Abigail House For Nursing & Rehabilitation

Based on observation, interview, and review of facility documents, it was determined that the facility failed to ensure a) fall interventions were in place for a resident with a history of falls. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #382) On 4/4/25 at 10:43 AM, the surveyor observed Resident #382 awake and alert lying in bed. The surveyor observed two blue floor mats folded and stored at the head of the bed leaning against the wall. The resident stated he/she has had falls and stated, That's why I am here. On 4/7/25 at 9:00 AM, the surveyor observed Resident #382 lying in bed with his/her eyes closed. The resident had a floor mat in place to the resident's left side, but the floor mat for the resident's right side was folded up and not in place. On 4/9/25 at 8:18 AM, the surveyor observed Resident #382 in bed with their eyes closed. The resident had a floor mat in place to the resident's left side, but the floor mat for the resident's right side was folded up and not in place. The surveyor reviewed the medical record for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure respiratory equipment was stored in an appropriate way to prevent the spread of infection for 2 of 4 residents (Resident #28 and #57) reviewed for respiratory care. This deficient practice was evidenced by the following: 1.) On [DATE] at 10:31 AM, the surveyor observed that Resident #28 was not in their room. The surveyor observed a nebulizer mask (a device used with a nebulizer machine to deliver medication in the form of a mist directly to the lungs through the nose and mouth) was lying directly on the nebulizer machine located on the bedside table, uncovered and not stored in a plastic bag. The surveyor observed oxygen tubing not in use lying directly on the floor. On [DATE] at 8:15 AM, the surveyor observed Resident #28 awake and alert lying in bed. Resident #28 had an intact tracheostomy (an opening created in the neck to insert a tube into the trachea (windpipe) This allows…

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

Based on observation, interview, record review and review of facility documents, it was determined that the facility failed to a.) obtain a physician's order b.) obtain consent, c.) perform a side rail safety assessment, and d.) follow the facility's policy for side rail assessment and protocol prior to the application of two half side rails and two quarter side rails to a resident's bed. This deficient practice was identified for 1 of 1 resident (#13), reviewed for restraints and was evidenced by the following: On 4/4/25 at 11:15 AM, during the initial tour of the facility, the surveyor observed Resident #13 lying in bed with two bilateral half side rails and two bilateral quarter side rails in the raised position on the resident's bed. When interviewed, the resident stated that he/she used the upper side rails to reposition in bed. The resident was unable to state when the side rails were placed on the bed. On 4/7/25 at 10:31 AM, the surveyor reviewed the medical record for Resident #13. A review of the admission Record (an admission summary), revealed the resident had diagnoses…

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

Based on observation, interview and record review, it was determined that the facility failed to ensure that as-needed (PRN) psychotropic medications were ordered for no more than 14 days. This was identified for 1 of 5 residents (Resident #40) reviewed for psychotropic medication use . This deficient practice was evidenced by the following: On 04/10/2025, at 11:35 AM, the surveyor observed Resident #40 sitting quietly and calmly in the day room, smiling. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dementia, and major depressive disorder with psychotic symptoms. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/10/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 6/15/2024, that the resident is at risk 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review other facility documentation, it was determined that the facility failed to ensure residents' records were kept confidential for 3 of 6 residents (Resident #30, #231, and #232) observed during the medication administration pass. This deficient practice was evidenced by the following: On 4/7/25 at 8:20 AM, the surveyor observed Licensed Practical Nurse (LPN) #3 prepare medications for Resident #30. When the nurse left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's record displayed on the nurse's laptop. On 4/7/25 at 8:30 AM, the surveyor observed LPN #3 prepare medications for Resident #231. When the nurse left the medication cart to administer the resident's medications, she did not put up a privacy screen to cover the resident's record displayed on the nurse's laptop. On 4/7/25 at 9:00 AM, the surveyor observed LPN #3 prepare medications for Resident #232. When the nurse left the…

