Orchard Valley Health and Rehabilitation

Based on observations and staff interviews the facility failed to maintain a clean floor in 1 of 1 walk-in cooler, 1 of 1 walk-in freezer, 1 of 1 dry storage rooms, and 1 of 1 kitchen; label and date open food items and discard expired food in 1 of 1 walk-in cooler and 2 of 2 reach-in coolers; cover and date open food items in 1 of 1 walk-in freezer and 1 of 1 reach-in cooler; date milkshakes to identify their use-by date in 1 of 1 reach-in cooler; maintain clean shelves on 5 prep tables in 1 of 1 kitchen; discard expired bread in 1 of 1 kitchen; and maintain clean refrigerators and freezers in 2 of 2 nourishment rooms (200 hall and 300 hall). This failure had the potential to affect food served to residents. Findings included: 1. An initial observation of the walk-in cooler, walk-in freezer, walk-in storage, and kitchen floor on 12/02/24 at 9:42 AM revealed multiple dried yellow and brown stains on the floor of the walk-in cooler, multiple dried black stains on the walk-in freezer floor, scattered dried brown stains on the floor of the dry storage room and surveyor's shoes stuck to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. An observation of the dresser of room [ROOM NUMBER]-B on 12/02/24 at 11:32 AM revealed an area of missing wood to the top of the dresser on the side closest to the bed, leaving an exposed sharp corner. Additional observations of the dresser of room [ROOM NUMBER]-B on 12/03/24 at 8:55 AM, on 12/04/23 at 7:42 AM, and 12/05/24 at 7:34 AM revealed an area of missing wood to the top of the dresser on the side closest to the bed, leaving an exposed sharp corner. An interview with the Maintenance Director on 12/04/24 at 10:57 AM revealed he was not aware of the top of the dresser in room [ROOM NUMBER]-B having missing wood resulting in a sharp corner being exposed. He stated he relied on nursing staff to notify him of rough edges on furniture since he was busy working on other projects. The Maintenance Director stated the dresser would need to be replaced. An interview with the Administrator on 12/05/24 at 5:12 PM revealed he expected furniture to be in good repair or be replaced. 7. An observation of the overbed…

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

Based on record review and staff interviews, the facility failed to notify the Regional Ombudsman when residents discharged or transferred from the facility for 6 of 6 months (April 2024, July 2024, August 2024, September 2024, October 2024, and November 2024). Findings included: Review of the facility's Admission/Discharge report for the period 04/01/24 to 04/30/24 revealed there were 25 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. Review of the facility's Admission/Discharge report for the period 07/01/24 to 11/30/24 revealed there were 125 residents who were discharged home, transferred to the hospital, or transferred to another nursing facility. During an interview on 12/06/24 at 3:52 PM, the Administrator stated he was unable to find any documentation that notifications of residents' discharges/transfers were sent to the Regional Ombudsman for the months of April 2024, July 2024, August 2024, September 2024, October 2024 or November 2024. He explained that the Admissions Director was the one who was previously…

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 comprehensive Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, referring to the last day of the assessment period) (Residents #6, #16, #21, #28, #29, #47, #68, and #78) and failed to comprehensively complete the Care Area Assessment (CAA) for Resident #89 for 9 of 45 sampled residents. Findings included: 1. a. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic medical record revealed an annual MDS assessment with an ARD of 01/20/24 that was marked as completed on 02/26/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #6's annual MDS assessment with an ARD of 01/20/24 was not completed within the regulatory time frame. b. Resident #16 was admitted to the facility on [DATE]. Review of Resident #16's electronic medical record revealed an annual MDS assessment with an ARD of 01/26/24 that 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 and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 14 of 45 sampled residents (Residents #6, #15, #16, #21, #28, #29, #42, #47, #48, #68, #78, #81, #83, and #85). Findings included: a. Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's electronic medical record revealed the following: -A quarterly MDS assessment with an ARD of 04/19/24 that was marked as completed on 06/29/24. -A quarterly MDS assessment with an ARD of 07/19/24 that was marked as completed on 08/21/24. -A quarterly MDS assessment with an ARD of 07/29/24 that was marked as completed on 08/21/24. During a joint interview on 12/04/24 at 12:43 PM, MDS Nurse #1, MDS Nurse #2 and MDS Nurse #3 all verified Resident #6's quarterly MDS assessments with ARDs of 04/19/24, 07/19/24 and 07/29/24 were not completed within the regulatory time frame. b.…

