Complete Care at Linwood, LLC

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date food products stored in a refrigerator, spice rack, and meat freezer; b) properly discard food products on or before the expiration date; and c) properly store food products in a manner without covers. The deficient practice was evidenced by the following: On 10/02/2024 from 9:47 AM to 10:48 AM, the surveyor, accompanied by the Dietary Director (DD) and later at 10:47 AM joined by the Regional Dietary Director (RDD), observed the following: 1.) Next to the preparation table near the sink, the surveyor observed breadcrumbs inside a clear container labeled flour and not labeled with an open and use by date. The surveyor then observed a refrigerator referred to as the everything refrigerator. Within the refrigerator, the surveyor observed the following: 2.) A stick of butter opened to air and not labeled with an open and use by date. 3.) Two tomatoes in plastic wrap labeled with a use by date of 09/24/2024. 4.) One quarter pan of cooked…

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

Based on interview and record review it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner. This deficient practice was identified for 3 of 5 residents reviewed for medication management (Resident #70, Resident #92, and Resident #50). The deficient practice was evidenced by the following: On 10/03/2024 at 08:48 AM the surveyor requested from the Director of Nursing (DON) the CP's recommendations for Resident #70, Resident#92, and Resident # 50, from the last 6 months. 1. A review of the admission Record for Resident#70 revealed the resident was admitted to the facility with the diagnoses which included but were not limited to Heart Failure, and Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). On 10/03/2024 at 01:17 PM, the DON provided the surveyor with Resident #70's CP recommendation reports for April 2024 through September 2024. The CP recommendation dated 09/12/2024, indicated that the medication Carvedilol (medication used…

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 #NJ167309 Based on interview, record review and document review it was determined that the facility failed to maintain documentation and ensure that a complete and thorough investigation was conducted for residents that had unwitnessed fall. This deficient practice was identified for 1 of 4 residents (Resident #278) reviewed for accidents and was evidenced by the following: The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Review of Resident #278's electronic medical record (EMR) Progress Notes revealed the following entries: On 07/22/2023 at 11:40 AM, a nursing progress…

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: NJ00167309 Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to revise a comprehensive care plan to identify the nursing intervention required to care of a surgical wound infection. This deficient practice was identified for 1 of 26 residents (Resident #278) reviewed for care planning. The surveyor reviewed the medical record for Resident #278. A review of the admission Record (AR) revealed that Resident #278 had diagnoses which included, but were not limited to, surgical aftercare following surgery on the digestive system and retroperitoneal abscess (an infection between the abdominal wall and spine). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/17/2023, reflected a brief interview for mental status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Under Section M (Skin Conditions) identified that Resident #278 had a surgical wound and surgical wound care. A review of Resident #278's Order Summary Report did not…

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

3.) A review of Resident # 70's admission Record indicated Resident #70 was admitted to the facility with diagnoses which include but were not limited to Heart Failure, Type 2 Diabetes Mellitus (a condition that occurs when the body doesn't respond properly to insulin, causing high blood sugar levels), and Morbid Obesity Due to Excess Calories ( a complex disease that occurs when the body stores to much fat due to an imbalance between calories consumed and calories used). A review of Resident #70's Treatment Administration Record (TAR) for March 2024 revealed a physician's order (PO) with an order date of 03/14/2024, for negative pressure therapy wound vac with Y connect to B/L [bilateral] hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed a blank on the TAR, there were no nurse's initials indicating the treatment was administered on 03/15/2024. Surveyor #3 observed a PO with and order date 03/07/2024 for Negative pressure therapy wound vac with Y connect to B/L hips, change every Mon, Wed, Fri for wound treatment. Surveyor #3 observed blanks on the TAR,…

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 # NJ00177156, 00176805 Based on observation, interview, and record review, it was determined that the facility failed to ensure residents received showers as scheduled for 1 of 2 sampled residents (Resident #21), reviewed for Activities of Daily Living (ADLs). This deficient practice was evidenced by the following: On 10/03/2024 at 10:39 AM, the surveyor observed Resident #21 in the room. He/She stated they would rather be home, but had no issues with this facility. According to the admission Record Resident #21 was admitted to the facility with diagnosis that included but were not limited to intellectual disabilities and depression. The Minimum Data Set (MDS), an assessment tool, dated 08/28/2024 reflected that Resident # 21 was moderately cognitively impaired and that resident required substantial assistance with showering. A review of the September 2024 Treatment Administration Record (TAR) for Resident #21 reflected that the Resident was scheduled for showers every Sunday and Thursday on the day shift and if the resident refused a shower, staff should document in the…

