Willow Valley Center for Nursing and Rehabilitatio

Based on observations, record reviews, and staff interviews, the facility failed to ensure the sanitizing solution (chlorine) was maintained at the required concentration of 50 ppm (parts per million) during the final rinse cycle according to manufacturer's instructions in the low temperature dish machine; failed to maintain the food service equipment clean, free from debris and in good working condition; failed to ensure leftover food items stored for use in the walk-in cooler and walk-in freezer were sealed, dated and labeled; and failed to ensure facial hair was covered by dietary staff during food preparation. These practices had the potential for cross-contamination of food served to residents. Findings included: 1a. During the initial tour of the kitchen on 6/10/24 at 10:40 a.m., the operation of the low temperature dishwasher of the soiled breakfast dishware by dietary staff was observed. The sanitizing solution (chlorine) for the low temperature dishwasher did not register on the chlorine testing strips provided by the dietary staff. After retesting the concentration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to maintain clean and sanitary floors and walls (bathroom of rooms #321 and #509), maintain clean and sanitary shower curtains (rooms #503, #509, #512, and #525), maintain clean and sanitary privacy curtains (rooms #302, #321, #503, #504, and #506), ensure the toilet was clean and in good repair (room [ROOM NUMBER]), maintain doors and walls in good repair (rooms #424, #517, #525, and #528), maintain privacy curtain ceiling tracks in good repair (rooms #504 and #506), maintain bathtubs/showers clean and in good repair (rooms #506, #507, #516, #517, and #525), maintain furniture in good repair (rooms #409, #513), and maintain the ceiling and polyvinyl chloride pipe (PVC) in good repair (room [ROOM NUMBER]) for 4 of 4 halls (200 hall, 300 hall, 400 hall, and 500 hall ) reviewed for safe, clean, and homelike environment. The findings included: 1. (a). Observations of room [ROOM NUMBER] on 06/10/24 at 11:45 AM and 06/11/24 at 10:00 AM revealed dried…

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 submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination 3 of 4 residents (Resident #37, Resident #102 and Resident #103) reviewed for PASRR. Resident #37, Resident #103 and Resident #102 received a new mental health diagnosis following admission. The findings included: 1. Resident #37 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included traumatic brain injury (TBI), dementia with agitation and major depressive disorder. Upon re-admission, Resident #37 had a Level I PASRR number. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. The MDS further revealed the resident had no behaviors during the look back period. Nursing note dated 10/19/23 and authored by Nurse # 11 revealed Resident #37 had increased agitation. Further review of the nursing note revealed Situation, Background…

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 consultant pharmacist interviews and record reviews, the facility failed to act on recommendations made by the consultant pharmacist and retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record for 1 of 7 residents whose medications were reviewed (Resident #97). The findings included: Resident #97 was admitted to the facility on [DATE]. Her cumulative diagnoses included an adjustment disorder with anxiety. A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for diazepam (an antianxiety medication). Diazepam is a psychotropic medication and a controlled substance medication. --A physician's order was received on 11/10/23 for 5 milligram (mg) diazepam to be given as one tablet by mouth every 8 hours as needed (PRN) for anxiety. The order was discontinued on 12/6/23. --On 12/12/23, 5 mg diazepam was ordered to be given by mouth every 8 hours PRN for…

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

Based on observations, interviews with staff, and record reviews, the facility failed to: 1) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 5 medication (med) carts observed (300 Short Med Cart); 2) Discard expired medications and/or meds without a legible expiration date on 4 of 5 medication carts observed (300 Short Med Cart, 300 Long Med Cart, 200 Long Med Cart, and 200 Short Med Cart); 3) Discard opened single-dose vials (SDV) after their initial use on 2 of 5 medication carts observed (300 Short Med Cart and 300 Long Med Cart); 4) Store medications in accordance with the manufacturer's storage instructions on 2 of 5 medication carts observed (300 Long Med Cart and 200 Long Med Cart). The findings included: 1. An observation was conducted on 6/11/24 at 4:00 PM of the 300 Short Med Cart in the presence of Nurse #9. The observation revealed the following medications were stored on the med cart: a. According to the manufacturer, in-use insulin glargine prefilled pens should be stored at room temperature of less than 86…

