The Greens at Gastonia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure a call light was plugged in and in working order for 1 of 5 dependent residents who were reviewed for reasonable accommodation of needs (Resident #158). The findings included: Resident #158 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II, hypertension and dementia. The resident was discharged to the hospital on [DATE]. Resident #158's quarterly MDS assessment dated [DATE] revealed she was severely cognitively impaired but was sometimes able to make her needs known. The assessment indicated Resident #158 required minimal to maximal assistance with activities of daily living and was always incontinent of bowel and bladder. Resident #158's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired but was sometimes able to make her needs known. The assessment indicated Resident #158 required substantial to maximal assistance with activities of daily…

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 staff interviews, the facility failed to have advance directives accurate throughout the medical record for 2 of 4 residents (Resident #68 and Resident #48) reviewed for advance directives. The findings included: 1.Resident #68 was admitted to the facility on [DATE]. Resident #68's care plan initiated on 12/18/24 indicated Resident #68's health directive was a full code. Interventions included to intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating, or the resident stops breathing. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #68 was severely cognitively impaired. A review of Resident #68's medical record indicated a physician's order dated 2/28/25 for Do Not Resuscitate (DNR). The advance directive binder at the nurses' station indicated a DNR form for Resident #68 which was signed by the Medical Director on 2/24/25. An interview with Nurse #1 on 4/8/25 at 10:34…

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 staff interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 6 sampled residents reviewed for CAA (Residents #99 and Resident #508). The findings included: a. Resident #99 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #99 with intact cognition. A review of Section V (care area assessment summary) of the admission MDS assessment dated [DATE] revealed 7 care areas were triggered for Resident #99. Other than the care area for nutritional status, the MDS Coordinator #2 did not provide any information for analysis of findings for 6 of the 7 triggered areas to describe the nature of Resident 99's problems, root causes, contributing factors, risk factors related to the care area, and reasons to proceed with 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 3. Resident #63 was admitted to the facility [DATE] with diagnoses that included schizoaffective disorder. Resident #63's Preadmission Screening and Resident Review (PASRR) level II determination letter dated [DATE] revealed nursing facility placement was appropriate for 30 days and the PASRR level II expired on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had a diagnosis of schizoaffective disorder but was not coded for a PASRR level II. An interview with MDS Nurse #2 on [DATE] at 2:27 PM revealed she was responsible for completing the PASRR level II section of the MDS. MDS Nurse #2 revealed she reviewed Resident #63's PASRR determination letter but was not familiar with a PASRR level II that expired after 30 days and thought it was a PASRR level I. MDS Nurse #2 stated the admission MDS was not coded accurately because she was unaware Resident #63 had a PASRR level II. During an interview with the Administrator on [DATE] at 5:27 PM she indicated a PASRR level II…

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 staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was obtained for a resident with an expired PASRR level II. This deficient practice occurred for 1 of 4 residents reviewed for PASRR (Resident #63). The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder. Review of the Preadmission Screening and Resident Review (PASRR) level II dated [DATE] revealed it expired on [DATE]. Resident #63 remained in the facility after [DATE] and a level II PASRR had not been completed since admission. An interview with the Social Services Director on [DATE] at 9:58 AM revealed she was responsible for monitoring and ensuring all level II PASRRs were obtained. She stated Resident #63 was admitted to the facility with a 30-day level II PASRR that expired on [DATE]. She indicated Resident #63 remained in the facility after [DATE] and a new level II PASRR should have been…

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 and staff interviews, the facility failed to administer medications as ordered by the physician for 1 of 5 (Resident #2) residents reviewed for medications. Findings included: a. Resident #2 was initially admitted to the facility on [DATE] and readmitted from the hospital on 1/13/2025. Resident #2 had diagnoses including chronic diastolic congestive heart failure, Type 2 diabetes Mellitus with diabetic polyneuropathy (a condition where nerve damage occurs due to persistently high blood sugar levels), intervertebral disc degeneration lumbar region without mention of lumbar back pain or lower extremity pain. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2's Physician's order dated 7/24/2024 read Pregabalin Oral Capsule 200mg (narcotic controlled substance) Give one capsule by mouth two times a day for Neuropathy (weakness, numbness and pain from nerve damage) Resident #2's controlled medication declining…

