The Grove At Valhalla Rehab And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification and abbreviated survey (#2575165) from 09/23/2025 to 09/30/2025, the facility did not ensure a resident's right to be free from unnecessary drugs. This was evident for one (Resident #14) of three residents reviewed for dementia care. Specifically, Resident #14 was ordered to receive Haldol 2 milligrams without a labeled indication and without consideration of recommendations by Psychiatry to decrease the dosage.The findings are: The facility policy titled Psychotropic Medication Use dated 08/02/2025 documented residents who have not used psychotropic medications are not prescribed or given these medications unless necessary to treat a specific condition that is diagnosed and the is based on a comprehensive resident review that evaluates underlying causes. Resident #14 had diagnoses of cerebral ischemia (reduced or blocked blood flow to the brain), dementia without behavioral disturbance, and psychosis. The Minimum Data Set…

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 conducted during the recertification survey from 09/23/2025 to 09/30/2025, the facility did not ensure special eating equipment and utensils for a resident who need them was provided for 1 of 1 resident (Resident #3) reviewed for adaptive equipment. Specifically, built up utensils were not provided for Resident #3 as per physician order. The findings are:The facility policy and procedure titled Adaptive Equipment dated 08/02/25 documented the purpose was to ensure that residents receive the appropriate adaptive equipment and staff members are trained in its proper use. The residents need for adaptive equipment should be assessed and evaluated by a qualified rehabilitation therapist. Following the assessment, the rehabilitation therapist should prescribe the specific equipment required. The responsible staff should promptly place an order, care plan and appropriate task for the adaptive equipment with the supplier, vendor.Resident #3 had diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Muscle…

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, and interview during the recertification survey conducted 9/23/25 to 09/30/25, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #12) reviewed for activities of daily living. Specifically, staff were observed transferring Resident #12 from the bed to chair in a lift and not wearing the required personal protective equipment for Enhanced Barrier Precautions. Findings include: The facility policy for Enhanced Barrier Precautions dated 08/05/25 documented Enhanced Barrier Precautions are used as an infection prevention and control intervention to reduce the transmission of multi drug resistant organisms to residents. Enhanced Barrier Precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. Examples of high contact resident care activities requiring 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 record review and interviews conducted during an Abbreviated Survey (NY00332525), the facility did not ensure that a resident's Care Plan was reviewed and revised to reflect the resident's changing needs and current status as evidenced by 1 of 3 residents reviewed for skin impairment. Specifically, Resident #1 acquired two pressure injuries on the buttocks and the care plan was not updated to reflect the goals and interventions to promote wound healing. The findings are: The facility's policy and procedure entitled Care Plans, Comprehensive Person-Centered revision date March 2022 documented 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Resident #1 had diagnoses that included Fracture of unspecified part of neck left femur, malignant neoplasm of prostate, Parkinson w/o dyskinesia and cognitive communication deficit. The Minimum Data Set (MDS, an assessment tool) dated 12/18/2023 documented that the resident had…

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

Based on record review and interviews conducted during an abbreviated survey (NY00320442), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accident hazards for 1 of 8 residents (Resident #1) reviewed. Specifically, on 07/19/2023 Certified Nursing Assistant (Staff #1) served Resident #1 (who required 1-person assistance for eating) rewarmed coffee from the microwave without assistance/setup. Resident #1 poured milk into the coffee and the coffee spilled onto their skin causing a blistering burn, measuring 3x3 inches to the right thigh. The findings are: Resident #1 had diagnoses that included Fracture of Second Thoracic Vertebra, Wedge Compression Fracture and Malignant Neoplasm of Colon. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 07/12/2023 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognitive. Resident #1 required supervision and setup help only with…

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 during a recertification survey 3/22/2023-03/30/2023, the facility did not ensure residents had the right to a dignified existence for one of two residents screened for dignity. Specifically, Resident #66 was observed their Foley catheter (tube draining urine from the bladder) bag uncovered with urine visible to staff, residents, and visitors. The findings are: Resident #66 was admitted with diagnoses including Thrombocytopenia, repeated falls, Hyperlipidemia, Benign Prostatic Hyperplasia (BPH) and on 3/21/2023 was readmitted after a fracture of right femur. The admission Minimum Data Set (MDS, a resident assessment tool) dated 03/07/2023 revealed the resident was cognitively intact and needed extensive assist of one person with bed mobility, transfer, dressing and toileting. Resident #66 was observed from the hallway on 3/22/23 at 10:47 AM, 12:46PM and 03:11PM, and on 03/23/2023 at 09:40 AM, in bed with the Foley bag positioned on the bed hanging near the lower edge of bed with urine in the tubing and bag, visible to passers by.…