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

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to ensure: a.) kitchen staff performed hand hygiene at the appropriate times and adhered to proper food handling procedures during the tray line observation b.) staff performed appropriate hand hygiene during meal service for 1 of 3 dining rooms observed (A Wing). This deficient practice was evidenced by the following: 1. On 4/9/25 at 12:16 PM, during a follow-up visit to the kitchen to observe the lunch meal tray line service, the surveyor observed [NAME] #1 who washed her hands at the handwashing sink for 21 seconds. [NAME] #1 then proceeded to donn (put on) a pair of gloves prior to preparing to obtain food temperatures from the steam table. [NAME] #1 placed several scoops and ladles in direct contact with the surface of the preparation area of the steam table. As [NAME] #1 proceeded to obtain food temperatures, her right arm brushed up against the scoops and ladles which caused them all to fall onto the floor. At 12:25 PM,…

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

Based on interview and review of other pertinent facility documentation, it was determined that the facility failed to ensure full implementation of the antibiotic stewardship program, including ongoing monitoring and use of a nationally recognized surveillance criteria when antibiotics were being prescribed. This deficient practice was identified for 3 of 3 residents (Resident #50, #78, and #124) reviewed for antibiotic stewardship. This deficient practice was evidenced by the following: On 4/9/2025 at 11:04 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she had worked at the facility full-time since February 24, 2025. The IP stated that she used the McGeer criteria (clinical and laboratory findings used to define and track infections in long-term care facilities). At that time, the surveyor reviewed the IP Checklist (a list of residents prescribed antibiotics). The IP checklist indicated the following: Resident…

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.

Complaint #: 165979 Based on observation, interviews, review of the medical record, and other pertinent facility documentation on 12/29/23, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) care as being provided to Resident #3 on the ADL Documentation form. This deficient practice was identified for 1 of 5 residents (Resident #3) reviewed for ADL care and evidenced by the following: Review of the admission Record revealed that Resident #3 was admitted to the facility on 6/2023 with medical diagnoses which included but were not limited to: Unspecified Dementia, Cerebral Palsy (a condition marked by impaired muscle coordination), Cerebral Infarction (disrupted blood flow to the brain), and Anxiety. Review of Resident #3's comprehensive Minimum Data Set (MDS) an assessment tool, dated 7/6/23, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 which indicated severe cognitive impairment. The MDS also indicated Resident #3 needed extensive assistance with ADL tasks including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have a surety bond in an amount large enough to cover the highest daily balance of the residents' trust fund account. This had the potential to affect 164 of 164 residents whose trust fund monies were held by the facility. Findings include: Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $202,548.31 on [DATE] and the highest daily balance for the period was $278,324.65 on [DATE]. Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $275,915.65 on [DATE] and the highest daily balance for the period was $354,435.91 on [DATE]. Review of the Resident Fund Trust Account bank statement, for the period of [DATE] through [DATE], revealed the lowest daily balance for the period was $350,361.47 on [DATE] and the highest daily balance for the period 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 observation, interview, record review, and policy review, the facility failed to ensure a call light was within reach for four of four residents (Resident (R) 14, R41, R65, R68) reviewed for call lights out a total sample of 47 residents. Findings include: 1. Review of R14's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following unspecified cerebrovascular disease (stroke) affecting left non-dominant side. Review of R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/18/23 revealed the resident required limited assistance with bed mobility and transfers and extensive assistance with dressing, toileting, and personal hygiene. Further review revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R14 was cognitively intact. Review of R14's Care Plan, initiated 08/06/16,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure information on the role of the State Ombudsman as an advocate was provided for three of three residents (Resident (R) 79, R46, and R88) reviewed in a total sample of 47 residents. This deficient practice resulted in the potential for lack of access to the State Ombudsman Advocacy Group. Findings include: 1.Review of R79's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diabetes mellitus, hypertension, and acute kidney failure. Review of R79's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 03/09/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R79 was cognitively intact. During an interview on 04/04/23 at 1:55 PM, R79 stated that he had been the Resident Council President of the facility for a year and a…

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

Based on observation and staff interviews, the facility failed to post in prominent locations the contact information for the Office of the State Long-Term Care Ombudsman program to include the name of the ombudsman, business address (mailing and email) and business number to ensure residents and resident representative were able to file a complaint. The resident census was 164 on the first day of survey. Findings include: Observations by five surveyors of the facility's lobby, hallways, resident units, and common areas of all three units throughout the entirety of the survey from 04/03/23 through 04/06/23, revealed the absence of postings of the contact information for the Office of the State Long-Term Care Ombudsman program. During an interview on 04/05/23 at 12:05 PM, the Activities Director (AD) confirmed the above required information was not posted. The AD stated that the ombudsman contact information posting had been removed during facility renovations in December 2022. During an interview on 04/05/23 at 2:15 PM, the Administrator stated the ombudsman posting had been removed…