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 Medical Director (MD) and staff interviews, the facility failed to ensure physician visits were performed every 30 days for the first 90 days of admission for 4 of 4 sampled residents reviewed for physician visits (Residents #21, #31, #41, and #55). Findings included: a. Resident #21 was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary disease (trouble breathing), heart failure, and respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #21 had moderate impairment in cognition. Review of Resident 21's Electronic Medical Record (EMR) revealed he was seen by the Medical Doctor (MD) on 06/14/24 and 08/26/24 during the first ninety (90) days of his admission to the facility. b. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes, chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues), heart failure, and chronic kidney disease.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, the facility failed to invite residents to participate and provide input in care planning for 2 of 3 sampled residents (Residents #50 and #11). Findings included: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic pain, chronic post-traumatic stress disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. Review of Resident #50's electronic medical record revealed no evidence she was invited to attend care plan meetings to discuss and provide input regarding her plan of care following the completion of the annual MDS assessment dated [DATE] or the quarterly MDS assessment 09/13/24. The comprehensive care plan for Resident #50 was last revised on 08/14/24. During an interview on 12/03/24 at 8:49 AM, Resident #50 stated she had not been invited to attend or had a care plan meeting scheduled since June 2024. During interviews on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located at the left side of her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #91). The findings included: Resident #91 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #91 had severe cognitive impairment. The MDS coded Resident #91 with impairment of one side of lower extremity and walking between locations inside the room for more than 10 feet was not attempted during the assessment period due to medical condition or safety concerns. During an observation conducted on 12/02/24 at 1:09 PM, the switch for the light fixture on the left side of Resident #91's bed 5 feet from the floor was attached with a cord 3 inches in length. Resident #91 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #91 on 12/02/24 at 1:13 PM.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 3 residents reviewed for advanced directives (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE]. Resident #65's advanced directive care plan, initiated on 07/15/21, with the most recent revision on 03/26/2024 had Resident #65 Care planned as a Full Code. Care Plan Goal listed as: Resident's advanced directives are in effect and their wishes and directions will be carried out in accordance with their advanced directives. Interventions included: Allow resident if able to discuss feelings regarding their Advanced Directives, An Advanced Directive can be revoked or changed if the resident and or appointed Health Care Representative changes their mind about the medical care they want delivered, Complete and update MOST form as needed. Honor residents and family wishes. Review advance directives at least quarterly and PRN. The appointed…

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 staff and Nurse Practitioner (NP) interviews and record review, the facility failed to notify the Physician when a urinalysis was not completed for 1 of 2 residents reviewed for notification of change (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with diagnosis that included bacteremia. Resident #38 had a physician's order for a urinalysis (UA) with culture and sensitivity for urinary pain one time only for one day. This was ordered on 9/24/2024 and marked completed on 9/25/2024. Review of the treatment administration record (TAR) for September 2024 revealed the UA was documented as completed on 9/25/2024. Review of the lab results revealed that there were no results for the UA ordered on 9/24/2024 for Resident #38. A phone interview on 12/06/2024 at 9:54 AM with Nurse #6 revealed revealed that she had completed and collected the UA specimen for Resident #38 on 9/25/2024 and placed it in the refrigerator for the lab to collect. She stated that if the specimen…