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 conducted during the recertification survey from 3/22/23 to 3/30/23, the facility failed to ensure that housekeeping and maintenance services provided a safe, clean, comfortable, and home-like environment for 1 of 1 residents reviewed for Environment (Resident #2). Specifically, a window unit AC (air conditioner) was observed to be in disrepair in the room of Resident #2. An observation was made on 03/22/23 at 10:00 AM, in Resident #2's room, of a window unit AC with visible gaps of approximately 1 centimeter to the outdoors on both sides of the unit. The gaps appeared to have been previously covered with duct tape, which was hanging off the bottom of both sides of the AC, and cold air was noted to be blowing through the gaps. A facility inspection sticker was observed on the left side of the AC unit with no date or initials to indicate that it had been inspected prior to use in a resident room. A facility policy titled 'Nonpatient Electrical Appliances and Equipment', last reviewed 10/2022, stated any equipment that appeared to 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 record review and interview conducted during the recertification survey from 3/22/23 to 3/30/23, the facility failed to ensure the resident or the resident's representative were notified in writing of the reason for transfer/discharge to the hospital in a language they understood and failed to notify the Ombudsman for 1 of 3 residents (Resident #2) reviewed for hospitalizations. Specifically, Resident #2 was transferred to the hospital on [DATE] and the facility could not provide evidence a written notice of transfer/discharge was provided to the resident or the resident's representatives, or that notification was sent to the Ombudsman. The Findings Include: A review of the facility policy, 'Transfer or Discharge Notice', last reviewed 11/30/22 documented the residents and/or representatives were notified in writing, in a language and format they understand, at least thirty (30) days prior to a transfer or discharge and in the event of an immediate transfer or discharge for urgent medical needs, notice…

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 conducted during the recertification survey from 3/22/23 through 3/30/23 and an abbreviated survey (#NY00296823), it was determined that for 2 of 2 residents (#2 and #494) reviewed for hospitalizations, the facility failed to ensure that the resident or the resident's representatives were notified in writing of the facility's Bed Hold Policy. Specifically, Resident #2 and Resident #494 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility's Bed Hold Policy was provided to the residents or the resident's representatives. The findings include: A review of the undated facility policy 'Bed-Holds and Returns', documented that the facility would provide information about the bed hold and payment amount to the resident or resident's representative before transfer to the hospital. 1. Resident #2 was admitted to the facility on [DATE] with diagnoses including but not limited to lumbar spina bifida with hydrocephalus,…

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

Based on record review and interview conducted during the recertification survey from 3/22/23 through 3/30/23, the facility failed to ensure the required Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) was conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. This was evident for 1 of 1 residents reviewed for Resident Assessment (Resident #86). The findings are: The MDS records of the following resident were reviewed and revealed that Quarterly assessments were not completed within the ARD (Assessment Reference Date) plus 14 days or 92 days from the last Quarterly Assessment. Resident #86's most recent Quarterly MDS assessment was last completed on 11/11/22 with an ARD date of 2/11/23. Resident #86's Quarterly MDS was not submitted until 3/24/23. During an interview on 3/24/23 at 1:08 PM, RN #1 (The Registered Nurse MDS Coordinator) stated quarterly MDS assessments should be completed and submitted for residents every 90 days. RN #1 stated the quarterly MDS…

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 conducted during the recertification and abbreviated surveys (NY00296823, NY00307253) from 3/22/2023 to 3/30/2023, the facility did not develop and/or implement comprehensive person-centered care plans to ensure the services were provided to maintain the resident's highest practicable physical well-being for 5 of 7 residents (#38, #66, #114, #344, #494) reviewed for Care Plans. Specifically, Resident #38's plan for weekly weights was not implemented;Resident #23 had diagnosis of thyroid disorder and no care plan to address the thyroid disorder; Resident #114 was not provided assistance with eating as planned, Resident #344 did not have a care plan for the presence of actual pressure ulcers, and Resident # 494 did not have a care plan for risk for pressure ulcers. The findings are: The policy and procedure titled, Care Plans dated 11/30/2022, documented the interdisciplinary team was responsible for the development of resident care plans. Resident's Care Plan…

