. This had the potential to affect all residents in the facility who receive a pureed diet (a texture-modified diet in which all foods have a soft, pudding-like consistency). The facility census was 110. Review of the facility's Types of Diets policy, dated May 2015, showed: -Pureed Diet: This diet is for the edentulous resident and residents with swallowing difficulties. Foods are blended to a mashed potato consistency or altered to meet the needs of the resident, using as little liquid as possible. Observation of lunch meal preparation on 9/28/2022 at 10:45 A.M., showed: -Dietary staff C began preparing the pureed lunch meal. -He/she placed cut up pieces of breaded chicken breast into the food processor. -He/she then turned on the food processor and began adding water from a pitcher until it was the desired consistency. -He/she did not use a recipe. Observation of pureed lunch meal on 9/28/2022 at 12:32 P.M., showed: -Breaded Chicken breast: Very…

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 record review and interview, the facility failed to employ an infection preventionist (IP) on at least a part-time basis. The facility census was 110. Review of the facility's Infection Surveillance policy, dated May 2016, showed: -The IP will be the hub of the Antibiotic Stewardship Program (ASP). They will have the knowledge and expertise to effectively develop, implement and monitor the ASP. -The IP or designee will be responsible to audit the clinical assessment documentation at the time of antibiotic prescription. -The IP or designee will be responsible for auditing the completeness of antibiotic prescribing documentation to include dose, route, start date, end date, days of therapy, and indication. -The IP or designee will monitor antibiotic imitation. -The IP or designee will track antibiotic resistant infections. During an interview on 9/29/2022 at 1:36 P.M., the Assistant Director of Nursing (ADON) said: -He/ she has completed the videos and training, but has not taken the test. -On 9/27/2022, Corporate provided the ADON an Infection Prevention and Control plan…

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.