Henderson Health And Rehabilitation

Based on observation, interview, and document review the facility failed to ensure foods were stored properly and ice machines were cleaned in 1 of 2 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 07/29/2025 in the morning, there was an open bottle, without a lid, containing apple cider vinegar in the dry food storage area with a use-by date of October 19, 2024.There was an open bottle of lemon juice in the reach in cooler with a use-by date of July 20, 2025.On 07/29/2025 at 8:34 AM, the Dietary Director explained the apple cider vinegar should not have been stored without a lid and both the lemon juice and the apple cider vinegar should have been discarded on or before the use-by date.On 07/31/2025 in the morning, there was an ice machine in the B building back auxiliary hall closet with a white and brownish film on the bottom of the inner ice shield, and the plastic ice scoop was resting on the top of the ice machine.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 interviews, record review, and document review the facility failed to ensure a resident was free from physical restraints for 1 of 8 sampled residents (Resident 7). The deficient practice placed the resident at risk of physical and psychosocial harm. Findings include: Resident 7 (R7) R7 was admitted on [DATE] with diagnosis including dementia. A brief interview for mental status (BIMS) was conducted on 04/10/2025 and determined R7 had a score of 03 indicating R7 had severe cognitive impairment. The facility policy titled restraints (revised April 2025), documented it was the facility policy to ensure each resident was not restrained for the purpose of discipline or convenience. A restraint device assessment would be conducted to determine if the resident would be safe using the specific restraint. A physician order would be obtained indicating the type of device to be used, indication, duration, and how often it was supposed to be released. A report to the state agency documented upon admission to 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 interview, record review, and document review, the facility failed to provide documented evidence assistance with activities of daily living (ADL) was provided for 1 of 8 sampled residents (Resident 6). The deficient practice had the potential for the resident's skin integrity to be compromised. Findings include: Resident 6 (R6) R6 was admitted on [DATE] and discharged on 04/12/2025 with diagnoses including end stage renal disease, muscle weakness, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) dated [DATE], documented R6 was frequently incontinent of bowel and bladder and dependent with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). R6's activities of daily living (ADL) documentation for toilet hygiene lacked documented evidence the task was performed every shift on the following days: -03/21/2025 through 03/23/2025 -03/25/2025 -03/28/2025 -03/30/2025 and 03/31/2025 -04/02/2025 and 04/03/2025…

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 document review, the facility failed to follow physicians' orders for the application of a BiLevel Positive Airway Pressure BiPAP (a non-invasive ventilation device that facilitates breathing and improve oxygenation for conditions that impair breathing like COPD) for 1 of 8 sampled residents (Resident #3). The deficient practice had the potential to cause inadequate oxygenation, respiratory distress, or worsening of underlying conditions such as COPD, placing the resident in a risk for complications, including hypoxia, increased carbon dioxide retention, and respiratory failure. Findings include Resident #3 (R3) R3 was admitted on [DATE], with diagnoses including acute on chronic hypercapnic respiratory failure, chronic obstructive pulmonary disease (COPD) exacerbation, and history of chronic hypoxic respiratory failure. A hospital history and physical dated 01/19/2025, documented R3 was admitted to the emergency department due to complaining shortness of breath (SOB) 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 document review, the facility failed to ensure the call light buttons were within the reach of the residents for 1 of 11 sampled residents (Resident 1). The deficient practice had the potential safety risk of the resident experiencing delays in receiving necessary assistance, leading to potential safety risks like falls, discomfort, and being unable to alert staff when they need help. Findings include: Resident 1 (R1) was admitted on [DATE], with diagnoses including secondary malignant neoplasm of bone, generalized muscle weakness, repeated falls, with need for assistance with personal care. On 01/28/2025 at 10:56 AM, R1 was lying in bed and the call light was not within reach. R1's call light button was at the bedside table of adjacent resident. On 01/28/2025 at 11:01 AM, a housekeeper confirmed the call light was not within R1 reach. On 01/28/2025 at 11:13 AM, a Licensed Practical Nurse (LPN) verbalized the call light should have been within R1 reach and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and document review, the facility failed to ensure a sampled resident (Resident #4) with severe cognitive impairment was adequately supervised and was not able to elope from the facility. The deficient practice had the potential for physical and psychosocial harm to the resident. Findings include: Resident 4 (R4) R4 was admitted to the facility on [DATE] and re-admitted on [DATE]with diagnoses including bipolar disorder and dementia. A brief interview for mental status (BIMS) assessment documented a score of 03 indicating the resident had a severe cognitive impairment. A facility report investigation indicated on 10/22/2024, R4 had eloped from the facility and was out of the facility from 3:30 AM and was returned to the facility at 12:30 PM. The following was a timeline based on the investigation notes and interviews from the facility: - after video review it was determined the resident left the building at approximately 3:30 AM. - at 5:40 AM, a nurse in training entered 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 document review the facility failed to ensure the walk-in freezer was maintained in safe operating condition, food items stored inside the reach-in refrigerator and freezer were labeled, dated, and not expired, the kitchen was maintained in sanitary condition and a hand washing sink was provided for the steam table set up in the main dining room for meal service. The deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On 08/20/2024 at 7:49 AM, an initial tour of the kitchen with the Dietary Supervisor was completed with the following findings: - significant dust build up on vents and light fixtures over the food preparation and tray line area. - in the dry storage room there were damaged cans of beans and mushrooms stored with the active food items to be used. - in the walk-in freezer there were three fans for cooling at back of freezer and one did not have a blade cover. - in the walk-in refrigerator…

