North Village Park

Based on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (this indicator disqualifies an individual from working in the facility) for three of ten newly hired employees (Maintenance Assistant I, Certified Nurse Aide (CNA) J and Dietary Aide L) reviewed. The facility also failed to check the Employee Disqualification List (EDL) for three of ten newly hired employees (Maintenance Assistant I, Dietary Aide L and Licensed Practical Nurse (LPN H) reviewed. The facility census was 172. Review of the facility's policy, Screening-Applicant, Employee, Volunteer and Vendor, revised 06/12/25 showed the following:-Human Resources (HR) department will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State health care programs, is eligible to work in the United States, and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied;-Applicant shall complete a Request for Criminal…

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 a written notice of transfer discharge to seven residents (Resident #85, #113, #30, #38, #5, #6, #75) or the resident representatives, in a sample of 47 residents reviewed, that included the reason for discharge/transfer, location being discharged to, resident's appeal rights and who to contact for an appeal hearing request, the contact information for the Ombudsman, the contact information for the advocacy agency for residents with intellectual and developmental disabilities or the contact information for the agency that is an advocacy for residents with mental illness. Further review showed the facility did not provide a bed hold policy to one resident (Resident # 113) or their representative at the time of their transfer. The facility census was 172. Review of the facility policy, Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave Policy, revised 4/28/25, showed the following:-With the exception of ceasing to operate,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for six residents (Residents #11, #20, #103, #179, #45, and #167), in a review of 47 sampled residents. The facility census was 172. Review of the facility policy, MDS 3.0, care assessment summary and individualized care plans, revised on 11/6/23, showed the following:-The purpose is to understand the changes presented by CMS for the MDS 3.0;-To define the intent of each section of the MDS 3.0;-To ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties;-The MDS 3.0 with the Care Area Assessment Summaries is a much more user-friendly assessment tool that addresses the wholistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident;-Section K is to be completed…

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 update care plans to reflect current care needs for six residents (Resident #45, #4, #172, #14, #87 and #10), in a review of 47 sampled residents. The facility census was 172. Review of the Resident Assessment Instrument (RAI) Manual dated October 2025 showed the following:-4.7 The RAI and Care Planning as required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool;-It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;-The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. 1. Review of Resident #45's Care Plan, dated 05/13/25, showed the following:-The resident was on a regular diet;-Dietary department will monitor diet monthly to ensure…

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 follow professional standards of practice for seven residents (Resident #24, #47, #118, #127, #113, #77 and #4) in review of 47 sampled residents. The facility failed to follow physician orders and obtain ordered bloodwork related to therapeutic medication level monitoring and bloodwork for five residents (Residents #24, #47, #113, #118 and #127). Further review showed no documentation the resident's physicians were notified when bloodwork was not obtained and/or documented as uncollected. Facility staff failed to obtain a blood pressure or pulse prior to administering a medication for high blood pressure, with ordered parameters on when to give the medication and when the medication should be held and not given for one resident (Resident #77). Resident #77 also had orders for an Accu Check (finger stick procedure to determine the amount of sugar in the blood) and insulin (injectable medication to treat diabetes and control blood sugars)…

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 five nurse aides (NA) (NA T, NA U, NA MM, NA QQ and NA UU), who performed resident care, completed a nurse aide training program within four months of their employment in the facility. The facility census was 172. Review of the facility policy titled, Nurse Aide Training Program Policy, dated 05/18/24 showed the following:-The facility, with oversight from the Director of Nursing, shall be responsible for the coordination and/or provision of nurse aide education;-The policy did not include nurse aides completing a nurse aide training program within four months of hire. 1. Review of the employee roster provided by the facility showed NA T was hired on 07/19/23. During interview on 12/8/25 at 10:20 A.M., NA T said the following:-He/She has worked at the facility for two years;-He/She worked as a NA and provided care to residents.-He/She was currently in a CNA class. 2. Review of the employee roster provided by the facility showed NA U was hired on 10/18/23. During interview on 12/8/25 at 10:25 A.M., NA U said 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 observation, interview, and record review, the facility failed to serve food items to residents at a safe and appetizing temperature. The facility census was 172. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperature to ensure food safety; -Record temperature reading on Food Temperature Chart form at beginning of tray line and during the tray line. Take the temperature of each pan of product before serving; -Acceptable serving temperatures include: -Greater than 135 degrees Fahrenheit (F), but preferably between 160 to 175 degrees F, for the following food items: gravy, casseroles, meat, entrees, potatoes, pasta, soup, pureed foods, hot pureed foods, vegetables; -Less than 41 degrees F: hazardous salads, milk, juice, and desserts; -If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discard out of temperature range foods;-Cold foods need to be put in the freezer half hour to three quarter hour prior to meal service. Bring…

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 staff served food items according to the menu for three residents (Residents #36, #127, and #135), in a review of 47 sampled residents, and for one additional resident (Resident #125), who had physician's orders for a mechanical soft diet. The facility census was 172. 1. Review of Resident #36's physician order sheet (POS) for December 2025, showed the resident had an order for a regular diet with mechanical soft texture (original order dated 11/20/25). Review of the facility's resident Diet Orders listing, printed 12/7/25, showed the resident had an order for a regular diet, mechanical soft texture. Review of the facility's diet spreadsheet menu for the breakfast meal served on 12/8/25 (Day 9 of menu cycle) showed residents on a mechanical soft diet were to receive ground sausage patty with gravy.Observation on 12/8/25 at 8:19 A.M., showed staff served the resident a sausage patty that was cut into bite-size pieces. (Staff did not serve the resident ground sausage patty with gravy as directed on 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 observation, interview and record review, the facility failed to provide nourishing snacks when substantial meals were scheduled 14 hours apart. Multiple residents during the group interview said snacks were not specifically offered and were not substantial. One resident (Resident #167), in a review of 47 sampled residents, and three additional residents (Resident #83, #39 and #95) said snacks were not offered on a routine basis at the facility. The census was 172. Review of the undated facility policy, Snacks, showed the following:-Policy: Daily snacks are provided in accordance with the prescribed diet and in accordance with state law. Individual and/or bulk snacks are available at the nurses' station for consumption by residents whose diet orders are not restrictive;-Procedure: At least one serving or a minimum of two of the following four food components is offered for the bedtime snack:-Fruit and/or vegetable or full-strength fruit or vegetable juice;-Whole grain or enriched cereals or breads;-Milk or other dairy products;-Meat, fish, poultry, cheese, eggs;-Combo meat…

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 implement effective pest control measures to eliminate mice from areas throughout the facility, including resident rooms, the facility's dry food storage room, and nourishment kitchens. The facility census was 172. Review of the facility policy, Pest Control Program Policy, revised 05/14/24, showed the following:-It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents;-Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats). 1. During an interview on 12/07/25 at 11:50 A.M., Resident #118 said the following:-Mice were bad at the facility. A few days ago, a mouse ran out from under his/her bed and ran into the bathroom; -Maintenance staff did not check the mouse traps or rebait them. During an interview on 12/7/25 at 11:54 A.M., Resident #42 said the following:-He/She found a mouse in his/her bed;-He/She 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 follow their policy to ensure staff completed weight monitoring, notifications with weight loss, provision of ordered supplements and reevaluation of the care plan for two residents with weight loss (Resident #45 and #103) in a review of 47 sampled residents. The facility census was 172. Review of the facility policy, Weight Monitoring Policy, revised 05/07/24, showed the following: -Purpose: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;-Monitoring weight: weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of 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.