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

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store, label, and remove expired drugs from the facility inventory. The deficient practice was observed in 1 of 3 medication rooms and 1 of 9 medication carts reviewed under the Medication Storage Task. On 10/04/2024 at 9:26 AM, the surveyor observed the [NAME] Wing Medication Storage room in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM) #1. At that time, the surveyor observed the following concerns: Three cultures that expired on 09/23/2024. Three cultures that expired on 08/08/2024. Two urine vacutainers that expired on 06/30/2024. One 1000 milliliter (mL) bag of Dextrose solution that expired in July of 2024. Two bottles of Pantoprazole 2 milligram(mg)/mL with a use-by date of 08/30/2024. One bottle of Pantoprazole 2mg/mL with a use-by date of 09/27/2024. At that time, during an interview with the surveyor, the LPN/UM # 1 stated that all medication should have an opening date. Further, she stated that she did not know when 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, record review and review of pertinent facility documentation, it was determined that the facility failed to A.) perform hand hygiene before applying gloves and between changing gloves and B.) failed to follow transmission-based precautions, specifically by not using a gown within a resident's room who was on transmission-based precautions. The deficient practice was observed for 1 of 2 nurses observed for Medication Administration task and 1 of 1 Resident (Resident # 425) reviewed for Transmission Based Precautions. This deficient practice was evidenced by the following: A.) On 10/03/2024 at 08:18 AM during the Medication Administration task, surveyor #1 observed Licensed Practical Nurse (LPN) # 1 putting on personal protective equipment (PPE) prior to administering medications to Resident #100. LPN# 1 did not perform hand hygiene prior to putting on gloves. On 10/03/2024 at 08:33 AM surveyor #1 observed LPN # 1 put on a pair of gloves without performing hand hygiene to place a medication patch on Resident # 32. LPN #1 then realized her pen was 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.

Complaint #: NJ00160150, NJ00169450, NJ00159215 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to, a.) provide sufficient staffing numbers to meet minimum staffing requirements and b.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: Refer F677(D) a.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. 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 Complaint #: NJ00160150 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to ensure that proper incontinence care was provided to dependent residents. This deficient practice was identified for 2 of 3 residents (Resident #13, and #14) observed for incontinence care and was evidenced by the following: On 12/29/23 at 7:52 AM, the surveyor accompanied by Certified Nursing Assistants (CNA) completed an incontinence tour on the South Wing Nursing Unit. Three random residents who were identified by the CNAs as being dependent on staff for care, were observed for incontinence care. Surveyor #1, Surveyor #2, and CNA #3 entered Resident #13's room. Resident #13 was in bed wearing a hospital style gown. At that time, the resident granted permission for the surveyors to observe his/her incontinence brief. Surveyor #1 observed an incontinence brief applied to the resident. The CNA opened that brief exposing an additional brief…

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.

Compliant Number: NJ00159616 Based on observation, interview, and record review, it was determined that the facility failed to provide indwelling urinary catheter (a tube that is placed inside the bladder to facilitate the flow of urine) care in a manner to prevent urinary tract infections (UTI). This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for catheter care and urinary tract infection and was evidenced by the following: According to the admission Record, Resident #6 was admitted to the facility with diagnoses which included but not limited to: neuromuscular dysfunction of bladder (person who lacks bladder control due to brain, spinal cord, or nerve problems), chronic kidney disease (gradual loss of kidney function over time), and Type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose). According to the admission Minimum Data Set (MDS), an assessment tool, dated 9/20/2022, revealed that Resident #6's cognitive skills were severely impaired, and had an indwelling catheter. Additional review revealed active diagnosis…

