Northern Pines Rehabilitation And Nursing

Based on interview and record review, the facility failed to fully investigate an abuse allegation for 5 (#s 4, 5, 7, 8, and 10) of 12 sampled residents. This deficient practice increased the risk of ongoing concerns of abuse due to the investigations being incomplete. Findings include:1. Review of a facility reported incident, dated 1/26/25, showed resident #5 and #10 were involved in an alleged resident-to-resident abuse incident. Resident #5 and #10 were in their room when a staff member heard resident #5 calling out, help, help, help. The staff member entered the room and the incident documentation showed, found [Resident #10] sitting in [Resident #5's wheelchair] pulling on [Resident #5's] arm. [Resident #5] stated he hit me. During an interview on 9/9/25 at 3:36 p.m., resident #10 could not recall the incident that occurred on 1/26/2025 with resident #5. Resident #5 was unable to be interviewed about the incidents he was involved in, as he had since passed away.Review of the facility reported abuse investigation documents, regarding resident #5 and resident #10, on 1/26/25,…

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

Based on interview and record review, the facility failed to ensure nursing staff followed professional standards for medication administration before administering a controlled substance for 1 (#3) of 12 sampled residents. This deficient practice resulted in the administration of a controlled substance without a current physician's order on three separate days. Findings include:During an interview on 9/9/25 at 12:40 p.m., staff member E stated that each resident had their own supply of resident-specific narcotic medications in the medication cart. When there was a change to the order or the medication was discontinued, the card should be pulled from the medication cart and destroyed. Staff member E stated this ensured the resident no longer received the medication once the medication was discontinued. During an interview on 9/9/25 at 12:51 p.m., staff member F stated that when a narcotic was discontinued, the medication card should be pulled from the locked narcotic box and destroyed by two nurses. Staff member F stated this was to help ensure the medication was not given after it…

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 director of food and nutrition services met the education qualifications required by CMS for a food service director, which increased the risk of residents being affected negatively since the director provided oversight for the entire dietary department. Findings include: During an interview on 11/19/24 at 12:13 p.m., staff member I stated staff member B told him to complete the first eight hour course of training and not to worry about the 16 hour training course until later. During an interview on 11/20/24 at 8:39 a.m., staff member D stated no policies specific to the dietary manager training requirements were available, and the facility used the CMS guidelines. During an interview on 11/20/24 at 9:41 a.m., staff member B stated staff member I did not have any further training in the Food Service Manager program. Staff member B stated staff member I had completed the first eight hours of the training course and did not realize he had the second part to complete. Staff member B stated no other staff in 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 staff failed to serve food in accordance with professional standards for food service safety, by not wearing hairnets, while in food service areas. Failure to uphold food safety may affect any resident at the facility. Findings include: During an observation on 11/18/24 at 2:51 p.m., staff member O had no hairnet on while walking through the kitchen while the cook was making meatballs. Staff member J was not wearing a hairnet while walking through the kitchen and working on stocking directly next to the prep table, where the cook was preparing meatballs. During an observation on 11/18/24 at 5:12 p.m., staff member J was prepping meal trays (for another location), and was not wearing a hairnet. She had braids hanging down past her shoulders in front. The ends of the braids hung over the food when she leaned forward. During an observation on 11/19/24 at 8:15 a.m., staff member J had braids hanging down past her shoulders, in the front, while prepping trays in the kitchen. Hair from the end of the braids was nearly…

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 administrator failed to provide adequate oversight and training for the Administrator in Training (AIT), and the DON, with regard to the responsibilities of the interdiscipliary team reviews and processes to be used, and how to conduct a performance improvement project related to the fall prevention protocol, for 3 (#s 7, 25, and 27) for 18 sampled residents; and the administrator failed to ensure the facility employed a certified Infection Preventionist, and failed to ensure the facility employed a qualified Dietary Manager which may affect any resident at the facility. Findings include: 1. Review of resident #25's EHR showed the resident sustained 12 falls between his admission on [DATE], and the start of the survey, on 11/18/24. The IDT did not address the first five falls sustained by the resident between 5/15/24 and 9/16/24. Resident #25 sustained a fall on 9/17/24 which necessitated an overnight hospital stay for monitoring and staples to a head…

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 designated Infection Preventionist was qualified through an approved certification program prior to assuming the role of Infection Preventionist. The deficient practice had the potential to affect all residents receiving care in the facility. Findings include: During an interview on 11/18/24 at 3:48 p.m., staff member A stated the facility's Infection Preventionist resigned approximately one week earlier, and staff member C was in the process of taking the class. Staff member A stated the facility did not have a certified infection preventionist currently. During an interview on 11/21/24 at 3:25 p.m., staff member C stated she had only been in the Infection Preventionist role for about one week. Staff member C stated she was still learning and had not yet completed the infection preventionist training. A request for the Infection Preventionist certificate of training was requested on 11/18/24. No documentation was received by the end of the survey.