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 develop a care plan for denture care needs for 1 of 35 sampled residents (Resident 15). The deficient practice had the potential to place residents at risk for inability to chew food, malnutrition and unintentional weight loss Findings include: Resident 15 (R15) R15 was admitted on [DATE], with diagnoses including lack of coordination and dysphagia. On 08/21/2024 at 8:28 AM, R15 was observed sitting up in a wheelchair eating breakfast in their room. R15 had two pieces of toast, scrambled eggs, one banana and a glass of juice. R15 did not have any teeth while eating the banana. R15 had dentures and required assistance to put on the dentures. R15 stated they frequently ate without the dentures because they did not get help putting the dentures on during meal service. R15 voiced frustration with not getting help putting on their dentures and stated it limited food and eating options. R15 indicated the dentures were in a yellow denture cup 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 interview and record review the facility failed to provide pressure ulcer (PU) preventative measures for 1 of 3 sample closed records reviewed (Resident 246). The deficient practice had the potential to place residents at risk for worsening pressure ulcers and diminished quality of life. Findings include: Resident 246 (R246) R246 was admitted on [DATE] with stage 3 pressure wounds to the right heel, right lower extremity and coccyx. Review of the Minimum Data Set showed R246 required substantial/maximal assistance, rolling from left to right. Review of the care plan showed R246 had impaired skin integrity and existing pressure ulcers. Goals included potential for complications would be minimized. Interventions included: -Provide assistance with turning and repositioning to prevent skin breakdown. Review of the turning and repositioning flowsheet from 02/20/2024 to 03/11/2024, showed R246 was not repositioned for 15 shifts during this period. 02/20/2024- Not repositioned on the AM and night shifts…

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 document review, the facility failed to ensure a resident was provided 1:1 feeding assistance per physician order for 1 of 35 sampled residents (Residents 114). The deficient practice had the potential to prevent residents from consuming provided meals to maintain optimal weight. Findings include: Resident 114 (R114) R114 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease and dysphagia oropharyngeal phase and Barrett's esophagus without dysplasia. On 08/22/2024 at 8:05 AM, R114 was observed sitting in wheelchair in the middle of the 2100-Hallway holding an empty blue bowl with right hand, white cereal contents were spilled on R114's clothes. The resident had difficulty mouthing words but managed to say yes when asked if the resident needed help. Several rooms away, a nurse was standing behind a medication cart, there were no other staff members observed in the unit. On 08/22/2024 at 8:07 AM, a breakfast tray placed…