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 a meal test tray observation and interviews with the Dietary Manager (DM), the facility failed to serve food that was palatable and at temperatures acceptable to 1 of 5 Halls (200 Hall). This practice had the potential to affect other residents. Findings included: An observation of the meal tray line service in the kitchen was conducted on 6/12/24 at 1:15 p.m. The temperatures of the food items on the steamtable were taken by the DM using a calibrated stem thermometer. The temperatures of the food items of regular consistency were greater than the acceptable 135 degrees Fahrenheit. The top of the plated meals was protected with lid covers, but no insulated bottoms due to the large plate size. The meals were placed in a stainless-steel meal delivery cart. The delivery cart was filled with plated meals for the residents on the 200 hall was missing the doors. The cart left the kitchen at 1:23 p.m. and arrived on the 200 long hall at 1:25 p.m. where the nursing staff immediately began serving the residents. A test meal tray of the regular textured foods was included in the meal…

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, staff interviews and record review, the facility failed to ensure the handrails in the facility corridors were properly secured to the walls, repaired and free from sharp edges on 3 of 4 floors where handrails were present. The findings included: An observation was conducted on 6/11/24 at 12:42 PM to 1:00 PM, revealed on the 500 floor the handrails were detached from the walls and needed repairs due to broken/cracked support backets and missing end caps in the corridor joining rooms 503, 507, 511, 514, 5/19, 520, 526, 527 on the hallways. The end of the handrails had sharp edges that were not covered by the endcaps. Staff and residents were observed using the handrails in the current condition. An observation was conducted on 6/11/24 at 1:30 PM to 1:45 PM on the 300 floor, revealed the unit handrails in the corridor joining the rooms 321, 326, 327 and near the janitor hall closet close to the dining room were loose, detached from the walls and needed repairs due to broken/cracked handrails…

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, resident and staff interviews, the facility failed to honor a resident's request to be assessed for smoking for 1 of 3 sampled residents (Resident #128) reviewed for choices. Findings included: Resident #128 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra, lumbosacral region, Parkinson's disease, and congestive heart disease. The admission Minimum Data Set, dated [DATE] indicated Resident #128 was cognitively intact. Review of the facility's Safe Smoking Screening dated 4/30/24 included Resident #128 did not currently smoke. During an interview on 6/11/24 at 1:09 p.m., Resident #128 revealed she was a smoker and since she was admitted to the facility had requested to be assessed to smoke. The resident stated smoking calmed her and she frequently begged staff (unable to name staff) to be assessed for smoking but was always told that staff did not have time to assess her for smoking. On 6/14/24 at 2:10 p.m. Nurse #2 revealed she completed 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, staff interviews, and record review the facility failed to maintain personal privacy by failing to prevent exposure of a resident's body parts during incontinence care for 1 of 3 residents (Resident #168) reviewed for personal privacy. The reasonable person concept was applied to this deficiency as individuals have the expectation of privacy during incontinence care. The findings included: Resident #168 was readmitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #168 was severely cognitively impaired for daily decision making and required extensive to total assistance by 1 staff for toileting needs. On 06/12/24 at 2:17 PM, an observation was conducted of the 500 hall. This surveyor, the Maintenance Director, and the Environmental Services Director observed Nurse Aide #1 (NA) provide incontinence care to Resident #168. The Resident's door was open, and the privacy curtain was not fully pulled around the bed to ensure his privacy.…