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 follow their abuse policy and procedure by not immediately reporting an allegation of resident-to-resident abuse to the Administrator for 1 of 5 sampled residents reviewed for abuse (Resident #11). Findings included: The facility policy titled, Abuse, Neglect and Exploitation revised 03/02/23, read in part: all alleged violations will be reported to the Administrator within specified timeframes: a) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #11 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #11 with intact cognition. Review of the staff progress notes for Resident #11 revealed an entry written by Nurse #4 on 04/08/24 at 6:49 AM with an effective date of 04/06/24 that read, Resident reports that another male resident came to her room, touched her on the thighs at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date and failed to develop comprehensive care plans that incorporated Level II PASRR determination for 2 of 3 sampled residents reviewed for PASRR (Resident #21 and #104). Findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder and anxiety disorder. A PASRR Level II Determination Notification letter dated [DATE] for Resident #21 had an expiration date of [DATE]. It was noted nursing facility placement was appropriate for a limited nursing facility stay lasting no more than thirty calendar days. A PASRR Level II Determination Notification letter dated [DATE] for Resident #21 had an expiration date of [DATE]. It was noted nursing facility placement was appropriate for a 90 day period with specialized services that consisted of psychiatric services provided by a Psychiatrist and rehabilitative…

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 and staff interviews, the facility failed to have a discharge planning process in place that incorporated the resident in the development of a discharge care plan that addressed the resident's discharge goals and post-discharge needs for residents who wished to discharge to the community for 2 of 3 sampled residents (Residents #50 and #70). Findings included: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic pain, chronic post-traumatic stress disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. The MDS noted there was no active discharge plan in place and Resident #50 wanted to be asked about returning to the community on all MDS assessments. A Discharge Planning Review at Admission/readmission assessment dated [DATE] noted Resident #50's discharge goal was to return to the community. Under the summary section it was noted in part that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Medical Director, Nurse Practitioner, and staff the facility failed to obtain a blood sugar as part of the change of condition assessment for a resident with a current diagnosis of diabetes mellitus that was being treated with routine oral blood glucose lowering medication for 1 of 1 resident reviewed for a change of condition (Resident #205). The findings included: Resident #205 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic kidney disease, and chronic systolic congestive heart failure. Review of the 5-day/discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205's cognition was moderately impaired, and medications received included a hypoglycemic. The baseline care plan dated 2/7/24 identified Resident #205's level of consciousness as being alert and intact. A physician's order revealed glipizide-metformin (medication used to lower blood sugar levels) oral tablet 2.5-500 milligrams (mg) was started…

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 staff interviews the facility failed to ensure a Nurse Aide (NA #8) transferred a resident safely for 1 of 8 residents (Resident #4) reviewed for supervision to prevent accidents. Findings included: Resident #4 was admitted to the facility 12/12/15 with diagnoses including muscle spasm and lack of coordination. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severely impaired cognitive skills for daily decision making and had impaired range of motion to one side of her upper extremities and impaired range of motion to both lower extremities. The MDS indicated Resident #4 was dependent for chair/bed transfers. Review of the activities of daily living (ADL) care plan last updated 09/20/24 revealed Resident #4 had an ADL self-care performance deficit and required a mechanical lift with 2-person assistance for transfers. Review of Resident #4's [NAME] (a document that gives a brief overview of the care each resident requires) last…

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, observation, and interviews with the resident and staff the facility failed to ensure the urinary catheter tubing was secured to the leg to prevent movement and trauma for 1 of 1 resident reviewed for urinary catheter (Resident #87). Findings included: Resident #87 was admitted to the facility on [DATE] with diagnosis including obstructive and reflux uropathy (obstruction of urine from bladder and a backwards flow). The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #87's cognition was moderately impaired with no rejection of care behaviors during the lookback period. An indwelling urinary catheter was in place and setup or clean up assistance was needed for toileting hygiene. A review of Resident #87's current physician's order to secure the indwelling catheter tubing using an anchoring device to prevent movement and urethral traction every shift was initiated on 10/02/24. The care plan last revised on 11/19/24 identified Resident #87 had an indwelling catheter…