Based on observation, interview, and record review, the facility failed to develop and implement a facility policy which contained the name and contact information for the grievance official; failed to provide forms within reach of residents who were unable to stand to reach the grievance forms; and failed to provide residents with the option to file grievances anonymously, for 4 (#s 15, 22, 25, and 32) of 18 sampled residents. Findings include: During an interview on 11/19/24 at 7:57 a.m., resident #25 stated he was upset the facility management had not ordered his electric wheelchair. Resident #25 stated he was concerned the staff would be mad if he filed a complaint about them. Resident #25 stated he did not know how to file a grievance anonymously. During an interview on 11/19/24 at 3:24 p.m., resident #22 stated the resident council met monthly, and he would complete the grievance forms on behalf of the resident council, for any concerns brought forward at the meeting. Resident #22 stated the facility provided grievance forms near the nurse's station, but there was not a way 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, and record review, the facility failed to ensure residents were offered hand hygiene before meals in the dining room for 1 (#22) of 18 sampled residents; and failed to follow appropriate infection control practices for proper hand hygiene between resident contact for 4 (#s 2, 19, 25, and 32) of 5 sampled residents for medication administration. Findings include: 1. During an observation in the dining room on 11/19/24 at 8:06 a.m., the residents were being brought down to the dining room and set-up at tables. Residents were offered a clothing protector and offered a drink of their choice. The meal trays were then being served by staff at the kitchen window. Residents were not offered the option to clean their hands before they received their meals. During an interview on 11/19/24 at 8:16 a.m., resident #22 stated the staff did not offer hand hygiene to the residents. During an interview on 11/19/24 at 9:35 a.m., staff member K stated hand hygiene was, offered sometimes, but we forget most of the time to be honest. And it's hard to get patients up 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 and record review, the facility failed to maintain an effective antibiotic stewardship program to include adequate monitoring of antibiotic use for 2 (#s 2 and 30) of 18 sampled residents. Findings include: 1. During an observation and interview on 11/19/24 at 11:52 a.m., resident #2 stated he had a suprapubic catheter and had a history of urinary infections. Resident #2 stated he had been on a number of antibiotcs in the past few months. Resident #2 stated he believed the doctor did not put him on antibiotics for enough time to treat his UTI. Resident #2 stated it took several months to get rid of the infection. Review of resident #2's physician orders, dated from 6/21/24 to 10/15/24, showed the following: - 5/7/24: Bactrim DS one tablet twice a day for seven days, - 6/21/24: clindamycin 300 mg, three times daily for 10 days for UTI, - 7/22/24: Macrobid 100 mg twice daily for 10 days for UTI, - 9/18/24: Levaquin 500 mg daily for seven days for UTI, and - 10/15/24: cefazolin 2 grams intramuscular injection daily for five days for UTI. 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.

Based on observation, interview and record review, the facility failed to ensure call lights were in reach for residents to call for assistance for 3 (#s 7, 25, and 27) of 18 sampled residents. Findings include: 1. During an observation and interview on 11/19/24 at 8:32 a.m., resident #7's call light was under her bed on the floor. Resident #7 was unable to tell the surveyor where her call light was located. 2. During an observation and interview on 11/19/24 at 10:17 a.m., resident #27's call light was clipped on the wall behind his bed. Resident #27 was unable to state where the call light was located. 3. During an observation and interview on 11/19/24 at 7:59 a.m., resident #25's call light was clipped to the wall behind the bed. Resident #25 was sitting in his recliner. Staff member H entered his room and gave resident #25 his medications. Resident #25's call light was not offered to him before the nurse exited. Resident #25 stated two CNAs came in this morning and helped him get up and did not give him his call light before they left. During an observation and interview 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.