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 during the recertification survey, dated 3/22/2023-3/30/2023, the facility did not ensure that each resident received the necessary assistance to maintain good nutrition for one (Resident #114) of one resident reviewed for activities of daily living (ADL). Specifically, Resident # 114 was not provided assistance with meals as planned. The findings are: Review of the 11/30/2022 Policy and Procedure for Activities of Daily Living documented residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #114 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA, stroke) with right sided hemiplegia (paralysis), and a history of hypertension. Review of the Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review during the recertification survey initiated on 3/22/2023 and completed on 3/30/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for one (Resident #23) of five residents reviewed for Unnecessary Medications. Specifically, Resident #23's Medication Administration Record (MAR) revealed 13 administration omissions within 14 days. The findings are: Resident # 23 was admitted on [DATE] with diagnoses including Hypertension, Congestive Heart Failure, Major Depressive Disorder, Anxiety Disorder, Atrial Fibrillation, and Thyroid Disorder. The Quarterly Minimum Data Set (MDS: a resident assessment tool) dated 3/8/2023 documented: A Brief Interview for Mental Status (BIMs) score of 6 which indicated severe impairment of cognitive abilities, and a Mood severity score of 00 which indicated no symptom presence. Received antianxiety medication, a diuretic, an antidepressant and 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 observation, interview, and record review conducted during the recertification survey 3/22/2023-3/30/2023, it was determined that the facility did not ensure the environment remained as free of accident hazards as possible for 2 of 7 residents reviewed for accidents and hazards. Specifically, space heaters were observed in resident rooms #270 and #271. Findings include: A review of the policy and procedure dated 1/18/2022, Use of Portable Space-Heating Devices documented portable space-heating devices shall only be used in-accordance with regulations and only temporarily. During observations on 03/22/2023 at 9:31 AM and 3/23/2023 at 9:00 AM, portable electric space heaters were observed in rooms [ROOM NUMBERS] on the floor with no visible sticker to demonstrate that they were checked by maintenance. During an interviews with the resident in room [ROOM NUMBER] on 03/24/2023 at 10:10 AM and 03/28/2023 at 10:10 AM, the resident stated they reported being cold and the facility provided the heater. 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 observation, interview and record review conducted during the recertification survey 3/22/23-3/30/23, it was determined for 1 of 7 residents (Resident # 38) reviewed for Nutrition and Hydration, the facility did not ensure the resident was provided the necessary care to maintain, to the extent possible, acceptable body weight. Specifically, for Resident #38 weekly weight monitoring was not implemented as ordered. The findings are: The facility policy for Management and Prevention of Significant Weight Loss, dated 9/20/22, documented there was a systematic and interdisciplinary approach to monitoring resident weights in the facility. The nursing staff would weigh all residents on weekly upon admission for 4 weeks, then monthly unless a physician's order stated otherwise. Resident #38 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Dementia, Psychotic disturbance, Mood disorder, Anxiety, and was out of the facility 12/15/22-12/20/22 for repair of left hip fracture. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that personnel handled, stored, processed, and transported linens in a manner to prevent the spread of infection. Specifically, a housekeeper was observed distributing linens in an unclean manner and from an uncovered linen cart. The findings are: The undated facility policy for Linen and Personal Clothing Handling and Storage documented clean linen and personal clothing for distribution should always be placed on a clean cart and kept covered during transit. Personnel were to avoid all unnecessary contact with clean linen and personal clothing. On 3/22/23 11:19 AM an observation was made of Housekeeper #1 distributing clothing on the 2 North unit. Housekeeper #1 collected clean clothing from the linen cart, held linen pressed against their abdomen and brought articles of clothing into room [ROOM NUMBER]B. Housekeeper #1 continued to distribute clean linen from an uncovered linen cart to rooms [ROOM NUMBERS]. Housekeeper #1 then…

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 interview conducted during a recertification survey, the facility did not ensure specicific food items were maintained in accordance with professional standards for food safety. Specifically, opened and outdated potentially hazardous foods (meat, fish, eggs and dairy products) were observed in one of the refrigerators. The findings are: The initial tour of the kitchen was conducted on 8/13/19 at 9:40 AM. The following items were observed in a refrigerated unit: -An opened box of defrosted bay flounder fillets with 2 dates on the packaging, 8/7/19 and 8/9/19 (4 or 6 days since being opened). -An opened package containing approximately two and a half pounds of uncooked ground beef, dated 8/10/19 (3 days since being opened). The Food Service Director (FSD) was interviewed at that time and could not say which date the flounder had been opened or when it should be used. The FSD then proceeded to check the facility guidance chart for storage of defrosted/opened fish and opened uncooked ground beef and could not find any guidance. In a follow up interview conducted…