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 document review, the facility failed to ensure 1) dialysis (renal replacement therapy) appointments were not missed, or full treatment not completed for 2 of 7 sampled residents (Residents 114 and 220); and 2) dialysis communication records were completed for 3 of 7 sampled residents (Residents 176, 113, and 126). The deficient practice placed the residents at risk for complications of insufficient dialysis including but not limited to fluid overload, uremia (toxins in the blood) and electrolyte imbalance. Findings include: 1) Resident 114 (R114) R114 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. A physician's order dated 07/23/2024, documented R114's received dialysis treatments on Tuesdays, Thursdays, and Saturdays at an outpatient dialysis provider. A nursing progress note dated 07/18/2024, revealed the assistant administrator instructed the nurse to ask the physician if it was okay 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 interview and record review, the facility failed to ensure the Abnormal Involuntary Movement Scale was completed (AIMS - a rating scale designed to measure involuntary movements known as tardive dyskinesia which could develop as a side effect of an antipsychotic medication) for 1 of 35 sampled residents (Resident 15). The deficient practice had the potential to result in adverse consequences for resident's health and well-being. Findings include: Resident 15 (R15) R15 was admitted on [DATE], with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder. The physician's order dated 06/14/2024, documented Aripiprazole (Abilify - an antipsychotic medication) oral Tablet 5 milligram (mg) Give 1.5 tablet by mouth two times a day for mood changes. R15's Medication Administration Record (MAR) for August 2024, documented the resident had been receiving Aripiprazole as ordered. R15's medical record lacked documented evidence an AIMS assessment was completed upon initiation 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 observation, interview, and document review, the facility failed to ensure food was served at a palatable temperature for three sampled residents (Residents 9, 10, and 11) and one unsampled resident. The deficient practice had the potential to affect the amount of nutrients consumed by residents and their nutritional status. Findings include: Resident 9 (R9) R9 was admitted on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 14, which indicated R9 was cognitively intact. On 12/12/2023 at 10:00 AM, R9 verbalized eating in the room for breakfast and dinner and the food was regularly served cold. On 12/13/2023 at 9:29 AM, R9 indicated the breakfast and soup from last night's dinner was served cold. Resident 10 (R10) R10 was admitted on [DATE] and had a BIMS score of 15, which indicated R10 was cognitively intact. On 12/12/2023 at 10:00 AM, R10 verbalized eating in the room for breakfast and dinner and the food was regularly served cold. On 12/13/2023 at 9:29 AM, R10 indicated the breakfast…

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 document review, the facility failed to ensure a physicians' order was obtained and an assessment was completed for the self-administration of medication for 1 of 38 sampled residents (Resident 8). The deficient practice had the potential for the resident's unsafe administration of medication or adverse reactions to medication. Findings include: Resident 8 (R8) R8 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, muscle weakness, Parkinson's disease, and gastro-esophageal reflux disease without esophagitis. On 08/15/2023 at 9:35 AM, R8 was lying in bed. A bottle of Alka-Seltzer Extra Strength Heartburn Relief Chews 120 Chewable Tablets was found on top of the resident's bedside table. On 08/15/2023 at 9:46 AM, a Licensed Practical Nurse (LPN) confirmed the observations and revealed there were more or less 100 tablets remaining in the bottle. The LPN explained a physician'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 Based on observation and interview the facility failed to ensure Protected Health Information (PHI) was safe guarded for 3 of 38 sampled residents (Resident 395, 396, 51). The deficient practice had the potential to reveal confidential information to staff, residents, and visitors with the potential for resident identity to be revealed and information to be used inappropriately by others. Findings include: Resident 395 (R395) R395 was admitted on [DATE] with medical diagnoses including hepatic encephalopathy (deterioration of brain function due to liver disease). Resident 396 (R396) R396 was admitted on [DATE] with medical diagnoses including end stage renal disease. Resident 51 (R51) R51 was admitted on [DATE] with medical diagnoses including heart failure. On 08/16/2023 from approximately 7:31 AM to 7:47 AM, a Registered Nurse (RN) in the 100-hall entered and exited the room of R396 three different times. The medication cart was slanted and not completely facing the room of R396. The computer located on top 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 interviews, record review, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) involved in a verified allegation of neglect with unprofessional conduct was reported to the State Board of Nursing (BON) in accordance with the facility policy for 1 of 38 sampled residents. The deficient practice had the potential to place residents at risk of health and well-being. Findings include: Resident 155 (R155) R155 was admitted on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left side and generalized muscle weakness. The facility reported incident (FRI) dated 12/12/2022 documented the following: On 12/11/2022 R155 had new complaints of pain in left leg and physician was notified and diagnostic imaging was requested. On 12/12/2022 at 7:50 AM, the facility received notification R155 had a left femur fracture and was sent to hospital for further treatment. On 12/12/2022 the facility sent a 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 interview and document review, the facility failed to update a resident's care plan following a resident-to-resident altercation for 1 of 38 sampled residents (Resident 107). The deficient practice had the potential to place the resident at risk for inappropriate care, supervision, and accidents. Findings include: Resident 107 (R107) R107 was admitted on [DATE] with diagnoses including dementia with behavioral disturbances and Alzheimer's Disease. According to a Licensed Practical Nurse and medical records, R107 was non-verbal. On 08/15/2023 at 11:21 AM, R107 was lying in bed, with eyes closed and no visible injuries were noticed. R107 was involved in a resident-to-resident altercation wherein R107 was one of three residents who were physically struck by another resident. Following the altercation, the medical records documented R107 had no signs of injury, distress, or change in mood. The facility submitted a final report of a facility reported incident to the State Agency, which documented all four…