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 interviews, record review, and policy review, the facility failed to make prompt efforts to resolve grievances, document evidence of investigations and resolutions for five of 12 grievances provided by the facility for review. Additionally, the facility failed to discuss the resolution or lack thereof with residents and family members. Findings include: Review of documents titled, Resident Concern Report, provided by the Director of Social Work (SSD) 2 from a binder located in her office, revealed five resident concern reports without resolution statements, documentation of the date that the grievance was turned over to the Social Work Department, the date the grievance with either resolved or unresolved, and/or if the resolution or the lack thereof was discussed with the resident or family. During an interview on 04/04/23 at 2:48 PM with the SSD1, she stated the grievances that are heard by the social workers are written up on a concern form and sent to the department manager of which the grievance correlates. SSD1 stated that the department managers follow up on their own…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete Pre-admission Screening and Resident Review (PASRR) Level 1 Screenings accurately and/or with new major mental illness diagnoses for three (Resident (R) 152, R34, and R141) of 47 sampled residents. Findings include: 1. Review of R152's admission Record, located under the Profile tab of the electronic medical record, revealed R152's principal admitting on diagnosis on 09/23/22 was schizoaffective disorder. Review of R152's Pre-admission Screening and Resident Review (PASRR) Level 1 Screen, dated 09/28/22 and located under the Misc tab of the EMR, indicated, . Does the individual have a diagnosis or evidence of a major mental illness limited to the following disorders . schizoaffective . The form was marked No and signed by Director of Social Work (SSD) 1. During an interview on 04/05/23 at 9:00 AM, SSD1 verified she had completed the Level 1 PASRR screening for R152. SSD1 stated she had obtained the diagnoses to complete the form from R152's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of R41's admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), and repeated falls. Review of R41's quarterly MDS with an ARD of 02/05/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated R41 was severely cognitively impaired and was totally dependent on the staff for personal hygiene. Review of R41's Care Plan, initiated 05/03/21 and located in the EMR under the Care Plan tab, revealed: R 41 requires extensive assist with daily bathing, dressing and hygiene; Intervention: R41 will need extensive assist of . hygiene. During an observation and interview on, 04/03/23 at 10:03 AM, R41 was observed appearing unshaven. R41 indicated to the surveyor that he would like a shave but would need assistance. R41's nails were observed dirty, with a dark brown substance underneath the…

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

Based on observation, record review, interview and review of facility policy, the facility failed maintain a medication error rate below five percent. Out of 37 opportunities there were five errors/omissions occurred during medication administration on one (A Wing) of three wings. The facility's medication error rate was 13.51% Findings include: Observation of medication passes throughout the facility on 04/04/23 and 04/05/23 revealed the following medication errors or omissions: 1. On A Wing 04/05/23 at 4:37 PM revealed Registered Nurse (RN)1 setting up medications for R92. A review of R92's physician orders located in the electronic medical records (EMR) Orders tab documented the resident was to receive cyclobenzaprine HCl Oral Tablet 10 milligrams (mg.) for muscle spasm. The resident did not receive the cyclobenzaprine for muscle spasm during the medication observation. Interview on 04/05/23 at 5:40 PM, RN1 verified she did not give the Cyclobenzaprine during the medication pass because none was available in the resident's medication box. 2. Observation on A Wing on 04/05/23 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.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide food storage in a safe and consistent manner, for one of three (Unit B) pantry refrigerators, and for one of one kitchen observed for food storage. This had the potential to affect 161 of 164 residents who consumed food from the kitchen, with possible foodborne illnesses related to the sanitation of food being stored and served. Findings include: During the initial tour of the main kitchen on 04/03/23 at 9:17 AM, accompanied by the Dietary Manager (DM) revealed dry spices [seasoning salt and cumin] and open liquid condiments [soy sauce] that were not labeled with either a received or opened dates. During observations of the Unit B refrigerator on 04/06/23 at 11:12 AM, revealed the second clear plastic shelf was covered with a light orange liquid substance. The refrigerator had five bottles of water, two which were opened and labeled with initials, but with no dates on them. There was leftover food in a plastic reusable container with initials and no date on top. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure that an admission record was completed for three residents (Resident (R)18, R137, and R141) in a total sample of 47 residents. Findings include: 1. Review of R18's 5 day scheduled Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 02/27/23, revealed R18 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating severe cognitive impairment. 2.Review of R137's quarterly MDS located in the EMR under the MDS tab, with an ARD of 02/21/23, revealed R137 was admitted to the facility on [DATE] with a BIMS score of 13 out of 15, indicating mild cognitive impairment. 3.Review of R141's quarterly MDS located in the EMR under the MDS tab, with an ARD of 02/11/23, revealed R141 was admitted to the facility on [DATE] with a BIMS score of 00 out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to ensure that binding arbitration agreements were explained in a form and manner that residents understood, and failed to inform the resident that they had the right to rescind the agreement within 30 days of signing, for three residents (Resident (R)101, R103, and R152) of three residents reviewed for binding arbitration agreements out of a total sample of 47 residents Findings include: 1. Review of R101's quarterly Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 01/04/23 revealed R101 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, major depressive disorder, and anxiety disorder and had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating she was mildly cognitively impaired. 2. Review of R103's quarterly MDS, located in the electronic medical record (EMR) under the MDS tab, with an ARD of…

