Bath Manor Special Care Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure all drugs and biologicals were properly secured and permit only authorized personnel to have access. This affected one (#221) of one resident reviewed for self-administration of medications. The facility census was 112. Findings include: Review of the medical record for Resident #221 revealed an admission dated of 04/28/25 with diagnoses that included peripheral vascular disease, type 2 diabetes, and congestive heart failure. Further review of Resident #221's medical record revealed there was no assessment indicating Resident #221 was safe to self-administer medication. Review of the progress note dated 04/29/25 timed 11:08 A.M. revealed Resident #221 had multiple scattered tinea areas on bilateral arms with discoloration. Review of the care plan dated 04/30/25 revealed Resident #221 had tinea corporis located on the left and right posterior forearm. Review of the physician…

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, review of the Emergency Medical Services (EMS) Prehospital Care Report and review of the facility policy, the facility failed to timely notify the Guardian of Resident #18 when a significant change in condition occurred. This affected one resident (#18) of three residents reviewed for notification of changes. The facility census was 109. Findings include: Record review for Resident #18 revealed an admission date of 12/31/21. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Record review revealed Resident #18 had a Legal Guardian. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, dependent upon staff for transfers, used a wheelchair, and was dependent for mobility. Review of the progress note for Resident #18 dated 12/27/24 at 2:29 A.M. completed by Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to provide A.M. care to include washing face and hands and oral care for Residents #76 and #106. This affected two residents (#76 and #106) of three residents reviewed for activities of daily living (ADL). The facility census was 109. Findings include: 1. Record review for Resident #76 revealed an admission date of 10/27/24. Diagnoses included spastic hemiplegic cerebral palsy, multiple sclerosis, cervical disc disorder, blindness in the left eye, muscle weakness and need for assistance with personal care. Review of the care plan dated 10/28/24 revealed Resident #76 had an ADL self-care and mobility deficit related to multiple sclerosis, weakness, debility, cerebral palsy, and impaired mobility. Interventions included assistance with hygiene/bathing hygiene, dressing, grooming, toileting, feeding, and oral care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the Emergency Medical Service (EMS) Prehospital Care Report, the facility failed to provide appropriate care and services to Resident #18, who had a significant change in condition with an altered mental status, difficult to arouse, and periods of unconsciousness. Resident #18 was administered by mouth routine medications to include psychotropic medications while being difficult to arouse and prior to notifying the physician of the change in condition. Once contacted, the physician requested Resident #18 to be transported to the emergency room. Resident #18 was not transported to the hospital emergency room per direction of the physician, Resident #18 was administered Narcan for a potential drug overdose then resided at the facility. There were no labs obtained to determine the cause for the potential drug overdose nor was the pharmacy utilized to review medications related to the potential drug overdose. This affected one resident (#18) of 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 interview, record review and review of the Emergency Medical Services (EMS) Prehospital Care Report, the facility failed to involve pharmacy services related to a possible overdose involving Resident #18 who was administered Narcan. This affected one resident (#18) of three residents reviewed for a potential overdose. The facility census was 109. Findings include: Record review for Resident #18 revealed an admission date of 12/31/21. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Record review revealed Resident #18 had a Legal Guardian. Resident #18 had no known allergies. Review of the care plan dated 07/15/24 revealed Resident #18 had behavioral symptoms not directed to others verbal/vocal symptoms like screaming, disruptive sounds, and refused to be shaved. Interventions included when the resident yells out, ask the resident if he needs anything. Provide encouragement 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 record review, observation, interview and review of the facility policy, the facility failed to ensure blood sugars were assessed prior to meal for Residents #82 and #112 as ordered by the physician to ensure accurate dosage of the sliding scale insulin and failed to ensure Resident #18's medication was administered correctly, (not to be crushed). This affected three residents (#82, #112, and #18) of four residents reviewed for medication administration. The facility census was 109. Findings include: 1. Record review for Resident #82 revealed an admission date of 01/06/25. Diagnosis included type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 was cognitively intact. Resident #82 used a wheelchair for mobility and was dependent upon staff for transfers. Active diagnosis included diabetes mellitus. Review of the physician order dated 01/19/25 for Resident #82 included insulin lispro solution 100 units (u) per milliliter (ml)…