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 Consultant Pharmacist, Medical Director, resident and staff interviews, the facility failed to ensure antibiotic eye drops were received from the pharmacy as ordered which resulted in five (5) missed doses for 1 of 6 sampled residents reviewed for pharmacy services (Resident #11). Findings included: Resident #11 admitted to the facility on [DATE]. Her cumulative diagnoses included chronic conjunctivitis. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate impairment in cognition. A Physician Order Sheet dated 11/20/24 and signed by the Ophthalmologist read, start Moxifloxacin eye drops - one drop twice a day, OD (right eye). Do not stop, continuous. Review of Resident #11's active physician orders revealed an order dated 11/21/24 for Moxifloxacin Hydrochloride (HCI) Ophthalmic Solution (antibiotic used to treat eye infections caused by bacteria) 0.5% - one drop in right eye two times a day for irritation. No stop date per Ophthalmology.…

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 Medical Director, resident and staff interviews, the facility failed to prevent a significant medication error when they failed to administer antibiotic eye drops as prescribed by the physician. As a result, Resident #11 missed 5 doses of antibiotic eye drops. This affected 1 of 6 sampled residents reviewed for unnecessary medications (Resident #11). The findings included: Resident #11 admitted to the facility on [DATE]. Her cumulative diagnoses included chronic conjunctivitis. A Family Nurse Practitioner progress note dated 08/19/24 revealed in part, Resident #11 had right eye conjunctivitis with chronic right eye redness and drainage that worsened intermittently. The FNP noted Resident #11 had been treated with multiple courses of antibiotic eye drops and the plan was to schedule an appointment with the Ophthalmologist for further management of ongoing symptoms. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had moderate impairment in cognition. A Physician…

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 staff and Nurse Practitioner (NP) interviews and record review, the facility failed to complete an ordered Urinalysis for 1 of 2 residents reviewed for laboratory services (Resident #38). The findings included: Resident #38 was admitted to the facility on [DATE] with a diagnosis that included bacteremia. Review of the quarterly minimum data set (MDS) dated [DATE] revealed that Resident #38 was cognitively intact. Resident #38 had a physician's order for a urinalysis (UA) with culture and sensitivity one time only for 1 day. This was ordered on 9/24/2024 and marked completed on 9/25/2024. Review of the treatment administration record (TAR) for September 2024 revealed the UA was documented as completed on 9/25/2024. Review of the lab results revealed that there were no results for the UA ordered on 9/24/2024 for Resident #38. A phone interview on 12/6/2024 at 9:54 AM with Nurse #6 revealed revealed that she had completed and collected the UA specimen for Resident #38 on 9/25/2024 and placed it 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and resident and staff interviews the facility failed to honor a resident's food preferences for 1 of 5 residents reviewed for food preferences (Resident #31). Findings included: Resident #31 was admitted to the facility 06/06/24. Review of Resident #31's Physician orders revealed an order dated 10/03/24 for a regular diet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and made himself understood and was able to understand others. Resident #31's nutrition care plan initiated 07/15/24 and last revised 12/03/24 revealed he was on a regular diet and desired double protein. Interventions included providing his diet as ordered and meeting his preferences. An interview with Resident #31 on 12/02/24 at 3:44 PM revealed he had asked the dietary department numerous times for large portions or at least double protein throughout his stay. He stated the last time he asked the Dietary Manager for large portions was on 12/01/24.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff, Registered Dietician (RD), and Nurse Practitioner (NP) interviews the facility failed to provide Resident #52 with a renal diet as ordered. This failure affected 1 of 3 residents reviewed for nutrition. Findings included: Resident #52 was admitted to the facility 09/11/24 with diagnoses including diabetes and dependence on renal dialysis. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact and received dialysis. Review of Resident #52's Physician orders revealed a diet order dated 09/17/24 for a regular renal diet and no potatoes, tomato sauce/soup, dried beans, cooked spinach, bananas, oranges/orange juice, raisins, cantaloupe, honey dew, star fruit, nuts, or chocolate. Resident #52's nutrition care plan last updated 11/13/24 revealed he was on a regular renal diet with thin liquids and interventions included providing his diet as ordered and weighing him as needed. An observation of Resident #52's meal ticket and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews, the facility failed to maintain a complete and accurate medical record when staff documented that they applied a splint when a splint was not applied. This occurred for 1 of 3 residents (Resident #73) reviewed for accurate medical records. The findings included: Resident #73 was admitted on [DATE] with diagnoses that included contracture of muscle, right hand. A physician's order dated 11/01/2023 read- Staff to don (apply) right hand splint, Place Pillow under right hip, all shifts to access for any skin irritation. Doff (remove) pm shift, every shift. An observation of Resident #73 on 12/02/2024 at 11:34am revealed Resident #73 did not have a splint in place to her right hand. During observation on 12/03/2024, Resident #73 was observed at 9:33am with no splint on right hand. A review of the Medication Administration Record (MAR) revealed it was documented by Nurse #2 on 12/02/2024 and 12/03/2024 that the splint was applied to Resident #73 ' s right hand.…