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 conducted during a recent recertification survey, it cannot be ensured that the facility is adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or to a centralized work area for 3 of 3 occupied resident bathrooms, 211, 234, and 240. The findings are: Observation on 8/15/19 from 11:29am through 1:28pm of residents' rooms 211, 234 and 240 was conducted and it was noted that the emergency call balls in the bathrooms were not functioning upon testing. Certified Nursing Assistant (CNA) #4 was interviewed on 8/15/19 during the time of the above observation and stated that she was not aware of the bells malfunctioning. CNA #4 then reported that malfunctioning call bells are verbally reported to a nurse who would in turn document the information in the computer or report it to the maintenance worker directly. Additional observation was conducted of rooms 211, 234 and 240 on 8/19/19 between 11:39AM and 12PM, in the presence of Certified Nursing Assistant (CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the recertification survey, the facility did not ensure that the comprehensive person-centered care plan for each resident was implemented. This was evident for 1 of 4 residents reviewed for nutrition. Specifically, Resident #47 had a Physician's (MD) order for a 1000 cc fluid restriction in 24 hours which was not consistently implemented. The findings are: Resident #47 was admitted with diagnoses including chronic kidney disease, renal dialysis and hypertension. The 5-day Minimum Data Set (MDS: an assessment tool) dated 8/8/19 documented the resident was cognitively intact for decision making, received a therapeutic diet, and received dialysis. The MD order dated 7/5/19 documented a fluid restriction of 1000 cc in 24 hrs. distributed at: 1. Dietary : 600 cc/day 2. Nursing 400 cc/day. On 7 AM-3 PM shift medication pass: 160 cc/day. On 3 PM-11PM shift medication pass: 120 cc/day. On 11 PM -7 AM shift medication pass: 120 cc/day. The Comprehensive Care Plan…

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 and interview conducted during the recertification survey the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living (ADLs). This was evident for 1 of 6 residents (Resident # 48). The findings are: Resident #48 was admitted with diagnoses including; Heart Failure, Cerebrovascular Accident and Huntington's Disease. The Annual Minimum Data Set (MDS-a resident assessment and screening tool) of 3/24/19 documented that the resident had severely impaired cognition, required extensive assistance for bed mobility, transfers, toilet use, personal hygiene and dressing. The ADL Care Plan initiated on 3/16/18 and updated on 8/2/19 had interventions that included but were not limited to; monitor for changes in status, notify interdisciplinary team as needed, therapy per orders. Multiple resident observations were made throughout the survey and the following were observed: 08/15/19 09:33 AM resident was observed in bed with untrimmed nails. 08/19/19 02:10 PM resident was observed in her wheelchair and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that a resident received the necessary treatment to meet skin care needs. Specifically, 1 resident (Resident # 39) reviewed for non-pressure-related skin issues did not receive the treatment prescribed by a Dermatologist. The findings are: Resident #39 had diagnoses and conditions including; Diabetes Mellitus, Xerosis and Pruritis. According to the 4/19/19 Annual Minimum Data Set (MDS; an assessment tool) the resident had a Brief Interview for Mental Status ( BIMS; a test for cognitive functioning) score of 12 out of 15 which indicated mild cognitive impairment. Physician's Orders dated 8/13/19 had instructions for Eucerin Cream (skin protectant) to be applied to both arms two times a day for Xerosis and Pruritis for 6 weeks. [NAME] Sensitive Lotion 1 % to be applied to both arms topically two times a day for Xerosis and Pruritis for 6 weeks. Physician's Orders revealed both treatments were…

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

Based on observation, interview, and record review conducted during a recertified survey, the facility did not ensure that facility staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 1 of 5 residents (Resident # 99) reviewed for pressure ulcer, and during a random room observation on 1 North and 2 North units. The findings are: 1. Resident # 99 has diagnoses and condition not limited to Hypertension, Chronic Kidney failure, and Pressure Ulcer. According to the 7/23/19 60-day Minimum Data Set ( MDS; an assessment instrument), the resident was at risk for developing pressure ulcer. An 8/15/19 Pressure Ulcer/Potential for Pressure Ulcer Care Plan documented the resident has a stage 3 coccyx wound. Interventions included wound consult, air mattress, and documentation of wound assessment. The Physician Orders dated 8/13/19 had an order to apply Silver Sulfadiazine 1 % cream to coccyx wound twice a day. A wound observation was conducted on 8/16/19 at 11:40AM on the 1 North Unit and the following was observed: 1) The Licensed Practical Nurse…

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.