Based on interview and record review, the facility failed to notify one resident's guardian (Resident #1) of eight sampled residents regarding the extent of the resident's injuries and upcoming surgery after the resident was in a physical altercation with another resident. The facility failed to notify the guardian the resident was transported by ambulance to a hospital to be evaluated by an orthopedic specialist, or the results of the evaluation which showed the resident sustained a right humeral fracture (a break in the upper arm bone) that required surgical repair. The facility census was 174. Review of the facility policy, Notification of Changes, undated, showed the following:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his/her authority, the resident's representative when there is a change requiring notification;-Circumstances requiring notification included accidents resulting in injury, potential to require physician intervention;-Significant change in 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.

Based on observation, interview, and record review, the facility failed to report physical abuse to the state agency and law enforcement for one resident, (Resident #2), in a review of seven sampled residents, when Resident #3 assaulted Resident #2. Resident #3 grabbed Resident #2 by the hair and pulled him/her to the ground causing Resident #2 to strike her head on the ground; Resident #3 then struck the resident again in his/her side. Resident #2 was sent to the emergency room for a closed head injury after he/she developed a large hematoma on his/her head. The facility census was 176. Review of the facility's Abuse and Neglect Policy, last revised 06/12/24, showed the following:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident and resident to resident altercations;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide necessary treatment and services for wound care for two residents (Residents #9 and #10) in a review of 22 sampled residents. Resident #9 was being treated for trauma wounds on his/her left foot. Resident #10 was being treated for diabetic pressure wounds on both of his/her feet. The facility did not adequately assess and document the condition of the residents' wounds, clearly identify the sites of the wounds, and failed to ensure the residents arrived at outside wound clinic appointments. Staff failed to complete dressing changes as ordered. Staff failed to ensure residents followed the non-weight bearing status as ordered by the physician and failed to notify the physician when the residents were noncompliant with physician orders. Staff allowed Resident #9 to cleanse the wound on his/her foot during a dressing change without ensuring appropriate infection control methods were followed. The facility census was 174. Based 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 observation, interview and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infections for two residents (Resident #9 and Resident #10) in a review of 22 sampled residents. Staff failed to utilize the appropriate personal protective equipment (PPE), including gowns, when providing care for Residents #9 and #10 who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multi-drug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities). The facility also failed to post EBP signage outside the door and provide PPE near the room for one sampled resident (Resident #9). The facility census was 174. Based on observation, interview and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infections for two residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #2), in a review of 12 residents, was free from abuse when Resident #1, who was being monitored by staff one on one, entered Resident #2's room by the connecting bathroom and took a power strip cord, labeled with Resident #2's name. Resident #2 confronted Resident #1 about the missing power strip cord. Both residents' voices were raised and Hall Monitor A, the one on one staff, said he/she stood in front of Resident #2 to prevent him/her from entering Resident #1's room. Hall Monitor C entered the room to assist, pulled the power strip cord out from underneath Resident #1's leg and gave it back to Resident #2. Hall Monitor C left the room to locate a cord for Resident #1. Hall Monitor A said Resident #1 sat on the side of his/her bed rocking back and forth, looking down at the floor with pinched lips and appeared angry, Resident #1 abruptly jumped up, ran into the hall and into Resident #2's room, and punched Resident #2…

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 safety of two residents (Resident # 9 and #10) who resided on a locked behavioral unit when a physical altercation occurred between the two residents. Hall Monitor D said Resident #9 came at his/her with fists up and tried to attack him/her. Resident #10 told Resident #9 to leave Hall Monitor D alone. Resident #9 turned around and went after Resident #10 and shoved him/her. Resident #10 shoved Resident #9. The residents shoved each other a second time. Staff working on the hall did not have walkie talkies available, or a functioning intercom system to call a Code [NAME] (behavioral health crisis) to access help. Hall Monitor D had to open the locked door to the unit and yell for assistance. The facility census was 177.Based on interview and record review, the facility failed to ensure the safety of two residents (Resident # 9 and #10) who resided on a locked behavioral unit when a physical altercation occurred between the two residents. Hall…

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.

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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure sufficient staff were employed with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for residents who resided on locked behavioral health units. Hall Monitor A was the only staff assigned to the [NAME] Senior 300-Hall when he/she called a Code [NAME] (behavioral emergency) for one resident (Resident #15) in a sample of 24 residents who was experiencing a behavioral health crisis in the outside smoke area. Additional staff did not respond to the Code [NAME] to assist Hall Monitor A. Hall Monitor A became upset, left the unit and left residents unsupervised. A resident-to-resident physical altercation occurred while Hall Monitor A left the unit unsupervised. The facility census was 178.Review of the facility's undated policy, Hall Monitor Duties, showed the following:-The purpose of the hall monitor was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 11 sampled residents, remained free from verbal, mental and physical abuse when Human Resource Manager (HR) A cursed, taunted, threatened and grabbed the resident by the shirt forcefully, putting him/her into a chair. The staff member aggressively and forcefully shoved the resident against the wall during a Code [NAME] (behavioral emergency). The facility census was 176. Review of the facility's policy titled, Abuse and Neglect, revised on 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of staff to resident abuse. Two staff members reported Human Resource (HR) Manager A was abusive to one resident (Resident #1) of 11 sampled residents during a Code [NAME] (behavioral emergency). The facility did not interview or obtain written statements from all witnesses that were present during the Code [NAME] or review video camera footage of the incident. The facility census was 176. Review of the facility's policy titled, Abuse and Neglect, revised on 6/12/24, showed the following: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical…

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 provide protective oversight of one resident (Resident #23), in a sample of 25 resident, when the resident burned the back of his/her left hand with a cigarette during a supervised smoke break. The resident said he/she was mad so he/she burned his/her hand. The resident had a history of self-harm and burned himself/herself earlier in the year with a cigarette. The facility failed to ensure all residents' smoking materials, including a nicotine vape pen (also known as an e-cigarette, a battery-operated device that heats a liquid into an aerosol that the user inhales. The liquid, often called e-liquid or e-juice, typically contains nicotine, flavorings, and other chemicals) were collected from the resident and secured at the end of smoking breaks. Resident #23 was observed by the surveyor with a vape pen in his/her possession, twice on 7/1/25 when it was not a scheduled resident smoking time, and the resident was not monitored by staff. The facility census was 178. Review of the facility policy Smoking Safety…

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 food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 178. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperatures to ensure food safety; -Acceptable serving temperatures are: -Cereal, greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Meat, entrees: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Potatoes, pasta and soup: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Hot vegetables, greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Pastries, cakes, greater than 60 degrees Fahrenheit; -If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discard out of temperature range foods. During an interview on 4/23/25 at 12:50 at 12:50 P.M., Resident #6 said the following: -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 two residents (Resident #7 and #8) in a review of 14 sampled residents were free from physical abuse. Activity Aide A heard Resident #1 call Resident #7 a name and accused the resident of being sexually inappropriate with Resident #1's significant other. Activity Aide A did not report the comments to staff responsible for Resident #1 and Resident #7's care and supervision. Resident #1 went into Resident #7's room and hit him/her multiple times. The residents were separated. Resident #7 was sent to the hospital for evaluation and treatment. Resident #7 returned the facility with a diagnosis of general assault. Hall Monitor D saw Resident #6 leave his/her room and heard the resident say his/her hand hurt from hitting Resident #8. Hall Monitor D stayed in the hallway while Nurse Aide H questioned Resident #6 in the hallway outside of Resident #8's room. While being questioned by staff outside of the room, Resident #6 went back into the room and hit…