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 resident, staff, Pharmacist, and Medical Director interviews the facility failed to prevent a significant medication error when scheduled pain medications were not administered as ordered by the physician for 1 of 3 residents (Resident #112) reviewed for assuring facility was free from significant medication errors. Resident #112 was ordered to receive a scheduled pain medication three times a day and failed to receive seven dosages of his scheduled pain medication due to the medication not being available at the facility. The findings included: Resident #112 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnosis included chronic pancreatitis, severe chronic kidney disease, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 was cognitively intact and was also coded for pain and receiving pain medication. Review of revised care plan dated 3/07/25 revealed goal for Resident #112 to be free of signs 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 observations, record review, and resident, staff and Medical Director interviews, the facility failed to store a lidded container of prescription topical medicated cream to treat foot pain (Resident #110), a lidded container of topical ointment to treat chest congestion, a lidded tube of topical medicated gel to treat arthritis pain, and a lidded tube of topical anti-itch cream (Resident #13) in a secure locked storage area for 2 of 2 residents observed with medicated creams at the bedside (Resident #110 and Resident #13). The findings included: 1. Resident #110 was admitted to the facility on [DATE] with diagnoses including dementia, gout and peripheral vascular disease. The admission Minimum Data Set (MDS) was in progress and no information was available. The baseline care plan dated 4/06/25 revealed Resident #110 had problem areas including impaired cognitive function and activities of daily living self-care performance deficit. The interventions included providing cues, reorientation and supervision…

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, record review, Physician and staff interviews, the facility failed to maintain a complete and accurate medical record when staff documented on the MAR that a scheduled medication was administered, but it was not signed as administered on the controlled medication declining sheets for 1 of 3 residents reviewed for medications (Resident #2). Findings included: A physician order dated 7/24/2024 read Pregabalin Oral Capsule 200mg (narcotic controlled substance) Give one capsule by mouth two times a day for Neuropathy. The order was discontinued on 1/10/2025. A physician order dated 1/13/2025 read Pregabalin Oral Capsule 200 mg (narcotic controlled substance) Give one capsule by mouth every 12 hours for pain. Observation on 4/9/2025 at 4:30pm of Resident #2's controlled medication declining sheets indicated Resident #2 had not received doses of pregabalin 200mg on the following: 10/20/2024 at 4:00pm 2/27/2025 at 9:00am 3/6/2025 at 9:00pm 3/18/2025 at 9:00am 3/27/2025 at 9:00am Review of Resident #2's Medication Administration Record (MAR) indicated the following: 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 observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Unit Manager #2 did not perform hand hygiene before donning clean gloves while providing suprapubic catheter care to Resident #83. This deficient practice occurred for 1 of 6 staff members observed for infection control practices (Unit Manager #2). The findings included: Review of the facility's policy entitled Handwashing/Hand Hygiene last updated October 2023 read in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene 1. Hand hygiene is indicated: b. Before performing as aseptic task; c. After contact with blood, body fluids or contaminated surfaces; f. Before moving from work on a soiled body site to a clean body site on the same resident; and g.Immediately after glove removal 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 5. The use of gloves does not replace hand washing/hand hygiene. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and staff interviews the facility failed to complete and document weekly skin assessments as ordered by the physician for a resident with a known stage IV pressure ulcer to the sacrum and a known stage III pressure ulcer to the right heel for 1 of 3 residents (Resident #3) reviewed for the treatment and prevention of pressure ulcers. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (CVA or stroke), left side hemiparesis, and pressure ulcer of the sacral region, unstageable. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and was dependent on staff for all activities of daily living. Additionally, the assessment revealed Resident #3 had two unhealed, unstageable pressure ulcers, was receiving pressure ulcer care and had pressure reducing devices in his chair and on his bed. Review of Resident #3's quarterly Minimum Data Set (MDS)…