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

Based on interview and review of facility documentation, the Quality Assurance (QA) committee failed to identify and take corrective action related to the following quality deficiencies: 1. sanitizing multi-use glucometers before and after each resident; 2. binding arbitration agreements; 3. surety bond; and 4. medication administration errors. Findings include: 1. The facility staff failed to sanitize multi -use glucometers before and after each resident increasing the risk of transmission of blood borne pathogens to residents undergoing blood sugar checks. Cross reference: F880-K Infection Control. 2. The facility failed to ensure residents understood the binding arbitration agreements prior to signing and failed to ensure residents were given a choice of a neutral arbitrator and the option to rescind the agreement within 30 days of signing. Cross reference: F847-E Entering into Binding Arbitration Agreements and F848-E Binding Arbitration Agreements. 3. The facility failed to ensure that the facility's surety bond covered all the residents in the facility. Cross reference: F570-F…

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

Based on interview, record review, and policy review, the facility failed to facilitate resident council meetings for three of three consecutive months (January 2023, February 2023, and March 2023) and to consistently respond to issues and concerns presented by resident council members, and/or discuss and document its responses to the resident's grievances and recommendations with the Resident Council President (Resident (R) 79). Findings include: Review of the resident council meeting minutes for January 2023, February 2023, and March 2023 provided by the Director of Social Work (SSD) 1 on 04/04/23 at 1:45 PM, revealed that the facility did not have resident council meetings for those three consecutive months. Furthermore, there were repetitive concerns from month to month without any documentation of the facility responses or of the concerns being addressed. Review of documents titled, Residents' Council, for January 2023, February 2023, and March 2023 stated, ln lieu of resident's council meetings, activity staff were doing room-by-room visits during months of lockdown. Residents…

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, interview, and facility policy review, the facility failed to ensure that residents received assistance with formulating Advance Directives and had completed Physician's Orders for Life-Sustaining Treatment (POLST) forms for three (Residents (R)18, R93, and R76) of 12 residents reviewed for Advance Directives in a total sample of 47 residents. Findings include: 1. Review of R18's 5 day scheduled Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 02/27/23, revealed R18 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included anemia, dementia, neutropenia (low white blood cell count), and schizoaffective disorder (serious mental illness of hallucinations (hearing, seeing, smelling, touching objects not real) and delusions (firmly held beliefs not base on reality). R18 had a Brief Interview for Mental Status (BIMS) score of seven out of 15,…

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 interview, the facility failed to develop all care plans for two residents (Resident (R)76 and R159) out of a total sample of 47 residents. Findings include: 1. Review of R76's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident had diagnoses that included post-traumatic stress disorder (PTSD). Review of R76's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/07/23, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R76 had moderately impaired cognition. R76 also exhibited signs and symptoms of feeling depressed, poor concentration, poor appetite, and trouble sleeping. Further review of this MDS revealed R76 had an active diagnosis of PTSD and received antidepressant medication daily. Review of the resident's psychological evaluation, dated 03/15/23 and located in EMR Miscellaneous tab, revealed diagnoses which…