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 residents received care and services in accordance with professional standards of practice when staff failed to ensure ordered medications were available for administration for two residents (Resident #15 and #17), in a review of 20 sampled residents. In addition, the facility failed to follow discharge instructions for pain medication after an emergency room visit for one resident (Resident #20). The facility census was 180. Review of the facility's policy, Transcription of Orders/Following Physician's Orders, revised 05/18/24, showed the following: -The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders; -Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident (Resident #1) in a review of 18 sampled residents, was treated with dignity and respect when Licensed Practical Nurse (LPN) A tried to prevent the resident from taking a cup from the dining room back to his/her room. The resident attempted to take the cup from LPN A and the drink mix ended up on both the resident and LPN A. The facility census was 181. Review of the facility policy Dignity and Respect, dated 6/29/23, showed the following: -Every resident had a right to be treated with dignity and respect; -All staff would speak to and treat all residents with dignity and respect. 1. Review of Resident #1's Care Plan, updated 7/28/24, showed the following: -Diagnoses of depression, weakness and abnormal gait and mobility; -The resident had behaviors of agitation and anxiety, triggers of being yelled at and arguing. Staff should avoid triggering the resident. The resident's coping skills were visiting peers, watching television,…

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 proper serving size for residents with a regular diet order was given to each resident or an alternative vegetable given if the resident did not like the vegetable served specified on the menu. The facility census was 178. Review of the undated facility policy, Standard Portions, showed the following: -Uniform food portions shall be established for each diet and served to all residents; -Instruct all dietary employees in the procedures of standardized portions. The dietary manager will monitor the cooks and their use of portion control utensils on tray line. Dietary employees will follow the portion sizes listed in the menu binder. Review of the undated facility policy, Substitutions, showed the following: -Substitutions in the menu actually served, being of equal nutritional value, will be recorded directly on the menu, or on substitutions list and filed in accordance with licensure regulations; -Procedure: Substitutions of a menu item may occur when: 1. Item or ingredient is unavailable; 2. Items 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.

Based on observation, interview and record review, the facility failed to ensure food served to residents was palatable and served at a safe and appetizing temperature. The facility census was 178. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperatures to insure food safety; -Acceptable serving temperatures are: -Meat, entrees: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Potatoes, pasta and soup: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Hot vegetables: greater than 135 degrees but preferably 160 degrees to 175 degrees Fahrenheit; -Pastries, cakes: greater than 60 degrees Fahrenheit; -If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discard out of temperature range foods. 1. During an interview on 6/20/24 at 9:49 A.M., Resident #2 said the following: -The food did not taste good and there was no variety; -The food was not warm when served; -He/She ate…

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 one resident (Resident #1) in a review of six sampled residents, remained free from misappropriation of property when Hall Monitor A took $40.00 of the resident's money by cash app (an electronic application on a cellular telephone in order to receive and send money electronically). The facility census was 169. On 5/15/24 at 12:40 P.M. the administrator was notified of the past noncompliance which occurred on 5/8/24. On 5/9/24 the administrator became aware of the violation of misappropriation of resident money. Upon discovery, the facility suspended Hall Monitor A, conducted an investigation, and notified appropriate parties. Staff reviewed the facility misappropriation policy, and all facility staff was educated on the facility misappropriation policy. Hall Monitor A was terminated. The deficiency was corrected on 5/14/24. Review of the facility Abuse and Neglect Policy dated 4/30/24 showed the following: -The purpose was to outline procedures for reporting and investigating complaints of abuse, neglect, 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 sufficient staff were employed with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for residents who resided on locked behavioral health units. The facility failed to ensure staff who provided one on one (1:1) supervision to residents were fully informed of the reason for the 1:1 monitoring they provided. The facility pulled staff from activities, laundry, housekeeping, and maintenance, away from their normally assigned duties, to monitor residents' smoking times and to provide 1:1 monitoring of residents who had experienced a behavioral health crisis. This resulted in the Hangout (common indoor/outdoor recreation area that residents from all units shared) being closed or monitored by one activity staff member which limited the times in which residents could access the area. The facility census 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 ensure residents or their representatives had the right to participate in the development and implementation of the resident's person-centered plan of care when facility staff did not invite two residents (Resident #1 and #3) or the residents' representatives to routine care plan meetings. A sample of 16 residents was selected for review. The facility census was 178. Review of the facility policy, Comprehensive Care Plans and Base line Care Plans, dated 1/19/22, showed the following: -The purpose of this policy is to ensure that the facility develops a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; -A licensed nurse, that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals otherwise known 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 observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2 and #11), of 14 sampled residents with mental disorders who lived on secured behavioral units, received individualized treatment and services to meet their needs. Residents displayed verbal and physical behaviors on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 175. Review of the facility's Behavioral Emergency Policy, last revised 1/5/23, showed the following: -The purpose is to provide safe treatment and humane care to the residents in a behavioral crisis, to outline steps to follow to correctly care for the residents in a behavioral crisis and to ensure that the resident is not being coerced, punished or disciplined 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.

Based on observation, facility document review, and interviews, the facility failed to ensure the kitchen floors, walls, cabinets, and equipment were kept clean and in good repair; failed to ensure staff utilized proper hand hygiene; and utilized appropriate thawing methods in the kitchen. This deficient practice had the potential to affect 178 of 178 residents who received meals prepared in the facility. The census was 178. Findings include: Review of the Food Safety and Sanitation Checklist, dated 09/21/23 and signed by the Registered Dietitian (RD), revealed the temperature logs for the dish machine were missing the last several days, not all foods were stored off the floor, the microwave and the can opener were not clean, and the fryer was not clean. Review of the undated kitchen cleaning schedule revealed a section for the duty, date, employee name, and manager mange. All the sections were blank. 1. During the kitchen tour on 11/13/22 at 10:04 AM with the Dietary Manager (DM), the following observations were made: -The instructions for the dish machine revealed to wash at 160…

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 interviews, record review, and facility policy review, the facility failed to ensure a water management plan was in place to prevent a potential Legionella (a potentially dangerous water-borne bacterium capable of causing pneumonia) outbreak in the facility of 42 sample residents. The census was 178. The findings include: Review of the facility's undated policy titled, Legionnaire's Policy read, in pertinent part, Most residents become infected (with Legionnaires' Disease) when they inhale microscopic water droplets containing Legionella bacteria. This might be the spray from a shower, faucet or whirlpool, or water dispersed through the ventilation system in a large building; and Prevention: Outbreaks of Legionnaires disease are preventable, but prevention requires meticulous cleaning and disinfection of water systems, pools, and spas. Review of the facility's comprehensive infection control program revealed nothing to indicate the facility had a program in place to monitor and prevent Legionella in the facility's water system. During an interview on 11/19/23 at 2:19 PM,…

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 promote and facilitate resident self-determination through support of resident rights to make choices about aspects of his or her life in the facility that are significant to the resident for four residents (Resident (R)27, R47, R98, and R5) of five residents reviewed for choices of 42 sample residents. The facility failed to ensure a resident's right to smoke, unless medically contraindicated for R27; the resident's right to sexual relations for R47; and the resident's right to receive additional food for R98, R27, and R5. The census was 178. Findings include: Review of the facility's statement of Resident Rights, dated 07/05/23, revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility. The Facility must protect and promote the rights of each resident. Review of the Title XXXI Trusts and Estates of Decedents and Persons under…