Based on interview and record review, the facility failed to protect residents from verbal and physical abuse by other residents for 2 (#1 and #11) of 18 sampled residents. During the survey, it was found the facility had previously identified, investigated, and corrected the non-compliance for the abuse between resident #1 and resident #11. Findings include: Review of a Facility-Reported Incident, submitted to the State Survey Agency on 10/14/24, showed resident #s 1 and 11 were involved in an incident on 9/14/24. The incident was documented in the EHR, but not identified as potential abuse until several weeks later when staff member P did an audit of resident progress notes and identified the interaction as potential abuse. Review of a second Facility-Reported Incident, submitted to the State Survey Agency on 10/15/24, showed residents #s 1 and 11 were involved in another incident on 9/17/24 which was also not identified as potential abuse. During an interview on 11/19/24 at 9:07 a.m., resident #1 denied having any issues with any other residents. During an interview on 11/20/24…

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 report allegations of abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 1 and 11); and failed to submit the results of an investigation within 5 working days for 1 (#12) of 18 sampled residents. Findings include: 1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on 10/14/24, showed resident #s 1 and 11 were involved in an incident on 9/14/24. The incident was documented in the EHR but not identified as potential abuse until 10/14/24, when the abuse allegation was reported on the State's reporting portal. The incident was identified as an abuse allegation when staff member P did an audit of resident progress notes and identified the interaction as potential abuse. Review of a second Facility-Reported Incident, submitted to the State Survey Agency on 10/15/24, showed residents #s 1 and 11 were involved in another incident on 9/17/24, which was not initially identified as potential abuse. The incident was identified as an abuse allegation when staff member P did an audit…

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 accurate MDS coding for 2 (#s 19 and 24) of 18 sampled residents. Findings include: 1. During an observation and interview on 11/18/24 at 4:22 p.m., resident #19 said he was hospitalized earlier this year for a psychiatric evaluation. Resident #19 stated he had mental health problems and took medications for them. Review of resident #19's physician orders, dated 6/24/24, showed an order for aripiprazole, 5 mg at bedtime, related to a diagnosis of major depressive disorder, recurrent severe without psychotic features. Review of resident #19's MAR, dated July of 2024, showed the resident was receiving the anti-psychotic medication aripiprazole 5 mg at bedtime for the entire month of July 2024. Review of resident #19's Annual MDS, with an ARD of 7/7/24, failed to show the resident was receiving an anti-psychotic medication (aripiprazole) daily during the observation period. The nurse who completed the MDS was no longer employed by the facility, and the reason for the coding error could not be determined. 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.

Based on interview and record review, the facility failed to revise an individualize comprehensive care plan to reflect the current management and interventions for a mental health diagnosis, for 1 (#30) of 18 sampled residents. Findings include: During an interview on 11/19/24 at 9:33 a.m., resident #30 stated she had, . a lot of anxiety and worry. Resident #30 stated, I have always been a worrier, for no good reason I suppose. During an interview on 11/20/24, staff member L was unable to state what non-pharmacological interventions were tried to help resident #30 with her anxiety. Review of resident #30's EHR showed resident #30 was taking alprazolam, sertraline, and quetiapine for the treatment of her anxiety. Review of resident #30's care plan, initiated on 6/19/24, with the latest update on 11/18/24, failed to show anxiety as a focus area, failed to show non-pharmacological interventions for the management of her anxiety, and failed to show the pharmacological treatments and potential side effects.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice by administering insulin by pen without first priming the pen. This deficient practice caused the resident to receive 2 units less insulin than prescribed and had the potential to cause an elevated blood glucose for 1 (#19) of 18 sampled residents. Findings include: During an observation and interview on 11/19/24 at 9:25 a.m., staff member H, who was orienting staff member N, was observed attaching a needle to an insulin detemir pen, 100 U/mL, and administering 10 units to resident #19 without first priming the pen with 2 units of the insulin. Staff member N stated she believed priming of insulin pens was considered standard practice and did observe staff member H not priming the pen prior to administering the prescribed dose of insulin. During an interview on 11/21/24 at 11:12 a.m., staff member C stated the priming of insulin pens was the expectation of all nurses prior to the administration of insulin and was considered standard practice, as per manufacturer'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 interview and record review, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay, and a post-discharge plan of care, for 1 (#34) of 2 residents sampled for a closed record review. Findings include: During an interview on 11/21/24 at 7:50 a.m., staff member G stated the nurses were responsible for the discharge summary at the time of a resident discharge. During an interview and record review on 11/21/24 at 2:25 p.m., staff member C stated the nurse discharging the resident would be responsible for the discharge summary. Review of resident #34's EHR failed to show any documentation of a recapitulation of the resident's stay, or a post-discharge plan of care, completed by nursing or the resident's physician. A document request was made on 11/19/24 at 3:30 p.m. for resident #34's discharge summary and recapitulation of stay. No additional documentation was received by the end of the survey.