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

Based on observations, record review, interview, and review of facility policy, the facility failed to revise care plans for one resident (Resident (R)64) out of a total sample of 47 residents. Findings include: Observation 04/06/23 at 2:10 PM revealed R64 lying on a low air mattress with bolster pads on the sides to prevent entrapment. The head of bed (HOB) was elevated 45 degrees. Tube feeding of 2 Cal HN (name of tube feeding formula) was hanging with the pump turned off with 100cc (cubic centimeters) of formula remaining. R64 was observed wearing a heel lift boot in bed. Review of R64's admission Sheet, located in the EMR Profile tab, documented the resident was admitted with diagnoses that included dysphagia (difficulty swallowing), right below the know amputation (BKA), and type II diabetes mellitus. Review of the resident's Medicare five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/23, located in the EMR MDS tab, documented a BIMS score of one out of 15 which indicated R64 had severely impaired cognition. R64 was dependent on staff for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to consistently implement necessary treatment and services to a pressure ulcer to for one of five residents (Resident (R)41) reviewed for pressure ulcers out of total sample of 47 residents Findings include: Review of R41's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), psychosis (out of touch with reality), severe dementia with mood disturbance, convulsions, and repeated falls. Review of R41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/23 revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated R41 was severely cognitively impaired, required extensive assistance from the staff for bed mobility, and was at risk of developing pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate monitoring and supervision for 12 (Resident (R) 98, R36, R149, R159, R5, R99, R113, R32, R100, R102, R124, and R129) of 32 residents that required supervision per the smoking safety screen out of a total of 43 residents who smoked. The facility further failed to assess one (R129) of 42 residents that smoke.The facility failed to ensure a medication cart was locked during medication administration. The medication cart on the A 100 wing remained unlocked for 15 minutes with eye drops on top on the cart with staff members and residents passing by. Findings include: 1. Review of R98's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of undifferentiated schizophrenia (serious mental illness of hallucinations (hearing, smelling, tasting, seeing objects not present) and delusions (firmly held…

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

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R) 6) of eight residents observed during medication administration received the correct insulin and dosage according physicians' orders. This failure has the potential for R6 to experience either hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) readings. Findings include: During medication pass on 04/05/23 at 4:50 PM Registered Nurse (RN)1 performed a glucose reading on R6. RN1 stated the reading was 290 and according to the physician's orders the resident was on sliding scale coverage. The resident was to receive 10 units of Lispro with the evening meal. And according to the sliding scale the resident was to receive an additional 4 units of the Lispro Insulin which R6 would receive a total 14 units of Lispro Insulin. RN1 drew up 14 units of Lispro Insulin and administered to R6's left arm subcutaneously (subq). Review of the resident's Physicians Orders, located in the electronic medical record (EMR) Orders tab, revealed orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure one (Resident (R) 68) of 47 sampled residents had a functioning call light system. Findings include: Review of R68's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia and diabetes. Review of R68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score that was not assessed due to cognitive impairment. During an observation on 04/03/23 at 12:52 PM and 04/04/24 at 8:34 AM, R68's call light outlet was observed with no call light cord attached. There was no call light cord observed in the room. During a concurrent observation and interview on 04/05/23 at 12:30 PM, the Maintenance Director (MD) observed the call light outlet with the surveyor and confirmed the call light cord was not present in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner in order to prevent foodborne illness. This deficient practice was evidenced by the following: On 1/20/21 from 9:00 AM to 9:32 AM, the surveyor, accompanied by the Floor Manager (FM), observed the following the kitchen area: 1. In the reach-in refrigerator, a plastic bin contained sliced deli ham. The plastic bin was dated, 1-12-21, which indicated that the sliced deli ham had been in the refrigerator for 8 days. A Labeling and Dating System Protocol on the refrigerator door stated, Deli Meat opened. Sliced three days. During an interview, the FM said, This is trash, I'm throwing it away. The FM threw the sliced deli ham in the trash in the presence of the surveyor. 2. In the walk-in freezer, an unidentified red substance was on the floor under the 3-tiered rear storage shelf. Unidentified food debris was also on the floor…

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.