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 Complaint # NJ00160024, NJ00160394, NJ00160202 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident nurse call system to operate as designed for 3 of 5 call bells observed. This deficient practice was evidenced by the following: On 12/29/23 at 8:00 AM, the surveyor observed North Wing Unit, no resident rooms had a call bell light illuminated above room doors. On 12/29/23 at 8:12 AM, the surveyor entered the Star Spa Bathroom (shower room) on North Wing and observed three call systems. The call bell located next to the toilet was activated by the surveyor at 8:12 am. The surveyor waited three minutes and exited the Star Spa Bathroom and notice no light was illuminated above the door. On 12/29/23 at 8:15 AM, the surveyor interviewed the Unit Clerk (UC). She indicated that if a call system is activated that the phone at the nurses station will sound and indicate what room it was triggered in, additionally the lights…

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 facility job description review, the facility failed to employ either a full time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service since March 2023. This failure had the potential to affect 115 residents who received food from the kitchen. Findings include: During an interview on 05/16/23 at 9:35 AM, the DM stated she had been employed as the facility's DM since March 2023. The DM confirmed that she recently completed the Serv Safe course but was not a Certified Dietary Manager (CDM). The DM stated the facility's Registered Dietitian (RD) was employed on a consultant basis and usually visited the facility once or twice per week. During an interview on 05/19/23 at 2:39 PM, the DM stated she worked as the facility's assistant dietary manager for a year prior to becoming the DM two and a half months ago. The DM confirmed she did not have prior experience working as a director of food and nutrition services in a nursing facility, was not a CDM and was not currently enrolled in a CDM course.…

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, resident, staff, and Ombudsman interviews, the facility failed to provide access to the resident identified telephone, for three of four units (West, East, and North), where calls can be made without being overheard. This failure created the potential for residents to be without private telephone communication. Findings include: On 05/17/23 at 1:00 PM, a Resident Council Meeting was conducted with seven residents (R31, R36, R39, R72, R84, R89, and R91) including the Resident Council President and the Resident Council [NAME] President. The residents present regularly attend the facility's monthly Resident Council meetings. R91 said the Resident Telephone, located at the end of the [NAME] Wing just before entering the secured South wing, is always blocked by wheelchairs and the lift. R91 further stated residents who do not have a private phone or a cell phone cannot access the phone. The other six residents, in attendance, confirmed R91's statement. R91 stated the concern had been raised numerous times with the Ombudsman (resident advocate) without any changes…

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, resident, staff, and Ombudsman interviews, the facility failed to provide a functioning ice/water machine on one (West) of four wings. This deficient practice had the potential to affect the proper hydration status of 38 residents who resided on the [NAME] unit. Findings include: 1. Review of R96's electronic face sheet, located on the Profile tab of the electronic medical record (EMR) revealed R96 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, hypertension, hyperlipidemia, anxiety disorder and anemia. Review of R96's Physician Orders, located under the Orders tab of the EMR, revealed no orders for a fluid restriction for R96. Review of R96's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/24/23 and located under the MDS tab of the EMR, revealed R96 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R96 was cognitively intact. The assessment recorded R96 was independent in locomotion,…

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, review of Resident Council meeting minutes, and facility policy review, the facility failed to have sufficient dietary staff to assure resident meals were served as scheduled. The failure had the potential to affect 115 residents who consumed meals prepared from the facility's kitchen. Findings include: 1. Review of the Resident Council meeting minutes, dated 04/25/23 and provided by the facility, revealed the following concern, . lunch and dinner has been served late . The staff response was . lunch trucks delivered at 11:30 AM and 4:30 PM . dietary must notify staff on the unit floor when trucks arrived . 2. A group interview was conducted on 05/17/23 at 1:00 PM with seven residents whom the facility identified as reliable historians. During the meeting, seven of the seven residents (Residents (R) 31, R36, R39, R72, R84, R89, and R91) voiced complaints about meals being served later than scheduled. R84 stated The food is always cold, tastes terrible, and it's late being delivered. R91 stated Meal trays are brought out on a cart, but…

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, tasting of foods on a requested test tray, record review, review of Resident Council meeting minutes, and facility policy review, the facility failed to serve food that was palatable and hot to eleven of eleven residents (Resident (R) 33, R34, R67, R111, R31, R36, R39, R72, R84, R89, and R91) reviewed for food palatability. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Review of R33's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/23 located under the MDS tab. The assessment recorded a Brief Interview for Mental Status (BIMS) score of 15 of 15 for R33, which indicated the resident was cognitively intact. During an interview on 05/16/23 at 10:40 AM, R33 stated the food served at meals was not hot. R33 specified the food served at the breakfast meal was cold more often than the other meals. 2. Review of the electronic…