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 staff interviews, the facility failed to prevent a resident (Resident #3) from being fed when his diet order was nothing by mouth (NPO) with continuous enteral tube feeding for 1 of 2 residents reviewed for gastrostomy tube care. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (stroke), hemiplegia, aphasia, dysphagia, stenosis of carotid arteries, muscle weakness, and gastrostomy tube (G-tube) for feedings. Review of Resident #3's orders for 04/01/24 revealed the following: -Diet: NPO (nothing by mouth). - Enteral Feed Order every shift Enteral Nutrition via Pump - Jevity 1.5 at 50 cubic centimeters (cc)/milliliters (ml) per hour for 24 hours via pump per PEG tube. - Enteral Feed Order every 4 hours auto pump 100 ml flush. - Enteral Feed Order one time a day for hydration 240 cc water flush. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely…

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, family and staff interviews the facility failed to provide food in the form to meet individual needs of 1 of 1 resident (Resident # 2) reviewed for nutrition. The findings included: Resident #2 was admitted to the facility on [DATE] and discharged on 3/15/24. A review of physician orders revealed a regular diet with no end date for Resident #2. Review of Resident #2's dental extraction report dated 12/4/23 revealed the resident had all remaining teeth extracted. The report did not indicate diet consistency changes. A quarterly minimum data set (MDS) dated [DATE] indicated Resident #2 was cognitively intact and required set up with eating. A Nurse Practitioner progress note dated 2/20/24 indicated Resident #2 explained her current biggest concern was her teeth since she was no longer a candidate for dentures and was having difficulty adjusting to her new diet. During a phone interview on 5/14 /24 at 10:16 am Resident #2's family member revealed while visiting during lunch on 3/9/24, the…

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

Based on observations, record review, and staff interviews, the facility failed to implement their Infection Control Policy for hand hygiene/handwashing when the Treatment Nurse did not perform hand hygiene according to the facility's policy and procedure when providing wound care to 1 of 3 residents (Resident #3) and when Unit Manager #1 did not perform hand hygiene according to the facility's policy and procedure when providing gastrostomy tube site care for 1 of 2 residents (Resident #3) reviewed for infection control practices. The findings included: The facility's policy entitled Handwashing/Hand Hygiene which is part of their Infection Control Policies and Procedures last revised 08/2019 under Policy Interpretation read in part: 7. Use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; m. After removing gloves; 8. Hand hygiene is the final step after…

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, record reviews, resident and staff interviews, and test tray the facility failed to provide palatable food that was appetizing in temperature for 6 of 6 residents reviewed for food palatability (Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) . This practice had the potential to affect other residents on all halls. Findings included: a. Resident #9 was re-admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. An interview was conducted with Resident #9 on 3/26/24 at 2:00 PM which revealed she resided on the 200 hall. She stated she received a meal for lunch and although the taste was acceptable, the temperature was cold. Resident #9 stated that she often received food items that were not the correct temperature. b. Resident #10 was re-admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively…