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 implement their abuse policy and procedures in the areas of employee training and investigation by not preserving evidence that could be used in a sexual assault allegation. Nurse #1 and Nurse Aide #1 provided incontinent care to a [AGE] year old female resident with severe impairment in cognition (Resident #2) and disposed of the brief after finding a [AGE] year old male resident with moderate impairment in cognition (Resident #1) with his short/boxers pulled down lying in bed up close and behind the female resident with the perceived intention of engaging in sexual activity. This deficient practice affected 1 of 4 residents reviewed for abuse. Findings included: The facility policy titled Abuse, Neglect and Exploitation with a revised date of 03/02/23 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that…

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, observation, and resident and staff interviews, the facility failed to ensure toenails were trimmed and refer a resident to podiatry services for 1 of 1 resident (Resident #85) reviewed for foot care. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included chronic gout with tophus (buildup of uric acid around joints). Resident #85's care plan revised on 3/22/23 indicated Resident #85 had an activities of daily living (ADL) self-care performance deficit related to impaired balance due to severe tophus feet deformities. Interventions included for nursing staff to provide ADL assistance per facility schedule and as needed. A review of Resident #85's medical record indicated a physician's order dated 3/22/23 of: May initiate evaluation and treatment by podiatry per regulation. There were no podiatry consults in Resident #85's medical record. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, resident, staff, Pharmacist, Nurse Practitioner, and Medical Director interviews, the facility failed to re-order medications from the pharmacy when there were 5 doses left to ensure medications were available to be administered for 2 of 2 residents (Resident #15 and Resident #35) reviewed for significant medication errors. The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atrial fibrillation, chronic pain, neuropathy, and muscle spasms. a. A review of Resident #15's physician's orders indicated an active order for Baclofen tablet 20 milligrams (mg) - give 20 mg by mouth 2 times a day at 6:00 AM and 6:00 PM for muscle spasm which started on 04/19/23. Resident #15's Medication Administration Record (MAR) from August to October 2023 indicated the following information. August MAR - on 08/27/23 the Baclofen which was scheduled to be given at 6:00 AM and 6:00 PM was missed for the 6:00 PM dose. The medication…

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, resident, staff, Pharmacist, Nurse Practitioner, and Medical Director interviews, the facility failed to administer medications as ordered by the physician that included Xarelto for atrial fibrillation, Baclofen for muscle spasms, Gabapentin for pain, Fentanyl patch for pain and Copaxone injections for Multiple Sclerosis. This occurred for 2 of 2 residents (Resident #15 and Resident #35) reviewed for significant medication errors. The findings included: 1. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atrial fibrillation, chronic pain, seizure disorder, neuropathy, and muscle spasms. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors and required limited to extensive assistance with all activities of daily living. The MDS assessment further revealed Resident #15 received anticoagulant medication 6 out of 7 days during the assessment period.…