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 interviews, and staff interviews the facility failed to record a grievance and to make efforts to resolve the grievance for 1 of 3 residents reviewed for grievances (Resident #36). Findings include: Resident #36 was readmitted on [DATE]. Review of Resident #36's most recent Minimum Data Set (MDS) revealed a quarterly assessment with an Assessment Reference Date (ARD) of 04/19/24. The resident was coded as having severe cognitive impairment. During a phone interview with the guardian of Resident #36 on 06/13/24 at 11:43 AM she stated she had visited Resident #36 on 06/07/24 and observed that Resident #36's roommate removed his brief and shredded the brief into many pieces. She stated she observed the roommate masturbate and play in the feces from the shredded brief during her visit. The guardian stated she sent an email to Social Worker (SW) Assistant #1 to inform her of Resident #36's roommate's behavior and to request moving Resident #36 to another room. The guardian stated 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 record review, resident and staff interviews, the facility failed to complete and submit an Initial Allegation Report within 2 hours to the State Regulatory Agency for 1 of 1 resident (Resident #209) reviewed for neglect. Findings included: Resident #209 was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #209 was cognitively intact and required substantial to max assistance with toileting. Upon interviewing Resident #209 on 6-10-24 at 11:25am, the resident voiced feeling dirty, neglected, and angry being left in 3 briefs that were soiled and urine soaked while she ate her breakfast meal. The Administrator was informed on 6-12-24 at 4:32pm by this surveyor of Resident #209's feelings of neglect, angry, and dirty' when the resident was left in 3 briefs, that were soiled, and urine soaked while she ate breakfast. A telephone interview on 6-18-24 at 11:17AM with the Administrator stated she had not completed an Initial Allegation Report and they had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and Ombudsman and staff interviews, the facility failed to provide written notification to the ombudsman of the transfer of 1 of 3 sampled residents (Resident #265) to the hospital. This practice had the potential to affect other residents discharged . Findings included: Resident #265 was originally admitted to the facility on [DATE]. The annual Minimum Data Set, dated [DATE] indicated Resident #265 was cognitively intact. Review of the clinical records revealed Resident #265 was transferred to the hospital on 5/10/24 per his request and physician's order related to pain and discomfort in his bilateral lower extremities. The resident was subsequently admitted to the hospital. There was no documentation indicating a written notice of transfer was provided to the ombudsman. A telephone interview with the Ombudsman on 6/13/24 at 9:24 a.m. revealed she had not received any of the facility's May 2024's discharge summaries, including Resident #265's discharge to the hospital on 5/10/24. During…

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 accurately code the Minimum Data Set (MDS) assessment related to the Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 4 residents (Resident #174) reviewed for PASRR. The findings included: Resident #174 was admitted to the facility on [DATE] with a cumulative diagnosis which included paranoid schizophrenia. Resident #174's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. The Identification Information section of this MDS assessment did not report Resident #174 had a PASRR Level II determination. Further review of the resident's electronic medical record (EMR) revealed Resident #174's care plan included the following area of focus, in part: The resident has a Level II PASRR related to serious mental illness (Initiated 8/3/23; Revised 4/2/24). An interview was conducted on 6/13/24 at 10:35 AM with the facility's Director of Social Work (SW). Upon request, the Director of SW…

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 resident interviews the facility failed to involve the resident and/or resident representative in the care planning process for 1 of 1 sampled resident (Resident #94) reviewed for care plan participation. The findings included: Resident #94 was admitted on [DATE] with diagnoses in part, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and major depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was assessed as cognitively intact Review of the Social Worker Note dated 2/21/24 and authored by Social Worker Assistant #2 indicated Resident #94 was assessed as alert and oriented to self, place, time and situation. The resident was able to make needs known to staff without issue. Resident #94 was assessed as cognitively intact. The resident would remain in the facility for Long Term Care (LTC) Services. SW will continue to monitor. Review of the resident's care plan (completion date) 3/18/24 revealed the resident was care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff, and resident interviews, the facility failed to provide (1) incontinence care to a resident dependent on staff. The facility also (2) failed to provide nail care to a resident who was dependent on staff. This occurred for 2 of 2 residents (Resident #209 and Resident #14) reviewed for activities of daily living (ADL) care. Findings included: 1. Resident #209 was admitted to the facility on [DATE] with multiple diagnoses that included enterocolitis and diabetes. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #209 was cognitively intact and required substantial to max assistance with toileting. The MDS also documented Resident #209 was frequently incontinent of urine and always incontinent of bowel. Resident #209's care plan dated 5-23-24 revealed the resident had an activities of daily living (ADL) deficit due to enterocolitis and diabetes. The goal for Resident #209 was to improve the current level of ADL function. The interventions were one staff…