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 reviews, observations, resident, and staff interviews, and a test tray, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a recertification and complaint investigation that occurred on 02/01/24, a complaint investigation that occurred on 06/26/23 and a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Activities of Daily Living for Dependent Residents (F677), a recertification and complaint investigation survey that occurred on 02/01/24, a recertification and complaint investigation survey that occurred on 04/15/21 for a deficiency cited in the area of Label/Storage of Drugs Biologicals (F761), a recertification and complaint investigation survey that occurred on 02/01/24 in the area of Palatable Food (F804), a recertification and complaint investigation survey that occurred on 10/03/22, a recertification and complaint investigation survey that occurred on 04/15/21 for 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 observations, record review, resident, and staff interviews, the facility failed to provide nail care and trim fingernails for 1 of 3 sampled residents (Resident #1) reviewed for activities of daily living (ADL). The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebrovascular accident, hemiplegia, and hypertension. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required maximal assistance with personal hygiene. An observation and interview with Resident #1 on 03/26/24 at 10:00 AM revealed him lying in bed with his eyes closed. The resident opened his eyes and was able to respond that he was doing well. Resident #1 was able to answer simple questions but unable to carry on a conversation. Observation of his fingernails on both hands revealed his nails were ½ inch beyond the tips of his fingers and he had brown colored debris 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, record review, resident, and staff interviews, the facility failed to provide podiatry services and/or toenail care for 1 of 3 sampled residents (Resident #1) reviewed for foot care. The findings included: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebrovascular accident, hemiplegia, and hypertension. Review of Resident #1's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required maximal assistance with personal hygiene. Review of a final appointment listing dated 02/05/24 revealed Resident #1 was not seen by the podiatrist on that date. An observation and interview with Resident #1 on 03/26/24 at 10:00 AM revealed him lying in bed with his eyes closed. The resident opened his eyes and was able to respond that he was doing well. Resident #1 was able to answer simple questions but unable to carry on a conversation. Observation of his toes revealed thick,…

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, record review, resident and staff interviews, the facility failed to secure medications stored at the bedside for 1 of 2 residents reviewed for medication storage (Resident #15). Findings included: Resident #15 was re-admitted to the facility on [DATE] with diagnoses that included shortness of breath and chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was moderately cognitively impaired. A review of Resident #15's March 2024 Physician's Order Summary revealed he was prescribed the following medication on 9/30/23: Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Budesonide-Formoterol Dihydrate)- 2 puffs inhale orally 2 times a day for COPD. The document did not reveal a current order for Albuterol AER HFA (an inhaled medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness) or Resident #15. An observation was made on 3/26/24 at 11:15 AM which revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to maintain complete and accurate medical records related to wound treatments for 1 of 3 residents (Resident #5) reviewed for wounds. The finding included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included pyoderma gangrenosum (a rare condition that causes large, painful sores to develop on the skin, most often the legs). Review of Resident #5's physician orders revealed an order dated 02/01/24 to cleanse left lateral medial thigh with soap and water, pat dry, apply non stick contact layer of oil emulsion gauge to wound bed, place calcium alginate on top then cover with ABD pad and secure with tape daily. Resident #5 was discharged home on [DATE]. A review of Resident #5's Treatment Administration Record (TAR) for 02/2024 revealed of the 15 days Resident #5 resided in the facility in the month of February, 4 days were not documented as the Resident receiving the ordered treatment. The days were: 02/01/24, 02/03/24,…

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 record review, observation, and staff interviews, the facility failed to implement their hand hygiene/handwashing policy as part of their infection control policy, when the Treatment Nurse did not perform hand hygiene according to the facility ' s policy and procedure when providing wound care to 1 of 3 residents (Resident #1) reviewed for wound care. The findings included: The facility ' s policy entitled Handwashing/Hand Hygiene which is part of their Infection Control Policies and Procedures last revised 08/2019 under Policy Interpretation and Implementation read in part: 7. Use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.,; k. After handling used dressings, contaminated equipment, etc.,; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does 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 observations, and resident and staff interviews the facility failed to have systems in place for providing evening snacks to residents' in 5 of 5 halls. The deficient practice had the potential to affect all residents requesting a evening snack. The findings included: a. Observations of Nourishment room [ROOM NUMBER] on 1/29/24 at 3:30 PM revealed snacks available and dated for 1/29/24 in the refrigerator. There were sandwiches, applesauce, pudding, juice, and milk. The sandwiches were on a tray stacked in three rows, two sandwiches on top of each other. The puddings were in four packs and the applesauce were in bowls on the tray with the sandwiches. There was an undated box full of cookie and crackers sitting next to the refrigerator. When the nourishment room refrigerator was checked on 1/30/24 at 9:00 AM the sandwiches, pudding, apple sauce, juice and milk remained on the tray as observed on 1/29/24. There was still a full box of cookies and crackers observed next to the refrigerator. An observation…