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, resident and staff interviews the facility failed to obtain dental services needed for extractions for 1 of 2 resident's reviewed for dental services (Resident #62). The Findings Included: Resident #62 was admitted to the facility on [DATE] with diagnosis that included congestive heart failure and kidney disease. The annual Minimal Data Set (MDS) dated [DATE] coded Resident #62 as cognitively intact and with no dental concerns. A review of Resident #62's dental records revealed Resident #62 last received dental service on 10/7/22 and a dental consent for tooth extractions was signed on 10/21/22 by Resident # 62 and a Nurse Practitioner. A review of Resident #62's medical record and progress notes revealed no additional dental exams or dental notes after the signed consent on 10/22/23. On 10/09/23 at 2:10 PM Resident # 62 stated he had been waiting 6 months to receive his upper dentures. Resident #62 said during his last dental exam, he agreed to have his remaining upper teeth pulled so he…

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 interviews with staff, the facility failed to clean 2 of 2 ice scoop holders and failed to store an ice scoop under sanitary conditions. This practice had the potential to affect beverages served to residents. The findings included: An observation of the A Hall ice chest cooler ice scoop holder on 10/11/23 at 9:44 AM revealed standing water with grey/brown debris in the water in the bottom of the ice scoop holder. The tip of the ice scoop was submerged in the water. An interview with NA #2 on 10/11/23 at 9:44 AM said the coolers and ice scoops were cleaned by the kitchen but was unable to recall when ice chest and scoops were cleaned. An observation of the B Hall ice chest cooler and ice scoop holder on 10/11/23 at 10:05 AM revealed grey/brown debris in the bottom of the ice scoop holder with standing water. The standing water was not touching the ice scoop. The Dietary Manager (DM) stated on 10/11/23 at 10:39 AM the ice chest and ice scoops were not the responsibility of the kitchen to be checked for cleanliness and to be cleaned. The DM stated he was…

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

Based on observations, resident and staff interviews and record review, the facility's Quality Assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification and complaint surveys dated 07/11/22 and 07/23/21 to achieve and sustain compliance. This was for 1 recited deficiency on the current recertification and complaint investigation survey of 10/13/23 related to food procurement, store/prepare/serve-sanitary. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: F-812 - Based on observations and interviews with staff, the facility failed to clean 2 of 2 ice scoop holders and failed to store an ice scoop under sanitary conditions. This practice had the potential to affect beverages served to residents. During the previous recertification and complaint survey on 07/11/22, the facility failed to change oil used in a deep fryer that appeared burnt and black in color,…

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, observation, and interviews with the resident, staff and the Medical Director, the facility failed to provide nail care to 1 of 2 residents (Resident #85) reviewed for assistance with activities of daily living. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included chronic gout with tophus (buildup of uric acid around joints). Resident #85's care plan revised on 3/22/23 indicated Resident #85 had an activities of daily living (ADL) self-care performance deficit related to impaired balance due to severe tophus feet deformities. Interventions included for nursing staff to provide ADL assistance per facility schedule and as needed. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #85 was cognitively intact and required limited assistance with personal hygiene. An observation and interview with Resident #85 on 10/9/23 at 9:44 AM revealed he had long, thick fingernails on the right hand which extended…

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

Based on observation, staff interviews and record reviews, the facility failed to store unopened medications in the temperatures specified by manufacturer's guidelines for 1 or 4 medications carts observed during medication storage checks (A hall medication cart #2). The findings included: Review of facility's medication storage policy and procedure dated 11/01/20 indicated all medications in the facility would be stored in the medication rooms or medication carts according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Review of manufacturer's package insert for Latanoprost eye drops reveled unopened bottle should be stored under refrigeration between 36° to 46° Fahrenheit (F) and protected from light. Once opened, Latanoprost may be stored at room temperature up to 77° F for up to six weeks. Review of manufacturer's package insert for insulin glargine injection indicated unopened pen should be stored in refrigerator at 36°F to 46°F until expiration and kept away from direct heat and…

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