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 review of facility procedures, the facility failed to ensure housekeeping and maintenance services were conducted to maintain a sanitary and orderly interior and to protect residents' property from loss or theft for five of 10 units. This had the potential to affect 100 residents on these units. The census was 178. Findings include: 1. Observation of bedroom [ROOM NUMBER] on 11/14/23 at 10:00 AM revealed a one foot by one foot stain on the floor in the entrance to the bedroom. In addition, the common room floor on 300 unit was very dirty with wheelchair tracks in the floor. None of the bedrooms on the unit, or bedrooms 302 through 315 had been swept or mopped. During an interview on 11/15/23 at 1:35 PM and again at 3:15 PM, the Director of Housekeeping (DHK) verified the stain on the floor, same size and description as stated earlier. The DHK confirmed the stain and stated the housekeeper for the unit mopped the floors each day. During an interview on 11/14/23 at 10:26 AM,…

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 timely reporting of allegations of abuse for five residents (Residents (R)89, R137, R73, R21, and R31) of 42 sample residents. This failure could place residents at increased risk of abuse. The census was 178. Findings include: Review of the facility's policy titled, Abuse and Neglect Policy, revised 01/05/23, revealed the facility must ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment or sexual assault including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the SSA. A final report of the investigation will be sent to the Department of Public Health/Department of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of potential abuse were thoroughly investigated for three residents (Residents (R)31, R89, and R137) of 11 residents reviewed for abuse out of 42 sample residents. The census was 178. Findings include: Review of the facility policy titled Abuse and Neglect Policy, revised 01/05/23, revealed that once the Administrator or designee determines that here is a reasonable possibility that mistreatment occurred, the Administrator or designee will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident. The investigation will include assessment of all residents involved and interventions to ensure protective oversight of all residents and involved residents in the Facility/ Interventions could include nursing staff separating alleged perpetrator and alleged victim including moving the residents to separate halls, physician involvement,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an individualized and consistent program of activities for four residents, (Residents (R) 1, R59, R5, and R27), of eight residents reviewed for activities out of 42 sampled residents. Activities were not provided routinely for residents per their assessed preferences and plans of care. In addition, activities posted on the activity schedules in each of the facility's units were not provided per the posted schedule. The census was 178. Findings include: Review of the facility's policy titled, Activities Policy, dated 07/19/23, read in part the purpose of this policy is to ensure that all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being and to ensure that an ongoing program of activities is designed. The Life Enhancement Director will monitor large and small group activities, 1:1…

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 policy review, the facility failed to follow menus for therapeutic diets, plan a vegan diet in advance, and serve substitutes of similar nutritive value for the facility and five (Residents (R) 428, R27, R4, R158, R59) of 16 residents reviewed for menus of 42 sample residents. The census was 178. Findings include: Review of the facility's policy, Dietary Menu Planning and Nourishment, revised 07/05/23, revealed the food and nutritional needs of residents shall be planned to meet the recommended dietary allowances as adjusted for age, sex, and activity, in order to provide menus that include safe and adequate intake of essential nutrients. Menus must be followed as written with the following exception: When ethnic, cultural, geographic, or religious habits of the resident population require a substitution. When substitutions are made, the replacement item must be: 1. Compatible with the rest of the meal, 2. Comparable in nutritive value. Plan and prepare…

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, record review, interviews, and facility policy review, the facility failed to provide bedtimes snacks that were suitable and nourishing for three residents (Resident (R)27, R85, and R158) of four residents reviewed for bedtime snacks. The census was 178. Findings include: Review of facility's policy, Diabetic Snacks, dated 12/12/22, revealed daily diabetic snacks are provided with the prescribed diet and in accordance with State Law. Individual and/or bulk snacks are available at the nurses station for consumption by resident whose diet orders are not restrictive. At least one serving or a minimum of two of the following four food components if offered for the bedtime snack: 1. Fruit and/or vegetable of full-strength fruit or vegetable juice. 2. Whole grain or enriched cereal or breads. 3. Milk or other dairy product. 4. Meat, fish, poultry, cheese, eggs. 5. Combo meat sandwiches. Review of the facility week two menu cycle revealed the evening snack included half cup of a fruit drink, one…

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 two of two outside dumpsters remained closed. The census was 178. Findings include: Review of the 2022 FDA Food Code, dated 01/18/23, revealed outside receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. Review of the Food Safety and Sanitation Checklist, dated 09/21/23 and signed by the Registered Dietitian (RD), revealed the garbage containers were not covered when not in use. During an observation on 11/15/23 at 10:10 AM, the lids on two large dumpsters located behind the facility were open, exposing the garbage bags inside. During an observation and interview on 11/17/23 at 2:30 PM, two large dumpsters located behind the facility were observed with the Dietary Manager (DM). The lid to the dumpster closest to the facility was open and exposed the garbage bags inside. Trash debris was heavily scattered in and around…

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 with facility staff, the facility failed to ensure two of nine total units had handrails on either side of the corridor. This has the potential to affect 41 residents on the 300 and 700 units. The census was 178. Findings include: Observation on 11/15/23 at 2:40 PM revealed no handrails in the main corridor between bedrooms [ROOM NUMBERS] for six feet on one side of the corridor. Interview with the Maintenance Director (MD) on 11/18/23 at 10:45 AM revealed he felt that due to a fire extinguisher in the middle of the six-foot section, a handrail was not necessary. Observation on 11/15/23 at 2:50 PM revealed a 14-foot section on both sides of the corridor leading into the 300 [NAME] unit lacking handrails. Interview with the MD on 11/18/23 at 11:00 AM verified the lack of handrails entering the 300 [NAME] unit. Residents were observed passing through the corridor on all days of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the rights of two of eight residents reviewed for physical abuse (Resident (R) 21 and R70) to be free from physical abuse by R73 and R85 out of a total sample of 42 residents. The census was 178. Findings include: Review of the facility's policy titled Abuse and Neglect Policy, revised 01/05/23, revealed VI. Prevention and Identification. The facility will identify and correct by providing interventions in which abuse, neglect or misappropriation of resident property is more likely to occur. This will include, assessment of the physical environment, which may make abuse or neglect more likely to occur, such as more secluded areas in the facility, the deployment of staff on each shift in sufficient numbers to meet the resident's needs and that the staff are knowledgeable of resident care needs. Supervisors should identify inappropriate behaviors such as derogatory language and neglectful care. Prevention will also include assessment care…

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 precautions were implemented to ensure one resident's smoking environment was safe for one resident (Resident (R) 48) of 42 sample residents. The census was 178. Findings include: 1. Review of R48's admission Record, dated 11/19/23 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), schizophrenia, and extrapyramidal and movement disorder. Review of R48's Brief Interview for Mental Status (BIMS), dated 07/08/23 and found in the EMR under the Assessments tab, indicated a score of ten out of 15 which indicated R48 was moderately cognitively impaired. Review of R48's Smoking Care Plan, dated 08/03/22 and found in the EMR under the Care Plan tab read R48 is at risk for injury related to being a smoker. He/She is a supervised smoker. He/She had a history of burning his/her eyebrows,…