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

Based on observations and staff interviews, the facility failed to date and label fresh vegetables in 1 of 1 kitchen walk-in refrigerators, store a bucket of counter cleaning solution away from food items in kitchen, date and label a resident's food item in 1 of 2 nourishment room refrigerators, and prevent possible cross contamination by storing a dirty meal tray on a cart with trays that had not been served for 1 of 5 tray carts. The findings included: Observations in the kitchen with District Dietary Manager (DDM) revealed the following: 1.a. An observation of the kitchen walk-in refrigerator on 1/29/24 at 9:35 AM revealed a bag of unlabeled and undated assortment of fresh vegetables. The bag full of fresh vegetables were tied off at the top, the vegetables did not appear to be rotten. During an interview with the DDM on 1/31/24 at 8:00 AM, she stated that the vegetables should not have been placed in an unlabeled bag, due to not being able to tell when they were opened and what was in the bag. Dietary staff were expected to label and date all food items before being placed into…

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 reviews, observations, and family and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following a complaint investigation that occurred on 06/26/23 and a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Activities of Daily Living for Dependent Residents (F677), a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the area of Free of Accidents/Hazards (F689), a recertification and complaint investigation survey that occurred on 04/15/21 for a deficiency cited in the area of Label/Storage of Drugs Biologicals (F761), a recertification and complaint investigation that occurred on 10/03/22 in the area of Food Procurement/Storage/Preparation/Serve Under Sanitary Conditions (F812), a recertification and complaint investigation survey that occurred on 10/03/22 for a deficiency that was cited in the 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.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies for the safe handling of soiled laundry when 1 of 5 staff members (Laundry Staff) failed to follow standard precautions during the infection control observation. The findings included: The facility's policy on Handling, Transport and Storage of Laundry dated July 22, 2020, stated Staff should handle all used laundry as potentially contaminated and use standard precautions (i.e., gloves). Laundry workers must always wear the proper protective equipment when handling the soiled linen. Contaminated linen and laundry bags are not held close to the body or squeezed. On 1/30/24 at 3:02 pm, the Laundry Staff was observed wearing a short rubber glove while sorting out the soiled laundry in the dirty side of the laundry room. The soiled laundry containing white sheets, towels, and personal clothes were in a black buggy. The staff was leaning closely over the buggy while sorting. The soiled laundry was touching his forearm and shirt, and the side of the black buggy 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 record review, staff and nurse practitioner interviews the facility failed to notify the provider when a resident experienced a severely low blood sugar and when a resident experienced a high blood sugar for 2 of 2 residents (Resident #74 and Resident #7) reviewed for notification. Findings included: 1. Resident #74 was admitted to the facility on [DATE] with diagnosis which included diabetes and hypertension. Resident #74's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was moderately cognitively impaired. The MDS further revealed Resident #74 was coded for insulin use. Review of resident #74's physician order dated 01/24/24 revealed the resident required fingerstick blood glucose with meals (ACHS). Review of Resident #74 physican order dated 01/24/24 revealed the resident required NovoLOG Injection Solution 100 unit/milliliters (ML) to i nject as per sliding scale: if 0 - 150 = 0 Units; 151 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units;…

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, observations, resident, family member, and staff interviews, the facility failed to provide showers to a dependent resident for 1 of 6 residents (Resident #83) reviewed for activities of daily living. The findings included: Resident #83 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, cerebral vascular accident (stroke), dementia and chronic pain. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #83 was moderately cognitively impaired and had no rejection of care behaviors. The MDS further indicated that Resident #83 required total assistance of 2 staff members with bathing and limited assistance of 1 staff with personal hygiene and grooming. Resident #83's care plan dated 12/17/23 indicated that the resident had an activities of daily living self-care performance deficit related to disease processes. The resident requires staff assistance to complete ADL tasks daily. The interventions…