Based on interview and record review, the facility failed to ensure residents did not receive medication without an adequate indication for its use for 1 (#30) of 5 residents reviewed for unnecessary medications. Findings include: Review of resident #30's EHR progress notes showed resident #30 was prescribed an antibiotic, pending results of a urine culture, on 9/21/24. A urine culture result was noted to be negative for infection on 9/22/24, but the resident remained on antibiotics for a total of eight days (9/21/24 - 9/28/24) as noted on resident #30's MAR. During an interview on 11/21/24 at 2:55 p.m., staff member C stated she was unaware resident #30 had been given an antibiotic after a negative urine culture. Review of resident #30's EHR failed to show any prescriber rationale or indication for the continued course of treatment over the eight-day period.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 (#30); and failed to complete the gradual dose reduction for 1 (#25) of 18 sampled residents. Findings include: 1. Review of a facility, pharmacy review, dated 9/28/24, reflected resident #25 was due for a gradual dose reduction for fluoxetine 10 mg daily. Review of a faxed gradual dose reduction order for #25, dated 9/28/24, reflected the pharmacist's recommendation to discontinue the fluoxetine. The physician reply showed the physician agreed with the pharmacist's recommendation and to please implement the order. Review of resident #25's MAR, dated September, October and Novemeber 2024, reflected resident #25 continued to receive fluoxetine, 10 mg daily, until this was questioned by the surveyor on 11/21/24. During an interview on 11/20/24 at 8:39 a.m., staff member D stated the gradual dose reduction was never implemented and was being addressed that day. 2. During an interview on 11/19/24 at 9:33 a.m., resident #30 stated she had, . a lot 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.

Based on observation, interview, and record review, the facility failed to provide dental services for 2 (#s 7 and 25) of 18 sampled residents. Findings include: 1. During an observation and interview on 11/19/24 at 8:28 a.m., resident #7 stated dental services had not been offered to her. During the interview it was observed the resident had a thick white plaque covering her teeth and a strong foul oral odor when she talked. Review of resident #7's BIMS assessment, dated 8/27/24, reflected resident #7 had a BIMS of 6, a severe cognitive impairment. Review of resident #7's care plan, dated 3/8/23-11/20/24, reflected resident #7 had top dentures and missing teeth on the bottom, with an initiated date of 11/20/23. 2. During an observation and interview on 11/19/24 at 7:50 a.m., resident #25 stated he had not been offered any dental care services at the facility or off site. Resident #25 had no dentures and many missing teeth per his report. Resident #25 stated he would like to see a dentist about his teeth. Review of resident #25's care plan, dated 5/7/24-11/20/24, reflected: - ORAL…

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 was sharing nursing staff throughout their shifts with the connected assisted living without properly scheduling and coding on the accrued time on records. The facility failed to ensure the facility licensed nurses were always working in the nursing home. This deficient practice had the potential to affect any resident needing assistance in the nursing home. Findings include: During an interview on 4/10/24 at 3:13 p.m., staff member A stated the facility did not have a policy for staffing the nursing department but had a chart for the number nursing staff per shift. Staff member A stated there was one nurse every 12 hour shift. Staff member A stated the facility had just hired a medication aide, and had two to three CNA's per shift depending on census, but always more than what was listed on the chart. During an observation of the daily nursing staff posting and interview on 4/11/24 at 9:52 a.m., staff member D stated the + 1 ALF was included in the census on the daily nursing staff posting because nursing staff would…

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 that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (#11) of 17 sampled residents.This practice had the potential to affect all residents in the facility. Findings include: During and observation and interview on 11/19/23 at 10:31 a.m., staff member E assessed the heels of resident #11. The heels were not floated on a pillow to prevent pressure and were pushing deep into the mattress. Staff member E stated,I'd say her left heel is a crunchy Stage two (pressure ulcer). I will complete the forms and notify the physician. She used to have a different boot she wore since her debridement from the pressure she had from the [NAME] boot, but it went missing. Staff member E stated resident #11 had a pressure wound earlier in the year because of pressure around the opening at the heel of the [NAME] boot.…