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, interview and record review the facility failed to ensure one (Resident (R) 20) of 42 sampled residents maintained acceptable parameters of nutritional status such as usual body weight. The census was 178. Findings include: Review of the facility policy titled Weight Loss, original date of 04/06/17 and revised date of 06/29/23, revealed a 10% weight loss such as this case requires notification of the physician by the Director of Nursing, dietician consult, orders to increase consumption, supplements, and increased supplements if necessary. Those residents that have weight loss concerns should be weighed weekly. 1. Review of R20's Diagnosis tab in the electronic medical record (EMR) revealed diagnoses which included pervasive developmental disorder, unspecified attention deficit disorder, obsessive compulsive disorder, histrionic personality disorder, psychoactive substance dependence, schizoaffective disorder, bipolar disorder, and food in respiratory tract causing asphyxiation. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure adequate and sanitary respiratory services for two (Residents (R) 172 and R86) of two residents reviewed for respiratory care out of 42 sample residents. Orders were not obtained for R172's use of oxygen and R86's oxygen tubing and concentrator filter were not changed or labeled appropriately. The census was 178. Findings include: The facility's oxygen administration policy was requested on 11/18/23 at 1:29 PM and again on 11/20/23 at 10:30 AM. The policy was not provided to the survey team prior to survey exit on 11/20/23. Review of the facility's policy titled, Transcription of Orders/Following Physician's Orders Policy, dated 09/20/23, read in pertinent part, the purpose of the policy was to outline procedures in accurately transcribing physician's orders and to ensure that all physician's orders are followed. That a process was in place to monitor nurses in accurately transcribing and following physician's orders. Upon receiving a physicians…

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 monitoring of behaviors and side effects of psychotropic medications and failed to ensure risk and benefit review was obtained for administration of psychotropic medications for two of five residents (Resident R61, and R172) reviewed for unnecessary medications of 42 sample residents This facility failure placed these residents at risk for unnecessary medications being administered. Findings include: 1. Review of R61's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/23 located in the MDS tab of the electronic medical record (EMR) revealed R61 was initially admitted on [DATE]. Review of R61's quarterly MDS with an ARD of 09/16/23 located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R61 was cognitively intact. R61 had a depressed mood, physical behavior toward others, and took antipsychotic medications on a routine basis. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain walls, floors, furniture, window coverings, doors, bathroom fixtures, mattresses, floor drains, shower rooms, main kitchen beverage preparation sink; and failed to provide a safe, clean, comfortable, and homelike environment through the facility. The facility census was 170. Observations on 03/29/21 between 9:50 A.M. and 4:40 P.M., showed the following: -The single-well sink, located next to the ice machine at the beverage preparation area in the kitchen, was not functional. The sink well was covered with gray serving tray. The drain pipe in the bottom of the sink was missing and was not connected. A stack of Styrofoam cups were placed on a section of piping under the sink covering up the open end of drain pipe. -In occupied resident room [ROOM NUMBER], two 3 inch round holes in the wall behind the residents bed covered with dried, cracked joint compound and no paint. The bathroom floor was covered in a thick layer of 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 observation, interview, and record review, the facility failed to ensure the ice machine was free of a buildup of debris; failed to maintain the range hood to be free of grease and debris; failed to maintain the floor in front of the fryer to be free of grease and debris; failed to cover trash cans when not in use; failed to maintain the walk-in cooler at 40 degrees F (Fahrenheit) or colder; failed to ensure leftover food items were discarded; failed to ensure sanitary practices were used in scooping ice and handling ready to eat food items; and failed to ensure the can opener was free of a buildup of debris. The census was 170. Review of the undated facility policy, Ice Machine, showed the following procedures: -Daily: Wash exterior machine, use sanitizing solution and clean cloth, and allow to air dry; -Monthly: Remove ice, wash inside machine, use sanitizing solution and clean cloth and allow to air dry. Review of the undated facility policy, Hoods and Filters, showed the following: -Wash hood with detergent solution using a brush, sponge, or cloth; -Remove filters 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 administration of the facility failed to use resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility census was 170. 1. Observations during survey from 3/29/21 through 4/15/21 showed the following: -No system for administration and tracking of influenza and pneumococcal vaccines; -No yearly staff education regarding care of residents with dementia; -Staff not following infection control measures consistently; -Dietary services not provided in a sanitary environment and not provided to meet residents individual needs on an ongoing basis; -Medication administration not provided consistently according to professional standards and without errors; -Pharmacy services and procedures not followed during count and control of narcotic medications. Antipsychotic medications not consistently reviewed and evaluated for possible dose reduction; -Behavioral health services to ensure…

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 the medical director worked with the facility's clinical team to assure residents attain or maintain their highest practicable physical, mental and psychosocial well-being and failed to ensure the medical director participated and was involved in conducting the Facility Assessment and the Quality Assessment and Assurance (QAA) Committee. 1. During an interview on 4/12/21 at 4:30 P.M., the administrator said she became the facility administrator in June 2020. She verified the medical director did not attend the QAA committee meetings. During an interview on 4/12/21 at 3:58 P.M., the Director of Nursing (DON) said the following: -The QAA committee met monthly and staff gathered information for the meetings weekly; -The committee consisted of all department heads, consultants, laboratory, pharmacy, and they tried to include direct care staff as well if there was an issue in their department; -The medical director did not attend the meetings; -The facility sent notes from the QAA meeting to the medical director 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 interview and record review, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against influenza and pneumococcal disease in accordance with national standards of practice as indicated by the current Centers for Disease Control (CDC) guidelines. Facility staff failed to administer pneumococcal vaccines when requested by the resident or the resident's responsible party for 21 residents (Resident #143, #83, #63, #6, #124, #159, #31, #9, #134, #100, #157, #175, #43, #138, #177, #27, #135, #45, #165, #69, and #8) in a review of 65 sampled residents and one additional resident (Resident #145). Resident #157 and Resident #45 developed pneumonia and were hospitalized . Facility staff also failed to administer influenza vaccines when requested by the resident or the resident's responsible party for 19 residents (Resident #143, #83, #63, #6, #124, #159, #31, #9, #134, #100, #157, #175, #43, #138, #177, #27, #38, #65, and #104) and one additional resident…

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 treated residents in a manner that maintained their dignity when staff utilized Styrofoam plates and bowls, plastic silverware and disposable plastic cups for meal service. The facility also failed to ensure staff spoke to one resident (Resident #175) in a dignified manner; failed to implement interventions following incidents of smoking in unauthorized areas or when in possession of smoking products during unauthorized smoking times which did not infringe upon the rights of three residents (Residents #22, #130, and #152); and failed to post the residents' rights on each unit where it would be visible to residents. The facility census was 170. Review of the facility policy, Resident Rights, last revised 3/22/17, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. The facility must protect 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 record review and interview, the facility failed to provide quarterly statements, including written documentation of deposits and withdrawals from the resident trust, to residents and their guardians or legal representatives. The facility managed resident funds for 127 residents. The facility census was 170. Review of the facility's policy, Resident Trust, dated 3/1/17, showed the following: -A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request. All accounts shall be reconciled monthly. The individual financial record shall be made available by statements on a quarterly basis; -The Resident Trust Clerk is responsible for sending out the quarterly statements; -Make copies of all statements and date stamp them with a date they were mailed. Retain the copies for the facility files; -Statements should be sent to the resident and his/her guardian or legal representative. 1. Review of Resident #83's Trust Transaction History report, dated 11/1/20 through 3/31/21, showed the resident maintained 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 record review and interview, the facility failed to timely submit an accounting of residents' personal funds to the Department of Social Services following death of four residents (Residents #305, #306, #307, and #308), who received aid from the Department, and failed to timely return personal funds to one resident (Resident #302) upon discharge from the facility. The facility census was 170. Review of the facility's policy, Resident Funds, dated [DATE], showed the following: -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident's trust account balance and personal possessions; -The resident shall be issued a check for all remaining personal funds in his/her account within five days of discharge; -Upon death of a resident who received aid or assistance from the Department of Social Services, the resident trust clerk shall submit in writing on form MO886-3103 a complete accounting of the resident's remaining personal funds. This must be submitted within 30…