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 document review the facility failed to ensure medications were appropriately administered and not left at the bedside for 1 of 38 sampled residents (Resident 220). The deficient practice had the potential to lead to missed medication doses and harm to the resident. Findings include: Resident 220 (R220) R220 was admitted on [DATE] with medical diagnoses including down syndrome and anxiety. On 08/15/2023 at 11:03 AM, R220 was observed lying in bed and on the bedside table there was a medication cup filled with a yellow-colored puree with a blue powder substance on top. On 8/15/2023 at approximately 11:10 AM, a Registered Nurse (RN) indicated R220 took their medications crushed in apple sauce. The RN acknowledged the medication cup on the bedside table and confirmed it contained the morning medications for R220. A review of the Medication Administration Record (MAR) for 08/15/2023 documented the following medications: - Entecavir 0.5 milligrams (mg), give one…

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 document review, the facility failed to ensure medications were not missed or administered late for 1 of 38 sampled residents (Resident 218). The deficient practice had the potential to negatively impact the overall health condition of the resident. Findings include: Resident 218 (R218) R218 was admitted on [DATE], with diagnoses including atrial fibrillation, hypertension, and seizures. On 08/15/2023 at 10:52 AM, R218 laid in bed and expressed frustration regarding the facility's medication administration practices. R218 indicated multiple medications were being given very late or not at all. The resident indicated being particularly concerned about mismanagement of R218's blood thinner. On 08/15/2023 at 10:59 AM, a Registered Nurse (RN) was behind a medication cart outside R218's room. The RN indicated the resident's Eliquis (anti-coagulant) was prescribed to be given twice a day, but it was not given this morning and the evening prior due to the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was not able to leave the facility without staff awareness for approximately seven hours for 1 of 38 sampled residents (Resident 238). The deficient practice had the potential to endanger the resident's well-being. Findings include: Resident 238 (R238) R238 was admitted on [DATE] with medical diagnoses including dementia, schizophrenia, hypertension, bradycardia (low heart rate), and generalized muscle weakness. A Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 10 which indicated R238's cognition was moderately impaired. The MDS dated [DATE] revealed R238 was occasionally incontinent of urine and bowel. A review of R238's Care Plan revealed the following: - R238 had bowel and bladder incontinence related to dementia: date initiated on 08/02/2023 - R238 was at risk for impaired cognitive function or impaired thought processes related to schizophrenia, psychosis, and dementia: date initiated…

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 document, the facility failed to ensure care orders were entered and followed for a resident's intravenous (IV) access for 1 of 38 residents (Resident 444). The deficient practice placed the resident at risk for phlebitis (site infection). Findings include: Resident 444 (R444) R444 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic heart failure, respiratory failure, and diabetes mellitus. On 08/15/2023 at 10:46 AM, R444 was seated on side of bed and had an intravenous (IV) access in left lower arm. The IV access had two purple ports and the insertion site was covered with a white dressing which was unsigned and undated. According to the resident, the IV access was inserted at the hospital but had not been used since the resident's return to the facility on [DATE]. The resident indicated not receiving any IV medications and expressed wanting to have the IV access removed because it was causing the resident discomfort. R44…

