Community Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy reviews, the facility failed to properly store frozen foods in the freeze for one (1) of four (4) survey days, as evidenced by, unsealed bags in the freezer. This has the potential to affect all residents in the facility. Findings Include:Record review of the facility's policy Storage of Frozen Food with a review date of 11/23 revealed The facility ensures the quality and safety of frozen food through accepted storage practices .8. Opened boxes with liners should be closed and sealed tightly with packing tape or twists ties .On 05/18/2026 at 10:15 AM, during the initial tour of the kitchen with the Dietary Manager (DM), nine (9) food items in the freezer were found to not be properly stored. The following items were observed: 1. Red [NAME] sausage in a plastic bag - bag was not sealed. 2. [NAME] dinner rolls in a brown box - plastic liner was torn open. 3. Rid's cobbler crust in a box - plastic bag torn open. 4. Bake Craft bread sticks, 10-pound box -…

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, interview, and facility policy review, the facility failed to ensure advance directives were completed and readily available on the charts for seven (7) of twenty-three (23) residents reviewed for advance directives. (Residents #1, 28, 29, 30, 31, 34, and 43) Findings included: A review of the facility policy titled Advance Directives, undated, revealed, Policy Statement: Advance directives will be represented in accordance with state law and facility policy. Policy Interpretation and Implementation . 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . A record review of the medical records for Residents #1, 28, 29, 30, 31, 34, and 43 revealed there was no documentation regarding information as to whether or not the resident had executed an advance directive. A record review of the admission Record revealed the facility admitted Resident #1 on 01/15/1996 with diagnoses including Hemiplegia and Hemiparesis, Resident #28 on 07/09/2019 with diagnoses including Parkinson'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, record review and facility policy review, the facility failed to ensure a resident's right to a dignified existence related to a urinary catheter drainage bag that did not have a privacy covering for one (1) of three (3) residents reviewed for catheters. (Resident #16) Findings included: A review of the facility's policy, Resident Rights, undated, revealed, .Policy Interpretation and Implementation .1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a. a dignified existence . On 01/14/2025 at 8:12 AM, during an observation, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door, with no privacy cover. The urine in the drainage bag was visible from the open door. On 01/14/2025 at 12:31 PM, during an observation, Resident #16 remained in bed. The urinary drainage bag remained uncovered with yellow urine visible. There was no privacy covering for the drainage bag. On 01/14/2025 at 12:32 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.

Based on observation, interviews, record review, and facility policy review the facility failed to accommodate the needs and preferences of residents who required adaptive equipment to take a shower for (1) of (23) sampled residents. Resident #1. Findings Include: A review of the facility policy, Resident Rights,, undated, revealed, Policy Statement .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .h. be supported by the facility in exercising his or her rights . On 1/14/25 at 10:38 AM, during an interview with Resident #1, he revealed that he would like to take a shower from time to time. He indicated that he was told there is no shower chair available for him, so he has to rely on bed baths. On 1/15/25 at 9:41 AM, Certified Nursing Assistant #2 (CNA) explained that he has cared for the resident over the past six months. He explains that the facility does not have a shower chair to accommodate his request for a shower but does provide the resident with 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, record review, and facility policy review, the facility failed to ensure that a resident was free from a physical restraint imposed for staff convenience related to fall prevention for one (1) of 23 sampled residents. Resident #52. Findings included: A review of the facility's policy titled Use of Restraints, revised April 2017, revealed, .Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or the prevention of falls . On 01/14/25 at 09:05 AM, during an observation, Resident # 52 was sitting in a wheelchair with a lap table secured to the wheelchair. On 01/14/25 at 12:23 PM, during an observation of the lunch meal in the dining room, Resident #52 did not have the lap tray attached to her wheelchair. Her posture was stable, and she was not leaning during the meal. A Certified Nurse Aide (CNA) attached a lap tray to Resident #52's chair before she was transported out of the room. On 01/16/2025 at 3:11 PM, during an interview, CNA #3 who is the Lead CNA, stated the lap tray was used to…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide nail care to a diabetic resident requiring nail care by a Registered Nurse (RN) for one (1) of 23 residents whose nails were observed. Resident #31. Findings included: A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, undated, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal hygiene . On 01/14/2025 at 8:29 AM, during an observation, Resident #31 was seated in his wheelchair in his room. His fingernails were noted to be long, dirty, and jagged. On 01/15/2025 at 12:21 PM, during an observation in the dining room, Resident #31 was seen eating lunch. His fingernails remained long, dirty, and jagged. On 01/16/2025 at 12:28 PM, during an interview, the Assistant Director of Nursing (ADON) stated that two Registered Nurses are responsible for providing diabetic nail care. He explained that residents' nails are supposed to…

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

Based on observation, staff interview, record review and facility policy review the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as evidenced by the catheter drainage bag coming into direct contact with the floor for one (1) of 1 resident reviewed with a catheter. Resident #16 Findings included: A review of the facility's policy, Catheter Care, Urinary, undated, revealed, .The purpose of this procedure I to prevent catheter-associated urinary tract infections .Infection Control .7 Be sure the catheter tubing and drainage bag are kept off the floor . During an observation on 01/14/2025 at 8:12 AM, Resident #16 was in bed and there was a catheter drainage bag that was positioned on the right-hand side of the bed facing the door. The drainage bag was touching the floor. During an observation on 01/14/2025 at 12:31 PM, Resident #16 remained in bed. The urinary drainage bag remained touching the floor in the room. During an interview on 01/14/2025 at 12:32 PM, Certified Nursing Assistant (CNA) #1 stated he was responsible…