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 interview the facility failed to have cautionary signage for oxygen (O2) use for 1 of 2 residents (Resident #176) reviewed for respiratory care. The findings included: Resident #176 was admitted to the facility on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #176 was cognitively intact. She was further coded as receiving oxygen therapy. Review of Resident #176 physician order dated 4/10/24 stated oxygen continuously at 3 liters per minute (lpm) via nasal cannula for COPD. Observation on 6/10/24 at 10:29 am revealed Resident #176 to be in her room with O2 being delivered via nasal cannula. There was no cautionary signage observed to the entrance of Resident #176's room indicating the use of O2. Observation on 6/11/24 at 4:26 pm revealed Resident #176 to be in her room with O2 being delivered via nasal cannula. There was no cautionary signage indicating…

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 ensure a resident attended an infectious disease clinic appointment at an outside facility for 1 of 1 sampled resident reviewed for medically related social services (Resident #616). The findings included: Resident #616 was admitted on [DATE] with diagnoses that included pneumonia, diabetes, latent tuberculosis, and chronic kidney disease. Review of Resident #616's hospital discharge summary 02/29/24 revealed an infectious disease clinic appointment scheduled for 03/11/24. Resident #616's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. There was no evidence in the medical record that Resident #616 attended her 03/11/24 infectious disease clinic appointment scheduled for 03/11/24 as noted on the hospital discharge summary. The medical record indicated Resident #616 was discharged from the facility on 03/13/24. A phone interview was conducted on 06/10/24 at 10:20 AM with Resident #616 and she…

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, interviews with a representative from the dispensing pharmacy and facility staff, and record reviews, the facility failed to ensure a medication (a topical anti-fungal powder) was available for application as ordered by a physician, resulting in multiple doses of the prescribed medication being missed for 1 of 4 residents (Resident #416) observed during the medication administration observation. The findings included: Resident #416 was discharged from a hospital to the facility on 5/30/24 with a diagnosis which included cirrhosis of the liver. His hospital Discharge Medication List (dated 5/30/24) indicated Resident #416 should discontinue use of 250 milligram (mg) terbinafine (an oral antifungal medication) previously taken and initiate the use of 2 percent (%) miconazole powder (a topical antifungal medication) to be applied topically two times daily. The resident's admission orders to the facility included a medication order dated 5/30/24 for 2% miconazole powder to be topically applied to folds of the skin twice daily for dry skin (Start Date 5/31/24). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 2 of 7 residents whose medications were reviewed (Resident #97 and Resident #28). The findings included: 1. Resident #97 was admitted to the facility on [DATE]. Her cumulative diagnoses included chronic obstructive pulmonary disease (COPD) and adjustment disorder with anxiety. A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for diazepam (an antianxiety medication). Diazepam is a psychotropic medication and a controlled substance medication. --A physician's order was received on 11/10/23 for 5 milligram (mg) diazepam to be given as one tablet by mouth…