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 document review, the facility failed to ensure an annual performance evaluation was completed for 1 of 5 Certified Nursing Assistants. The failure to complete the performance evaluation of the Certified Nursing Assistant (CNA) in a timely manner could potentially compromise the quality of care provided to the residents. Findings include: The personnel records checklist dated 08/16/2023, documented a CNA who was hired on 07/01/2022 was missing an annual performance evaluation. On 08/17/2023 at 11:24 AM, the Assistant Administrator confirmed the CNA was due for an annual performance evaluation on or before 07/01/2023. The Assistant Administrator indicated the DON was responsible for completing the performance appraisals for all nursing staff members. The Assistant Administrator explained the purpose of performance appraisals was to ensure all CNAs were competent to perform job duties and were compliant with facility policies. The Assistant Administrator could not speak to why the DON had not completed the CNA's annual evaluation. On 08/17/2023 at 5:30 PM, 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, interview, and document review the facility failed to ensure medications were stored in a locked medication cart and medication cart keys were secured. The failed practice had the potential for staff, residents, and visitors to have access to medications including narcotics. On 08/16/2023 from approximately 7:31 AM to 7:47 AM, a Registered Nurse (RN) in the 100-hall entered and exited room [ROOM NUMBER] three different times. The RN initially entered the room to introduce themselves and explain care to the resident. The RN then entered the room a second time to check the resident's blood sugar, and lastly to check the resident's blood pressure. Each time the RN entered the resident's room, the medication cart was left unlocked. The medication cart was slanted and not completely facing the room of R396. While the RN was talking to the resident and providing care, the RN's back was to the medication cart. On 08/16/23 at 08:05 AM, the RN entered room [ROOM NUMBER] leaving medication cart…

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 document review the facility failed to ensure refrigerated items were not expired when accepting delivery, resident food items were dated and labeled in nourishment rooms, tube feed solution was not expired, and nourishment rooms were free from pests. The deficient practice had the potential to place residents at risk for a food-borne illness. Findings include: On 08/15/2023 at 10:39 AM, there were four containers of sour cream with a delivery date of 08/08/2023 and expiration of 08/05/2023 in the refrigerator of the main kitchen. On 08/15/2023 at 10:40 AM, the Dietary Manager (DM) verbalized the containers were delivered on 08/08/2023 and were accepted by facility staff already expired. On 08/15/2023 at 10:45 AM, there were multiple food items in containers and wrapped in plastic bags in nourishment room in building A not labeled or dated. The freezer designated for resident food contained raw fish. On 08/15/2023 at 10:48 AM, the DM explained there should be no raw food items in the freezer for resident food in the nourishment rooms and 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 document review, the facility failed to ensure Hospice services were provided for 1 of 38 sampled residents (Resident 211) in accordance with the Hospice agreement and facility policy. The deficient practice placed the resident at risk for not receiving end-of-life care. Findings include: Resident 211 (R211) Resident # 211 was admitted on [DATE] and readmitted [DATE], with diagnoses including mononeuropathy and Alzheimer's dementia with unspecified severity, and psychotic and mood disorder. On 08/15/2023 at 11:57 AM, R211 was leaned back on a Geri-chair in the activities room. The resident did not appear to be alert and oriented and did not respond to questions. On 08/15/23 at 12:37 PM, R211 was in the restorative dining room receiving full assistance with lunch meal. A physician's order dated 07/01/2023, revealed R211's hospice evaluation had been completed. R211 was to be admitted into the hospice program due to Alzheimer's disease. R211 was to be seen by 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 interview and document review the facility failed to ensure mandatory training which included abuse, fire, disaster, and dementia training was provided to 5 of 5 sampled Certified Nursing Assistant (Employees 1, 2, 9, 10 and 11). The deficient practice placed residents at risk for inappropriate care. Findings include: Employee 1 Employee 1 was hired as a Certified Nursing Assistant (CNA) on 09/12/2022. Employee file review revealed Employee 1 had not completed Abuse, Fire and Disaster training. On 08/17/23 at 10:57 AM, the Assistant Administrator and Human Resources (HR) Director confirmed Employee 1 had no record of abuse, fire, and disaster training. Employee 2 Employee 2 was hired as a CNA on 10/24/2022. Employee file review revealed Employee 2 had not completed fire and disaster training. On 08/17/23 at 11:05 AM, the Assistant Administrator and HR Director confirmed Employee 2 had no record of fire and disaster training. Employee 9 Employee 9 was hired as a CNA on 07/01/2022. Employee file review revealed Employee 9 had not completed disaster training. On 08/17/23 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.