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 the facility's meal schedule, the facility failed to have no more than 14 hours between the resident evening meal and breakfast meal the following day. This failure had the potential to affect 115 residents who received meals from the facility's kitchen. Findings include: Review of the facility's undated policy titled, Food Truck Delivery Schedule, revealed the following scheduled resident evening and breakfast meal delivery times for each unit and the total time scheduled between these two meals that exceeded the 14-hour time frame requirement: Ventilator Unit: Dinner 4:40 PM and Breakfast 7:45 AM- A total of 15 hours and 5 minutes scheduled between the resident evening meal and following breakfast meal. South Unit cart 1: Dinner 4:45 PM and Breakfast 8:20 AM- A total of 15 hours and 35 minutes scheduled between the resident evening meal and following breakfast meal. Low North Unit: Dinner 4:50 PM and Breakfast 8:10 AM- A total of 15 hours and 20 minutes scheduled between the resident evening meal and following breakfast meal. West…

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 facility policy review, the facility failed to keep the kitchen's milk refrigerator, electric slicer, three kitchen drawers, and canned food storage racks clean and sanitized and failed to date opened bread products and discard creamed soup and hot dog buns with expired use by dates. This failure had the potential to affect 115 residents who consumed food prepared from the facility's kitchen. Findings include: 1. Observation during the initial kitchen inspection on 05/16/23 from 9:45 AM to 10:30 AM, with the Dietary Manager (DM) present, revealed the following unclean food preparation and storage equipment: a. The interior of the kitchen's milk refrigerator had a very strong odor of soured milk. Observation under the crates of milk stored inside this refrigerator revealed a brownish and white colored liquid pooled in the bottom of refrigerator that smelled like soured milk. b. The kitchen's electric slicer, covered and ready for use, was unclean with a greasy residue and food debris on its blade and base. c. Three kitchen drawers, with food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy to one of 43 residents (Resident (R)101) on the South unit during care. The failure created the potential for R101 to be exposed to other residents, staff, and visitors. Findings include: Record review of the Medical Diagnoses, located in the electronic medical record (EMR), revealed R101 was admitted to the facility on [DATE] with diagnoses including dementia, gastrostomy, and colostomy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/15/23, located in the ''MDS'' tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severely impaired cognition. R101 was assessed to require extensive assistance of two persons for activities of daily living (ADL's). R101 was observed on 05/16/23 at 3:47 PM lying in bed in his room. The door to the room was open as well as the privacy curtain which permitted the resident to be seen, without obstruction,…

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, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 43 facility residents on one of four wings (South). For seven of 43 residents (Resident (R) 76, R17, R60, R122, R35, R30, R82) the environment was not maintained. Throughout the South unit the temperature was not controlled in a comfortable range creating a warm environment for residents, staff, and visitors. Findings include: ENVIRONMENT Observations of the South wing, a secured unit with 43 residents, on 05/16/23 10:44 AM, revealed the following: Resident (R)76's room: Part of a floor tile, approximately five by eight inches, near the head of bed B was heavily damaged with tile missing. There was an unsightly glue-like substance underneath the length of the windowsill that appeared to have run down and dried on the wall. The paint on the bathroom door was heavily marred and scarred. R17's room: There was a broken stationary chair, missing the right arm which exposed an approximate seven-inch spindle where the armrest should have been. 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, interviews, and facility policy review, the facility failed to ensure one of two medication carts on the secured unit was locked while unattended. This had the potential to affect 10 (Resident (R) 80, R93, R30, R57, R240, R115, R13, R95, R17 and R10) of 43 residents who were at risk for wandering on the secured unit. Findings Include: Review of R80's quarterly Minimum Data Set (MDS), located under the MDS tab of the electronic medical record (EMR) and with an Assessment Reference Date (ARD) of 03/10/23, revealed R80 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R80 was severely cognitively impaired. The MDS recorded R80 had diagnoses which included dementia, anxiety, and major depressive disorder, and self-propelled per wheelchair. Review of R93's significant change MDS, located under the MDS tab of the EMR and with an ARD of 02/23/23, revealed R93 had a BIMS score of 0 out of 15, which indicated R93 was severely cognitively impaired and had diagnoses including dementia with agitation, major depressive disorder, 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.