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

Based on observation, interviews, and record review, the facility failed have a certified person to serve as the director of food and nutrition services. This practice had the potential to affect all residents. Findings include: During an observation on 11/18/23 at 10:45 a.m., staff member K was working at the stove without his beard fully covered and no hair net. During an interview on 11/19/23 at 2:20 p.m., staff member H stated she was working on some course material for the dietary certification and would then schedule a proctor exam. Staff member H stated she had taken over as the dietary manager as of October 2023. Staff member H stated staff member G was available by phone and was supposed to come in and work with her once a month. Staff member H stated she was on vacation when staff member G was last in facility, so she had not completed any direct training with staff member G. During an interview on 11/19/23 at 2:23 p.m., staff member G stated he gets up there (facility) about once a month. Staff member G stated he was not aware of the backorder on beard covers and was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This practice had the potential to affect all residents. Findings include: During an observation on 11/18/23 at 10:45 a.m., the following items were found: - staff member K working at the stove without his beard fully covered and no hair net. - full one gallon milk jug sitting on the prep counter. - boxes tossed in a pile on the floor in cooler, with tomatoes, apples, and broccoli on the floor of walk-in cooler. - jar of mayonnaise on the floor in the walk-in cooler. - boxes of produce on the floor in the walk-in cooler. - 2 heads of cauliflower brown with rotted sections in walk-in cooler. - boxes of food stacked on the floor of the walk-in freezer. - lemon juice in cooler, half empty, with no open date. - open personal (staff) iced tea, half empty, in cooler next to meats thawing. - applesauce jar, half empty, no open date. - pancake syrup with no open…

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 review and update the infection prevention policies annually; failed to ensure staff provided proper infection control practices of hand hygiene for residents when providing meal service; and failed to perform hand hygiene when changing gloves after providing cares for 1 (#11) of 17 sampled residents. Findings include: 1. Review of the facility's infection prevention program showed: - Infection Prevention and Control Program, Revised July 2016, Adopted 12/19/16 - Handwashing/Hand Hygiene, Revised August 2014, Adopted 12/19/16 During an interview on 11/19/23 at 2:59 p.m., staff member B said, I am going to be honest, I have not been able to do anything with the infection control program. During an interview on 11/20/23 at 8:41 a.m., staff member C said the facility infection program was reviewed when the facility was purchased in July 2023. 2. During an observation on 11/19/23 at 8:12 a.m., residents were brought to the dining room for breakfast. No residents were observed to be offered hand hygiene prior 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, interviews and record review, the facility failed to provide treatments, as ordered, by the physician, and identify and document skin breakdown in accordance with professional standards of practice, and for maintaining the resident's quality of life, over multiple days and shifts, for 1 (#9) of 17 sampled residents. It was identified the resident had at least six areas of skin breakdown. Findings include: During an observation and interview on 11/18/23 at 11:42 a.m., resident #9 was lying in bed watching television. Resident #9 stated the facility was, missing the cream for under (the resident's) breasts and folds for her rash. Resident #9 stated she had to put Kleenex under her breasts to keep moisture away, because the facility was no longer providing her with moisture pads. Review of resident #9's Physician Orders, last updated 11/17/23, reflected: -May place skinfold dry sheet under left inframammary fold daily per resident request, with a revision date of 12/2/22. -Hydrocortisone External Cream 1%, apply to rash/hives topically, with a revision date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the antibiotic stewardship program was followed with monitoring and tracking of antibiotic use for 1 (#29) of 17 sampled residents. Findings include: Review of resident #29's EMR, showed resident #29 was admitted to the facility following an inpatient stay and treatment for septic shock. Resident #29 was admitted to the facility on [DATE] with an order to continue Vancomycin (an antibiotic) 125mg, four times a day, for enterocolitis due to clostridium difficile. Resident #29 completed a nine-day course of Vancomycin. No documentation was found in the EMR for follow-up by the nurse or the physician on the resident #29 being cleared for clostridium difficile. During an interview on 11/19/23 at 2:59 p.m., staff member B said she was not currently tracking antibiotic use in the facility. During an interview on 11/20/23 at 8:41 a.m., staff member C said staff member B was in training to be the infection preventionist, was responsible for the…