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, and resident, staff, and Nurse Practitioner interviews, the facility failed to follow a physician order to recheck a resident's blood sugar for 1 of 5 residents (Resident #7) reviewed for unnecessary medication. The findings included: Resident #7 was readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was cognitively intact for decision making. Resident #7 was coded as receiving insulin on 6 out of the 7 days during the assessment period. A physician order dated 1/30/24 read Insulin aspart solution pen injector 100 units per milliliter (ml) sliding scale at 6:30 AM, 11:30 AM and 4:30 PM. The order indicated if Resident #7's blood sugar was greater than 400 to administer 14 units of insulin, notify a provider and repeat the residents blood sugar within 30 minutes to 1 hour. A review of Resident #7's Medication Administration Record (MAR) dated February 2024…

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, responsible party and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #56). Finding included: Resident #56 was admitted on [DATE] with diagnoses that included diabetes mellitus, dementia, high blood pressure, and stage III chronic kidney disease. Resident #56 transitioned to Hospice care 10/26/2023 and was discharged home with Hospice services on 01/22/2024. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #56's cognition was assessed as moderately impaired, and she required extensive to total assistance with all activities of daily living (ADL). The MDS also revealed Resident #56 transitioned to Hospice care with adult failure to thrive. Resident #56's care plan revised on 11/07/2023 revealed Resident #56 was care planned for ADL self-care performance deficits related to disease processes. The goals included extensive and total…

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 reviews, and interviews with resident and staff, the facility failed to provide care in a safe manner for 1 of 4 residents (Resident #49) reviewed for supervision to prevent accidents. On 05/10/23, Resident #49's lower half of his body went off the other side of the bed during incontinence care but did not result in an injury. The findings included: Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE] under Hospice services. His admission diagnoses included nontraumatic spinal cord injury resulting in paraplegia, spondylosis, myelopathy at level of thoracic spine and neurogenic bladder. Resident #49's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intake. The MDS also revealed the resident required extensive assistance of 2 staff members with bed mobility, transfers, and had impairment on both sides of lower extremities. Review of a fall report dated 05/10/23 and written by Nurse #5 revealed Resident #49 rolled out of his bed…

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, observations, resident, family member and staff interviews, the facility failed to provide sufficient nursing staff to provide showers to a dependent resident for 1 of 6 residents reviewed for staffing (Resident #83). This tag was cross-referenced to: F677 - Based on record review, observations, resident, family member, and staff interviews, the facility failed to provide showers to a dependent resident for 1 of 6 residents (Resident #83) reviewed for activities of daily living. An interview with NA #2 and NA #3 on 01/31/24 at 2:34 PM revealed they typically worked the shower team unless they were pulled to work as a NA on the hall. NA #2 indicated they were sometimes pulled to the hall to work as a NA and on those days, it was up to the NA on the floor to complete the resident's showers or bed baths. NA #2 and NA#3 stated they had often been pulled from the shower team to a hall assignment due to staffing or call outs in the facility. An interview with NA #9 on 01/31/24 at 9:37 AM revealed since the end of September she had often been on the hall alone 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 observations, staff interviews, and record review the facility failed to date opened multi-dose vials of medications in 1 of 3 medication administration carts (400 Hall). The findings included: An observation of the 400 Hall medication cart on 01/31/2024 at 11:14 AM with Nurse #1 revealed two opened and unlabeled vials of Lidocaine (injectable numbing medication). Both vials were available for use in the top drawer of the medication cart. A review of the manufacturer's literature indicated to discard Lidocaine multi-dose vials 28 days after opening. During the observation, an interview with Nurse #1 revealed she was not sure if the open vials of Lidocaine were currently being used. She also stated vials of Lidocaine were usually used to dilute antibiotics. Nurse #1 also indicated that both vials should have been discarded since they were not labeled or dated but she did not notice them when she administered medications from the medication cart that morning. She further stated that the nurses should check the medications in the medication carts when they had time to do so.…

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.