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, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 29 opportunities, resulting in a medication error rate of 6.9% for 2 of 4 residents (Resident #74 and Resident #416) observed during the medication administration observation. The findings included: 1. Resident #74 was admitted to the facility on [DATE]. Her cumulative diagnoses included hypertension and a history of cerebrovascular accident (stroke) with dysphagia (difficulty swallowing). On 6/12/24 at 8:28 AM, Nurse #4 was observed as he prepared to administer medications to Resident #74. The nurse collected blood glucose (sugar) monitoring supplies, checked Resident #74's blood glucose, and administered 4 units of Humalog insulin (a rapid-acting insulin) to the resident in accordance with her physician's orders. At 8:39 AM on 6/12/24, Nurse #4 was observed as he completed his preparation of five (5) medications for administration via a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to document providing education of the influenza vaccine pneumococcal vaccine and the resident's or resident representative's refusal to receive the pneumococcal vaccine for 1 of 5 residents reviewed for immunizations (Resident #182). Findings included: Resident #182 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #182 was severely impaired cognitively. There was no documentation in the electronic medical record (EMR) Resident #182 had received the pneumococcal vaccine at the facility. There was also no reported history of Resident #182 receiving a pneumococcal vaccine outside of the facility prior to being admitted . The facility was unable to provide written documentation Resident #182 or Resident #182's Representative had received education to consent to receive or refusal of administration of pneumococcal vaccine. Attempts to interview Resident #182's Responsible Party were…

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, and staff interviews the facility failed to prevent 1 of 3 residents (Resident #1), reviewed for accidents, from falling from bed. Resident #1 fell from the bed when it was left at the highest level by a staff member which put him at increased risk of injury. Findings included: Resident #1 admitted to the facility on [DATE] with diagnoses of stroke and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required extensive assistance with bed mobility and transfers from the bed. Resident #1's Care Plan dated 8/7/2023 indicated he was at increased risk of falls due to limited mobility and weakness due to a stroke. The Care Plan further indicated Resident #1 should have his bed in the lowest position to prevent injury. Review of Resident #1's medical record revealed a Progress Note written by Nurse #1 on 8/22/2023 at 10:09 pm which stated Resident #1 was found on the floor beside his bed on his…

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

Based on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the 5/24/2022 recertification and complaint investigation survey. The deficiency was in the area of supervision to prevent accidents F689. The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: The tag is cross-referenced to: F689-Based on record review, observations, and staff interviews the facility failed to prevent 1 of 3 residents reviewed for accidents (Resident #1) from falling from the bed. Resident #1 fell from the bed when it was left at the highest level by a staff member which put him at increased risk of injury. During a recertification and complaint investigation survey completed 5/24/2022 the facility failed to provide safe care to a dependent resident which resulted in the resident falling out of bed and sustaining injuries. 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 resident and staff interviews, and review of the Resident Council Minutes, the facility failed to respond to repeat concerns related to dietary issues voiced by residents during Resident Council meetings for 3 of 4 months (April 19, 2023, June 22, 2023, July 19, 2023). Findings included: The Resident Council meeting minutes for April 2023, June 2023 and July 2023 revealed resident council members made the Activity Director aware of repeat dietary concerns and there was no evidence that follow up was provided to the resident council members. The minutes indicated Resident #25, Resident #249, Resident #87, Resident #171, and Resident #166 attended meetings routinely. A review of the grievance logs from April 2023- July 2023 revealed no group grievances were submitted by or on behalf of resident council members for these months. On 08/2/23 at 2:00 PM a Resident Council meeting was held and attended by 6 alert and oriented members of the resident council (Resident #25, Resident #249, Resident #87, Resident #171, Resident #166). During the meeting the residents were notified…