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 complete required employee background screenings by failing to provide documentation of criminal background checks (CBC), employee disqualification list (EDL) checks, and/or nurse aide registry checks completed prior to employment for eight of 14 newly hired employees (hired since the last survey). The facility census was 170. 1. Review of the facility's policy and procedure, Pre-Employment Screening and Employee Screening, dated 03/2021, showed the following: -Human Resources department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States and, if applicable, is duly licensed or certified to perform the duties of the position for which they applied; -Applicant shall complete a Request for Criminal Records Check and Request for Consent to Employee Disqualification Check Form. A criminal background check (CBC) should be done through 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 interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment and misappropriation of resident property were reported to the state survey agency immediately but no later than two hours after the allegation was made regarding three residents (Resident #43, #52, #152) in a review of 65 sampled residents and for one additional resident (#304). The facility also failed to ensure the results/conclusions of investigations from self-reported allegations were sent to the State Survey Agency within five working days of the incident for nine sampled residents (Resident #6, #10, #17, #43, #52, #63 #102,#152 and #169) and eight additional residents (Resident #3, #19, #57, #106, #139, #579, #679 and #680). The facility census was 170. Review of the facility policy Abuse and Neglect last reviewed 7/2020 showed the following: Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to define terms of abuse/neglect and misappropriation of funds 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 complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #32, and #62), in a review of 65 sampled residents and one additional resident (Resident #48), within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 170. 1, Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a plan of care consistent with residents' specific conditions, needs, and risks for five residents (Residents #31, #60, #67, #141, and #144), in a review of 65 sampled residents. The facility census was 170. Review of the facility policy, Comprehensive Care Plans and Baseline Care Plans, last revised 2/1/20, showed the following: -The purpose of this policy is to ensure the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment; -A registered nurse (RN) that has been designated by the facility administration will coordinate each assessment with the appropriate participation of health professionals otherwise known for the purposes of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff)/care planning…

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 follow physician orders and report blood sugar levels outside of set parameters to the physician and failed to administer scheduled insulin as ordered to one resident (Resident #178) with a hemoglobin A1C (test used to determine blood glucose levels over three months) last documented at 15.6 (normal range 4.1 to 6.1); failed to flush one resident's (Resident #159)'s peg tube (tube inserted through the abdominal wall for nutrition) before administering medications or enteral feedings according to acceptable standards of practice; failed to document accuchecks (finger stick blood test that measures the amount of glucose in the blood) were completed for three residents (Resident #56, #62, and #176) as ordered by the physician; failed to administer medications as ordered for four residents (Residents #52, #62, #157 and #180); failed to properly identify and label medications removed from their original packaging, and failed to document on 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 four residents (Residents #31, #32, #62 and #69), in a review of 65 sampled residents, and two additional residents (Residents #48 and #145), who required assistance with activities of daily living received the necessary care and services to maintain good grooming and personal hygiene. The facility census was 170. Review of the facility policy, Care of Nails (fingers and toes), dated 2/12/01, showed the following: -Soak the hands for five minutes in a basin of lukewarm water; -Scrub the nails gently with a brush and remove from basin; -Put hands on a towel, trim and clean nails, if necessary. A nurse is to cut a diabetic resident's fingernails. Review of the facility's policy, Perineal Care, dated 10/22/02, showed the following: -Purpose: To keep the female and male genital area clean; -Procedure: Wash your hands thoroughly before beginning the procedure; Apply disposable gloves; Wash perineal area with soap and water and rinse…

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 Surveyor: [NAME], [NAME] 7. Record review of Resident #85's Pre-admission Screening and Resident Review (PASRR), dated 9/21/16, showed if the resident were admitted to a nursing facility, he/she would need services of structured socialization activities to diminish tendencies toward isolation and withdrawal. Review of the resident's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -The resident's diagnoses were autistic disorder, attention deficit hyperactivity disorder, bipolar disorder, mood disorder and major depressive disorder. Record review of the resident's care plan, revised on 1/20/20, showed the following: -The resident required encouragement and reminders to attend groups, he/she participates in the [NAME] of Focus(WOF) program; -The resident will express satisfaction with the type of activities and level of activity involvement when asked; -The resident will participate in activities of choice; -Modify daily schedule, treatment plan as needed to accommodate…

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 ensure residents with limited range of motion (ROM), received appropriate treatments and services to increase ROM and/or prevent further decrease in ROM. The facility failed to provide restorative therapy services for two residents (Residents #32 and #104) in a review of 65 sampled residents and two additional residents (Residents #48 and #51), who the facility identified as in need of restorative therapy services and who had physician orders for restorative therapy services. The facility census was 170. Review of the 2001 revision of the Nurse Assistant in a Long-Term Care Facility manual showed the reasons for providing restorative nursing included: -Follow basic nursing care measures to maintain present function and keep resident functioning at his/her highest potential; -Restore lost function after illness or injury; -Prevent complications of immobility; -Goals of restorative nursing were to keep the resident functioning at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were clean and free of body odors for three residents (Resident #32, #62, and #69 ) in a review of 65 sampled residents and one additional resident (Resident #48). The facility also failed to provide sufficient staffing to ensure medications were passed timely for two sampled residents (Residents #56 and #157). Additionally, the facility also failed to provide sufficient staffing to ensure restorative nursing services were provided as ordered for residents to maintain or improve in activities of daily living (ADLs) for two sampled residents (Resident #32 and #104), and two additional residents (Resident #48 and #51). The facility also failed to provide adequate staffing to ensure safety during smoke time for one additional resident (Resident #145) which resulted in the resident rolling down an incline and into a fence. The facility census was 170.…

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 ten residents (Resident #6, #52, #138, #124, #152, #131, #178, #85, #102 and #169) of 65 sampled residents and three additional residents (Resident #94, #139 and #158), with mental disorders who lived on secured behavioral units, received individualized treatment and services to meet their needs. Residents displayed verbal and physical behaviors directed towards staff and other residents on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 170. Review of the facility's [NAME] of Focus Program: An Accountability and Responsibility System. A Comprehensive Care Plan for the Mentally Ill, Second Edition 2019, showed the following: -The vision of the program is…

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 inventories of schedule II controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule III through IV controlled substance medication were reconciled by at least two qualified staff to ensure accountability. Further review showed Certified Medication Technician (CMT) YY documented administering narcotics to residents but did not document he/she had removed the medications from the medication cards and documented removing medications from the medication cards when he/she had not. The facility also failed to inventory a schedule IV controlled substance medication for one resident (#58) that requested the medication and was unable to be found by staff. The facility census was 170. Review of the facility policy Counting Narcotics between Shifts dated 7/31/06 showed the following: Purpose: To ensure that the residents receive their medications as ordered and to ensure that all narcotic medications…