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, staff interview and record review, the facility failed to prevent possible complications related to the storage of a Continuous Positive Airway Pressure (CPAP) mask, for one (1) of two (2) residents reviewed for respiratory. Resident #47 Findings included: On 1/14/2025 at 8:49 AM, during an interview, Resident #47 stated she uses her CPAP machine nightly. She explained that the mask had never been stored in a designated bag and was left on top of the dresser by her bedside. On 1/15/2025 at 12:08 PM, during an observation, Resident #47 was eating lunch in her room, and her CPAP mask remained on the table without being stored in a bag. On 1/15/2025 at 2:32 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed that the mask was not in a designated storage bag on 1/14/2025 or 1/15/2025. She stated the mask should be stored in a bag to prevent it from getting dirty and causing complications. On 1/15/2025 at 4:15 PM, during an interview, Registered Nurse (RN) #1, the Infection Preventionist, stated the mask should always be stored in a bag to prevent…

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, staff interview, and facility policy review, the facility failed to ensure medications and a medication cart were locked and secured for one (1) of three (3) medication carts observed. Findings included: A review of the facility's policy, Medication Labeling and Storage undated, revealed, .The facility stores all medications and biologicals in locked compartments . A review of the facility's policy, Administering Medications, undated, policy revealed, .Medications shall be administered in a safe and timely manner as prescribed. Policy Interpretation and Implementation .During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide .No medications are to be kept on top of the cart. The cart must be clearly visible to personnel administering medications, and all outside surfaces must be inaccessible to residents or others passing by . On 01/14/2025 at 7:40 AM, during an observation, an unattended, unlocked medication cart was noted with an unlabeled white tablet in a medication cup left…

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 staff interview and the Facility Assessment review, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning that do not require activation of the facility's emergency plan for three (3) of (3) days of survey. Findings Included: A record review of the facility's Facility Hierarchy (Facility Assessment), signed 7/1/2024, revealed the Plan for average daily schedule of direct care staff to meets in 24-hour period was three (3) Registered Nurses (RNs), seven (7) Licensed Practical Nurses (LPNs), and 17 Certified Nurse Aides (CNAs). The assessment did not indicate specific staffing needs for each shift, based on changes to its resident population. Further review revealed the Facility Assessment did not include any information or plans regarding staff recruitment and retention, and did not include contingency plans for events that do not require the emergency operations plan to be activated. On 1/16/2025 at 5:01 PM, during an…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure proper hand hygiene when a Licensed Practical Nurse (LPN) did not wash her hands or change her gloves during Percutaneous Endoscopic Gastrostomy (PEG) care for one (1) of (1) resident reviewed for care. Resident #22. Findings included: A review of the facility's policy titled Wound Care undated, revealed, .Steps in the Procedure .Wash and dry your hands thoroughly . Loosen tape and remove dressing. Discard soiled dressing and gloves into appropriate receptacles. Wash and dry your hands thoroughly. Put on gloves . On 01/15/2025 at 3:46 PM, during an observation of PEG site care and interview with LPN #2 revealed LPN #2 did not change gloves throughout the procedure. LPN #2 used the same gloves to remove the soiled dressing, cleanse the site, and pat the site dry. LPN #2 confirmed that she did not change gloves during the procedure and acknowledged that gloves should have been changed between removing the soiled dressing and cleaning the site. On 01/16/2025 at 9:55 AM, during an…

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

Based on observation, interviews, record reviews and facility policy review the facility failed to implement the comprehensive care plan related to a resident's food preferences for one (1) of 19 sampled residents. Resident #12 Findings include: A record review of the facility's policy Using the Care Plan, undated, revealed. The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident . Policy Interpretation and Implementation .6. Documentation must be consistent with the resident's care plan . Record review of the Face Sheet revealed the facility admitted Resident #12 on 05/01/2018 and he had diagnoses including Hypokalemia, Chronic Ischemic Heart Disease, and Dysphagia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/23 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. Record review of the Care Plan for Resident #12 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and facility statement review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of two (2) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. Resident # 43. Findings include: The facility provided a written statement on letterhead and signed by the Director of Nurses (DON), that the facility does not have a policy that states which discipline can turn a feeding pump on or off. On 8/14/23 at 10:54 AM, Certified Nursing Assistant (CNA) #1 was observed placing Resident #43's enteral feeding pump on hold. The CNA then repositioned the resident by turning her from her right side to her left side. After the resident's care was completed, CNA #1 turned Resident #43's enteral feeding pump back on. On 8/14/23 at 11:00 AM, in an interview with CNA #1, she confirmed that she had put Resident #43's feeding pump on pause, but stated she is allowed to pause and restart the pump, but she is not…

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

Based observation, interviews, record review, and facility policy review the facility failed to support the nutritional well-being for a resident while respecting an individual's right to make choices about his or her diet for one (1) of 19 residents sampled. Resident #12 Findings include: A record review of the facility's policy Food and Nutrition Services, revised October 2017, revealed .Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Policy Interpretation and Implementation 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits . 4. Reasonable efforts will be made to accommodate resident choices and preferences . A record review of the facility's policy Substitutions, revised April 2007, revealed . Food substitutions will be made as appropriate or necessary . Policy Interpretation and Implementation…

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.