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 reviews, and staff interview, the facility failed to provide residents with the correct portion sizes as specified by the menus and the meal production worksheets for 1 of 1 meal observation. This practice had the potential to affect all residents with regular consistency diets. Findings included: An observation of the dietary staff plating meals from the meal steamtable in the kitchen was conducted with the Dietary Manager (DM) on 8/2/23 at 1:15 p.m. One cooked patty of hamburger steak was placed on the plates of residents receiving meals of regular texture. The hamburger steaks on the tray line were all of equal shape and size. Only one hamburger steak patty was plated for each tray observed. This surveyor requested and the DM weighed one of the cooked hamburger steak patties from the steamtable which yielded a weight of 2-ounces. The dietary department's meal production worksheet used in determining the amount of each food item to serve to each resident indicated each resident was to receive 4-ounces of cooked hamburger steak patty. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on test tray observation, record reviews and interviews with residents and the Dietary Manager (DM), the facility failed to serve food that was palatable and at temperatures acceptable to 1 of 5 Halls (400 Hall). This practice had the potential to affect other residents. Findings included: Resident #26 was admitted to the facility on [DATE]. Resident #26 resided on the 400 Hall. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and independent with eating after assistance with meal set up. During an interview with Resident #26 on 08/01/23 at 11:15am she indicated she had concerns with her meals being cold and the taste of the food was not good. She stated she only would receive a small amount of food and it would be cold on her meal trays. Resident #26 indicated she had reported this information to the Administrator, but he never did anything about it. An interview was conducted on 08/03/23 at 1:00pm with Resident #26 during her lunch meal…

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 interview, the facility's Quality Assessment and Performance Committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigation survey conducted on [DATE], recertification/revisit and complaint survey conducted on [DATE] and the recertification and complaint investigation survey conducted on [DATE]. This was for five deficiencies in the areas of: Advanced Directives (F578), Notification of Changes (F580), Quality of Care (F684), Nutrition/Hydration Status Maintenance (692), and Menus Meet Residents Needs (F803) which were originally cited during the recertification and complaint investigation survey conducted on [DATE] and recited during the current recertification and complaint investigation survey conducted on [DATE]. In addtion, Accuracy of Assessments (F641) was cited on the complaint investigation survey conducted on [DATE], recertification/revisit and complaint…

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 determine on admission a resident's desired advanced directives throughout the medical record for 3 of 35 residents (Resident #189, # 399, and # 8) reviewed for advanced directives. The findings included: 1.a. Resident #189 was admitted to the facility on [DATE]. A review of Resident #189's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident had severe cognitive impairment. A review of Resident #189's care plan dated 4/6/23 and last revised on 7/27/23 for advance directive. The goal was to honor Resident's advanced directive through the next review. The intervention was to follow the advanced directive on the MOST (Medical Orders for Scope of Treatment) form. A review of Resident #189's physician orders revealed no order for advance directives and/or code status. A review of unit 500's code status/advance directive book revealed there was not a MOST form or information for Resident #189's code status/advance directive in the book. 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 staff interviews and medical record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change occurred for 1 of 1 residents (Resident #8) reviewed for Hospice. Findings included: Resident #8 was admitted to the facility on [DATE]. The diagnosis included, in part, cerebrovascular disease and chronic pulmonary obstructive disease. The significant change MDS assessment with an assessment reference date (ARD, the last day of the assessment period) of 7/24/23 was reviewed and revealed the assessment has not been completed as of 8/4/23. Review of the Hospice admission agreement revealed Resident #8 received hospice services starting on 7/1/23. An interview was conducted with the MDS Coordinator on 8/4/23 at 3:28 PM. She revealed that the significant change in status assessment was late because she was not aware that Resident #8 had started hospice services on 7/1/23 until 7/24/23. She further…

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 accurately document Preadmission Screening and Resident Review (PASARR) status and dental status on the Minimum Data Set (MDS) assessment. This occurred for 1 of 35 residents reviewed for accuracy of assessments (Resident #31). The findings included: 1.a. A level II PASARR determination notification dated 12/30/2019 was observed for Resident #31. Resident #31 was admitted to the facility on [DATE] with diagnoses that included schizophrenia and a traumatic brain injury. The comprehensive MDS dated [DATE] noted Resident #31 was not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. An interview was conducted with MDS Consultant #1 on 8/3/2023 at 10:55 a.m. He reviewed the comprehensive MDS dated [DATE] and stated the level II PASARR was coded inaccurately. 1.b. Resident #31 was admitted to the facility on [DATE] with diagnoses that included…

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.