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 three residents (Residents #31, #100 and #135) of 65 sampled residents and two additional residents (Residents #101 and #148) orders for as needed (PRN) psychotropic medications (medications that affects brain activities associated with mental processes and behavior), were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility also failed to ensure gradual dose reductions (GDR) (the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.), were attempted or the physician/psychiatrist documented the rationale for not attempting a GDR on antipsychotic and hypnotic medications for one sampled resident…

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 administer medications with an error rate of less than five percent (%) for three residents (Resident #11, #65 and #69), in a review of 65 sampled residents, and for two additional residents (Residents #78, and #144). There were 55 opportunities with 12 errors, which resulted in an error rate of 21.8%. The facility census was 170. Review of the facility's policy, Medication Administration and Monitoring, dated April 2017, showed the following: -Medications are to be given per the physician's orders; -Medication error is defined as a mistake in prescribing, dispensing, or administering medications. A medication error occurs when a resident receives an incorrect medication, medication dose, dosage form and quantity, route of administration, concentration, or rate of administration. This also includes failure to administer the medication at the appropriate times or administering the medication on an incorrect schedule; -Dispense the medication, if time is specified, give medication as ordered on 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.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when facility staff failed to date the label of multi-use vials of insulin when first accessed and administered insulin from the opened, undated multi-use vial of insulin. The facility failed to ensure outdated/expired medications were removed from the medication cart. The facility census was 170. Review of the facility policy Blood Glucose Monitoring dated 4/2017 showed no information regarding storage and labeling of multi-use insulin vials. 1. Review of the Insulin Administration Student Reference Manual, Revised 2001 showed the insulin expiration date must be checked on the vial. Outdated insulin must not be given. 2. Review of www.drugs.com showed the following: -Use opened Levemir (long-acting insulin medication used to lower blood glucose levels administered by injection) insulin within 42 days, discard any remaining medication after 42 days; -Store opened Lantus insulin (a long acting insulin…

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 residents received food to meet their nutritional needs, and failed to ensure residents received condiments with meals/snacks. The facility census was 170. Review of the undated facility policy, Dietary Department Objectives, showed the following: -The purpose and scope of the dietary department is to provide a program that meets the nutritional needs of all residents. Standardized methods are practiced in the preparation and presentation of therapeutic and/or modified diets in accordance with primary care physician's orders. Consideration is given to the resident's physical, psychological and social needs. Recognition is also given to the patient's individual preferences and eating habits, which are sometimes influenced by cultural or religious background. The recommended standards are adjusted based on primary care physician's order; -Dietary department supervision is to be under the guidance of a full-time person qualified by…

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 meals were served to meet the needs of the residents. The facility failed to provide a spreadsheet menu that could be utilized by staff when preparing and serving meals, failed to follow a spreadsheet menu by not providing the correct portion sizes for supper on 3/29/21 for residents on a pureed or a mechanical soft diet; failed to prepare and serve all items according to the spreadsheet menu for lunch on 3/30/21 and failed to serve appropriate portion sizes to the residents in the Assist to Dine dining room. The facility also failed to post menus in visible accessible locations for the residents. The facility census was 170. Review of the undated facility policy, Cycle Menus, showed the following: -Menus are implemented by the dietary manager in conjunction with the registered dietician; -When changes in the menu are necessary, the changes must provide equal nutritive value. Menu changes are made on the menu (posted in dietary) for regular and therapeutic diets before the meal is served, or on 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 observation, interview, and record review the facility failed to ensure staff prepared and served food at a safe and appetizing temperature. The facility also failed to prepare and serve food items by methods to conserve flavor and appearance. The facility census was 170. Review of the undated facility policy, Food Temperatures, showed the following: -Foods will be served at proper temperature to ensure food safety; -Record reading on Food Temperature Chart form at beginning of tray line and during the tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. 1. During an interview on 3/29/21 at 10:22 A.M., Resident #157 said the food was lousy. The hot foot was always served cold. Once in a while the food was warm; the residents got excited about luke warm because it was never hot. The eggs were watery, cold and rubbery. The vegetables were over cooked and mushy. The food had no flavor and was bland. During an interview on 3/29/21 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.

Based on observation and interview, the facility failed to ensure food was prepared to the proper texture and consistency for residents on pureed diets. The facility identified five residents on a physician-ordered pureed diet. The facility census was 170. Review of the undated facility policy, Standardized Recipes, showed the following: -Standardized recipes will be used for all products prepared; -Use standardized recipes provided with menu cycle; -The dietary manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added the recipe file, they must be written, standardized and approved by the registered dietician; -Recipes will have diet modifications noted. Review of the facility policy, Pureed Diet, dated 2017, showed the following: -The pureed diet is designed for individuals who have difficulty in swallowing or who cannot chew foods of the dental soft (mechanical soft) consistency; -The pureed diet follows the regular diet with alterations in the consistency of foods to a pureed consistency as needed; -All foods are prepared in a 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, interview, and record review, the facility failed to ensure three sampled residents (Residents #69, #175, and #178), in a review of 65 sampled residents, and one additional resident (Resident #89), were served food items that accommodated their allergies, food intolerances and preferences. The facility failed to provide appealing options of similar nutritive value to residents who chose not to eat the items initially served at the meal. The facility census was 170. Review of the undated policy, Dietary Department Objectives, showed the following: -The purpose and scope of the dietary department is to provide a program that meets the nutritional needs of all the residents; -Standardized methods are practiced in the preparation and presentation of therapeutic and/or modified diets in accordance with the primary care physician's orders; -Consideration is given to the resident's physical, psychological and social needs; -Recognition is also given to the patient's individual preferences and eating habits, which are sometimes influenced by cultural or religious…

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 residents who were sleeping or required assistance to get to the dining room were provided meals and were not omitted from meal service. The facility census was 170. Review of the undated facility policy, Tray Sequence, showed the cook and charge nurse will determine the tray card sequence based on the current situation. This provides an efficient sequence of trays for delivery that help to assure each resident receives his/her tray while the food is at the correct temperature. Review of the undated facility policy, Nursing Department Responsibilities at Mealtime, showed the following: -The nursing department is responsible for distributing food trays to all residents in the facility that are served in their rooms and dining rooms; -The nursing department is responsible for preparing residents for meals and for assisting residents who are unable to feed themselves; -The nursing department is responsible for distributing food trays…

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 provide special equipment for four residents (Residents #38, #62, #157, and #165), in a review of 65 sampled residents, and five additional residents (Residents #7, #8, #24, #93, and #145), who the facility identified needed the equipment to assist with eating and drinking. The facility census was 170. Review of the undated facility policy, Adaptive Equipment-Feeding Devices, showed the following: -Adaptive feeding equipment is used by residents who need to improve their ability to feed themselves in order to enable residents with physically disabling conditions to improve their eating functions; -Procedure: Upon request, verbal or written, from dietary or nursing, a therapist, when possible, will assess any potential problems; -If the assessment indicates a feeding problem can be improved with therapy intervention (treatment and/or adapted equipment), a referral will be obtained from the attending physician; -Adaptive equipment will be provided by the therapy department. Equipment may 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.