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

Based on interview and record review, the facility failed to fully inform and obtain a verbal or written consent containing the complete explanation of risks versus benefits with a resident's POA, prior to giving a psychotropic medication, for 1 (#23) of 17 sampled residents. Findings include: Record review of resident #23's electronic medical record did not contain a consent for psychotropic medication. Record review of resident #23's medication administration record, showed bupropion HCL ER tablet, 150 mg to be given once daily with an order date of 4/13/23. Record review of a facility document, Consent for Psychotropic Medication Use, provided after a surveyor request, and dated during the survey, 11/19/23, showed a verbal consent from the POA for bupropion 150 mg, to be given once daily. During an interview on 11/19/23 at 2:59 p.m., staff member B said she was falling behind on resident documentation and was doing her best to get things completed. Review of a facility policy, Psychotropic Medication Use, dated 7/22, showed: .4. Residents (and/or representatives) have the right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have consistent code status information in the resident's medical record, for 1 (#20) of 17 sampled residents. Findings include: Review of resident #20's EMR showed a lack of a POLST form. A request was made for resident #20's POLST on [DATE] at 4:40 p.m. Review of resident #20's Physician admission Orders, dated [DATE], showed the resident had an order for no CPR. Review of resident #20's care plan, with a revision date of [DATE], showed the resident had a DNR code status. Review of resident #20's provided POLST form, dated [DATE], had the box for attempt CPR checked. During an interview on [DATE] at 4:17 p.m., staff member A stated they had lost the old form and when the resident representative was contacted to fill out a new POLST they declined so the resident was now listed as a full code.

Based on observation, interview, and record review, the facility failed to document the ongoing re-evaluation of bolsters placed on the resident's bed, to ensure they were not utilized as restraints, for 1 (#11) of 17 sampled residents. Findings include: During an observation and interviews on, 11/18/23 at 12:19 p.m., resident #11 was lying in her bed with full length bolster pads belted to the mattress on both sides of the bed. The bolster pads were tight against resident #11's body on both sides. Resident #11's legs were bent up with her heels pushing into the mattress. Staff member I entered the room and stated resident #11 was non-verbal, and rarely responded to her picture chart at this time. Staff member I stated resident #11's legs were contracted up, so her knees do not bend open, and no restorative was in place at the facility. Staff member N entered the room and stated, We check on [resident #11] every two hours if we can, we are running behind but will get her up soon. She has not been up yet; we try to get her up by 10:00 (a.m.). She can wiggle in bed a little is all.…

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

Based on interview and record review, the facility failed to complete a Significant Change assessment for a resident with a severe unavoidable weight loss, who had medications discontinued, and she was placed on comfort care, for 1 (#1) of 17 sampled residents. Findings include: During an interview on 11/20/23 at 9:16 a.m., staff member A stated resident #1 had been placed on comfort cares, determined to have unavoidable weight loss, and had most of her medications discontinued. Staff member A stated the MDS was being managed by a team of three people, and they did not identify resident #1 as needing a Significant Change assessment completed for her care transition. Review of resident #1's Weight Summary, dated May 2023 - November 2023, showed: - 9/5/23 resident #1 weighed 149.5 lbs. - 10/9/23 resident #1 weighed 132 lbs. This represented an 11.41% or severe weight loss in one month, and a change in the resident's status. Review of resident #1's submitted MDS assessments showed, a Quarterly Assessment with an ARD of 9/20/23, and a Quarterly Assessment in progress with an ARD 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.

Based on interview and record review, the facility failed to complete a person-centered, comprehensive care plan for 2 (#s 28 and 29) of 17 sampled residents. This deficient practice had the potential for the resident's needs, safety, and well-being to be unfulfilled. Findings include: 1. During an observation and interview on 11/18/23 at 11:36 a.m., resident #28 was observed lying in bed, fully clothed and had a strong smell of urine. Resident #28 said he needed new briefs, and he only had one more pair in his drawer. He said he had been wearing the same brief all day and had been wiping down the inside of the brief with toilet paper every time he used the restroom. Resident #28 said he was independent and takes care of himself. During an interview on 11/20/23 at 9:27 a.m., staff member O said resident #28 was independent with toileting, but would roll up a piece of toilet paper and put it in the front of his brief to stop his leaking. Staff member O said resident #28's family supplied him with gray briefs, and he did not recognize the white briefs, supplied by the facility, as his…