Based on interview and record review, the facility failed to provide documentation that the Quality Assessment and Assurance (QAA) committee met on a quarterly basis and included the appropriate attendees. Additionally, the facility failed to identify, develop, implement, monitor and evaluate system problems. The facility census was 170. Review of the facility's undated Quality Assurance Performance Improvement (QAPI) plan showed: - Purpose: to provide quality excellence in resident care and do a root cause analysis for identified areas of concern and improvement; - The QAA committee will review data from areas the facility believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for the organization; -The administrator is responsible for assuring all QAPI activities and required documentation is provided to the corporation.; - All department managers, the administrator, the director of nursing (DON), antibiotic steward, the infection control and prevention officer, medical director, consulting…

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 8. Observation on 3/29/21 at 11:37 A.M. showed Dietary Staff P worked in the kitchen and wore an N-95 mask below his/her mouth and nose. Observation on 3/29/21 at 11:49 A.M. showed Dietary Staff P prepared meal trays for the residents from the steam table. Dietary Staff P placed nacho meet onto tortilla chips. Dietary Staff P wore his/her N-95 mask below his/her nose. Observation on 3/29/21 at 12:32 P.M. showed Dietary Staff P assisted with preparing residents' trays during the meal service. He/She wore his/her face covering below his/her nose and mouth during the entire meal service. Observation on 3/29/21 at 2:31 P.M. showed the assistant dietary manager did not wear a mask at all while working in the kitchen. Observation on 3/29/21 at 2:32 P.M. showed the Dietary Staff M and Dietary Staff N did not wear a mask at all while working in the kitchen. Observation on 3/29/21 at 4:07 P.M. showed Dietary Staff Q scooped ice from the ice machine. He/She wore his/her N-95 mask below his/her chin. Observation on 3/29/21…

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 an effective pest control program to address roaches and mice in the facility. The facility census was 170. 1. Review of the administrator's email, dated 04/15/2021, showed the administrator documented the facility did not have a policy for pest control. 2. Observations of the facility on 03/29/21 between 8:50 A.M. and 4:20 P.M., showed the following: -In the 100 hall dining area, the windows were open and there were no screens on the windows. The back exit door had a three inch by four inch area at the bottom that was rusted away and daylight could be seen, the side exit door had a ½ inch gap all the way down the side and the door frame was rusted and daylight could be seen; -In room [ROOM NUMBER] the window was open and the window screen was torn at the bottom; -In room [ROOM NUMBER] there were mouse feces in all of the bedside table drawers; -In the 700 hall resident smoking room there was a ¼ inch gap on both sides 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 interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 170. 1. Review of the facility Training Required for Facilities document, dated 5/2020, showed the following: -Training for Certified Nurse Assistants (CNA) staff to meet 12 hours required training topics; -Hand hygiene; -Safe transfers; -Restorative nursing, bowel and bladder; -Back injury prevention; -Perineal and catheter care; -Empowering residents through Activities of Daily Living; -Infection control and prevention; -Oxygen safety; -Resident rights; -Handling aggressive behaviors; -Effective communication; -Fire safety; -Compliance and ethics training; -HIPAA; -Preventing, recognizing and reporting abuse; -Abuse and neglect; -Sexual harassment; -Workplace violence; -The Training Required for Facilities document did not include dementia management training. Review of the facility's staff in-service course completion history, 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 observation, interview, and record review, the facility failed to create an environment respectful to the rights of each resident to make choices about significant aspects of their lives. The facility failed to administer medications per the resident's preference for two residents (Residents #176 and #143) in a review of 65 sampled residents. The facility census was 170. Review of the facility policy Crushing Medications, dated 1/1/2000, showed the following: 1. Medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing, or is a tube-feeder; 2. The following guidelines must be used when the crushing of the medication is necessary: a. The resident's medication administration record (MAR) must indicate the necessity for crushing the medication. 1. Review of Resident's #176's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/14/21, showed the following: -Diagnoses included Crohn's disease…

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 notify the resident's guardian, emergency contact, and/or next of kin (NOK) after falls or changes in condition for one resident (Resident #179) in a review of 65 sampled residents. The facility census was 170. Review of the facility policy Resident Rights last revised 3/22/17 showed the following: 11. Notification of changes: i. The facility must immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an interested family member when there is: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention; B. A significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications; C. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1.…

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 (Resident #152), was free from misappropriation of his/her property, when the resident's tablet computer went missing shortly after his/her admission to the facility. The facility census was 170. Review of the facility policy Abuse and Neglect, revised 8/2018, showed the following: Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to ensure that a due process for appeals to the accused is outlined related to establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. 1. Review of Resident #152's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's inventory sheet, dated 5/22/20, showed the following: -Laundry staff documented the resident's inventory; -The list included an RCA Tablet ID-9903A-RC78873WR. Review of the resident's nurse's notes, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide evidence that all alleged violations of abuse, neglect, and misappropriation were thoroughly investigated for two of 65 sampled residents (Residents #56 and #152), and for one additional resident (Resident #82). The facility census was 170. Review of the facility's policy, Abuse, Neglect, Grievance Procedures, dated 11/28/16, showed the following: -It is the policy of the facility that every resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. It is also the policy of this Facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; -Mistreatment, neglect, or abuse of residents is prohibited by this facility; -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, 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 ensure discharge notices included the resident's appeal rights, how and where to appeal, the ombudsman contact information, and the contact information for the advocacy group for mentally ill individuals for two residents (Resident #157 and #155) of 65 sampled residents when the facility initiated transfer of both residents to the hospital. Additionally, the facility failed to give a written discharge notice for Resident #157 and Resident #155 when the facility initiated transfer to the hospital. The facility census was 170. 1. During an interview on 4/15/21 at 7:30 A.M., the administrator said the facility did not have a policy regarding discharge notices for facility-initiated discharges. 2. Review of Resident #155's medical record showed the following: -Resident discharged to the hospital on 4/23/20, 7/12/20, 1/14/20, and 3/23/21; -There was no evidence the facility provided written discharge notice to the resident or the resident's representative…

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, facility staff failed to assist one resident (Resident #63) out of 65 sampled residents, to obtain vision services when the resident's glasses broke. The census was 170. 1. Review of Resident #63's physician order sheet showed an order for the resident to have eye examinations, treatment and management, dated 11/19/19. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 1/14/21, showed the following: -Diagnoses included anxiety, manic depression, psychotic disorder, and schizophrenia; -Cognition was intact; -The resident wore corrective lenses. Review of the resident's care plan, revised 1/29/21, showed the following: -The resident wore glasses at all times; -The resident would have eye exams and treatments as needed or ordered; -Staff to assist the resident with maintenance of glasses as needed. Review of the resident's nurse's note, dated 2/20/21, showed the resident was in a physical altercation with another resident. Broken 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, interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to administer the correct dose of insulin (a medication used to regulate the amount of glucose (sugar) in the blood) per physician orders for one sampled resident (Resident #144) and one additional resident (Resident #24). The facility failed to dispose of one sampled resident's (Resident #165) and three additional residents' (Resident #11, #16 and #24) insulin per the manufacturer's recommendations and staff administered the expired insulin. Staff failed to obtain ordered insulin for one sampled resident (Resident #144) and borrowed insulin that had expired from other residents. The facility census was 170. Review of the facility policy Medication Administration last revised 4/2017 showed the following: -It is imperative that all medications are given using the seven rights to medication administration and that the professional caregiver ensures that medications are swallowed; a. Right resident; b. Right medication; c. Right dose;…

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.