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 update a resident's care plan to reflect ongoing interventions for recurrent falls for 1 (#29) of 17 sampled residents. Findings include: During an interview on 11/19/23 at 2:19 p.m., staff member E said resident #29 had fallen three times in the last month. Staff member E said the assistant director of nursing was working on the fall assessment for resident #29, but was no longer working at the facility. Staff member E said she did not know who was responsible for completing the assessment and updating the care plan for fall interventions now the person responsible was not longer working at the facility. During an interview on 11/19/23 at 2:59 p.m., staff member B said the facility had an effective fall policy and process in place, but it was changed when the facility was purchased by a new company. Staff member B said she was aware of the new process, but had not had time to implement the new process. Staff member B said she knew the process was to identify the root cause (for a fall) and to update the resident's 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.

Based on observation, interview, and record review, the facility failed to provide range of motion services to a resident who had decreased range of motion and a hand contracture, for 1 (#11) of 17 sampled residents; failed to provide range of motion services for a resident with bilateral lower extremity contractures for 1 (#12) of 17 sampled residents. Findings include: 1. During an observation and interview on 11/18/23 at 2:20 p.m., resident #12 said he was not provided therapy by the facility, and he was not able to use his left arm and hand. Resident #12 said he had requested on numerous occasions for some therapy services and was told no longer had insurance coverage. Resident #12 would like to have more use of his left hand. Resident #12 was unable to straighten his left arm at the elbow without assistance from his right arm and was unable to move his left hand at the wrist. 2. During an observation and interviews on 11/18/23 at 12:19 p.m., resident #11 was lying in her bed with full length bolster pads belted to the mattress on both sides. The bolster pads were tight against…

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 clean nebulizer equipment for 1 (#11) of 17 sampled residents, increasing the risk for respiratory infections. Findings include: During an observation on 11/18/23 at 12:19 p.m., resident #11 had a nebulizer on her bedside stand, open to air. The nebulizer tubing had no dates reflecting when it was last changed, and there was dried crust inside the mask and medication chamber. During an interview on 11/18/23 at 12:31 p.m., staff member E stated resident #11 had a physician's order, for nebulizer treatments, for when she had wheezing. Staff member E stated, resident #11's wheezing was often in the afternoon and evening, so she did not know how often the nebulizer was used. During an interview on 11/18/23 at 12:44 p.m., staff member B stated resident #11 did not have an order for the nebulizer, and the nebulizer should have been removed from the room months ago. Staff member B stated resident #11 only used the nebulizer for a short time. Review of resident #11's physician orders reflected resident #11 did have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to store medications in locked compartments for 2 (#8 & 9) of 17 sampled residents; and failed to ensure expired medications and supplies were removed from the medication room, supply closet, and medication cart. Findings include: 1. During an observation and interview on 11/18/23 at 11:42 a.m., resident #9 had the following medications on her bedside table: - Asper crème with lidocaine, exp: 5/19 - Real time pain relief [NAME] pain w/methanol 1.5% - Orajel medicated exp 1/23 - Orajel max/ benzocaine 20% & methanol 0.26% exp 6/2019 - Anasep gel antimicrobial skin and wound gel exp 7/27/23 Resident #9 stated she puts the Anasep gel antimicrobial skin and wound gel on her left shoulder for aching. Resident #9 then began applying the gel to her shoulder during the interview. Resident #9 had a BIMS of 6. 2. During an observation and interview on 11/18/23 at 12:14 p.m., resident #8 had the following medications on her dresser: - refresh tears…

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, facility staff failed to respond to a door alarm sounding, for 1 (#3) of 4 sampled residents, and the resident had a fall in the parking lot. Findings include: Review of a facility reported incident, dated 7/17/23, showed resident #3 exited the facility. The resident was wearing a wanderguard, and the door alarm did sound. Facility staff were in the process of assisting other residents to the dining room for dinner, and failed to respond to the alarm. Resident #3 was then found on the ground in the parking lot by staff from the hospital. The hospital staff took resident #3 to the emergency department for assessment. The emergency department did lab work, and diagnosed resident #3 with a urinary tract infection, but the resident did not sustain any injuries from the fall. The facility was notified by the hospital that resident #3 had been admitted to the emergency room. During an interview on 10/18/23 at 3:43 p.m., staff member A said resident #3 had an unwitnessed fall in the parking lot. Staff member A said the resident was found on the ground…

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.