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 the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure infection control practices were maintained while assessing Residents #82 and #112's blood glucose levels via fingerstick. This affected two residents (#82 and #112) and had the potential to affect an additional 19 residents (#1, #7, #13, #14, #17, #21, #31, #49, #50, #53, #63, #65, #66, #69, #74, #80, #91, #94, and #97) identified by the facility as receiving blood glucose levels via fingerstick. The facility census was 109. Findings include: 1. Record review for Resident #82 revealed an admission date of 01/06/25. Diagnosis included type two diabetes mellitus. Review of the physician order dated 01/19/25 for Resident #82 included insulin lispro solution 100 units (u) per milliliter (ml) subcutaneously per sliding scale with meals scheduled at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Observation on 01/22/25 at 8:42 A.M. of a blood sugar assessment via glucometer revealed Licensed Practical Nurse (LPN) #418 took 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, interview, observation of photographic evidence, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure communication and coordination of services with the dialysis center regarding the care of Resident #119's dialysis catheter. This affected one resident (#119) of four residents reviewed and observed for dialysis catheter care. The facility census was 112. Findings include: Review of Resident #119's closed medical records revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #119 had a diagnosis of chronic kidney disease and was dialysis dependent. Resident #119 expired on [DATE]. Review of Resident #119's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119 had impaired cognition. Review of Resident #119's care plan dated [DATE] revealed Resident #119 required dialysis. Interventions included providing access site care as ordered and monitor and report signs of infection. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and review of the facility policy, the facility failed to ensure timely notification of death of the legal guardian for Resident #119. This affected one resident (#119) of three residents who were reviewed for notification of significant incidents or changes in condition. The facility census was 118. Findings include: Review of the closed medical record for Resident #119 revealed an admission date of [DATE] with diagnoses including acute and chronic respiratory failure, extended spectrum beta lactamase (ESBL) resistance, hypothyroidism, major depressive disorder, end stage renal disease, thrombocytopenia, severe protein-calorie malnutrition, dysphagia, myxedema coma, dysphagia, and abnormalities of gait and mobility. Further review of the medical record revealed a discharge date of [DATE] after expiring in the facility. Review of the significant change Minimum Data Set (MDS) assessment completed on [DATE] revealed Resident #119's cognitive function was severely…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interview, review of drug information on triamcinolone 0.1% cream (a topical corticosteroid) on Drugs.com, and review of the facility policy the facility failed to ensure ongoing care and services remained appropriate and failed to address repeated concerns voiced by state tested nurse aides (STNAs) regarding a black discoloration in Resident #82's percutaneous endoscopic gastrostomy (PEG) tube (a surgically placed feeding tube into the stomach) resulting in the resident being transferred to the hospital related to a clogged PEG tube with maggots noted in the tube. This affected one resident (#82) of three residents reviewed for tube feedings and had the potential to affect twelve residents (#67, #68, #70, #71, #72, #73, #74, #75, #76, #77, #81, and #82) whom the facility indicated were receiving nutrition via an enteral feeding tube. The facility census was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure and allegation of verbal abuse towards Resident #23 was thoroughly investigated. This affected one resident (Resident #23) out of three residents reviewed for abuse. The facility census was 122. Findings include: Review of Resident #23's medical record revealed an admission date of 04/30/15 and a readmission date of 11/14/23. Resident #23's diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic subarachnoid hemorrhage affecting left dominant side, repeated falls, and need for assistance with personal care. Review of Resident #23's Self-Reported Incident (SRI) tracking number 246669 dated 04/23/24 included the category of allegation, suspicion was neglect by facility staff. The initial source of the allegation, suspicion was a visitor, family member. Resident #23 provided meaningful information when interviewed. The Administrator received an allegation Resident #23…

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 review of the facility policy the facility failed to ensure Resident #125's physician was provided accurate information regarding a discharge Against Medical Advice to ensure the safest discharge possible. This affected one resident (Resident #125) out of three residents reviewed for a safe discharge. The facility census was 122. Findings include: Review of Resident #125's medical record revealed an admission date of 09/27/23 and diagnoses included anxiety disorder, depression, and disorder of the brain, unspecified. Review of Resident #125's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #125 was independent for self-care, needed some help with ambulation, and used a walker. Review of Resident #125's physician orders dated 09/27/23 revealed Resident #125 may go on LOA (leave of absence) with supervision. Review of Resident #125's Quarterly Minimum Data Set, dated [DATE] revealed Resident #125 was cognitively intact. Review of Resident #125'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 record review and interview, the facility failed to timely ensure a comprehensive treatment plan was in place to properly drain, monitor, and dress Resident #125's chest tube. This affected one resident (Resident #125) of three residents reviewed for quality of care. Findings include: Review of the closed medical record for Resident #125 revealed an admission date of 03/14/24 and a discharge to the hospital on [DATE]. Diagnoses included acute and chronic diastolic heart failure, end stage renal disease and cardiomyopathy. Review of the hospital discharge orders dated 03/15/24 revealed the orders did not identify how to care for the chest tube or how often it should be drained and how often the dressing should be changed. Review of an email dated 03/15/24 from the admission Director to the facility care team revealed the facility was aware Resident #125 had a chest tube upon admission. Review of the care plan initiated on 03/17/24 revealed a goal to manage Resident #125's diagnosis of congestive heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #121's incontinence care was completed timely. This affected one resident (Resident #121) out of three residents reviewed for incontinence care. The facility census was Findings include: Review of Resident #121's medical record revealed an admission date of 04/13/23 and diagnoses included altered mental status, unspecified dementia, unspecified severity with agitation, type two diabetes mellitus with diabetic chronic kidney disease. Review of Resident #121's care plan dated 04/14/23 included Resident #121 was incontinent of bladder and bowel. Resident #121 would receive assistance with toileting, maintained comfortable, clean and dry, and free from skin breakdown. Interventions included to provide incontinence care as needed, and monitor peri-area for redness, irritation, skin excoriation and breakdown. Resident #121 had noncompliance related to history of noncompliance at home with not taking…

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 ensure a clean and sanitary kitchen area. This had the potential to affect all residents who received meals from the kitchen. The facility identified 12 residents (#2, #13, #15, #41, #62, #77, #80, #88, #94, #96, #420, and #670) that had a nothing by mouth (NPO) diet. The facility census was 123. Findings include: Observations of the facility kitchen on 12/04/23 at 8:22 A.M. revealed a fan located by the ice machine covered in dust. The ice machine had a white colored build up at the gaskets and the down sides. There was an unidentified brown substance on the inside of the ice machine. There were juice concentrate boxes (cranberry, fruit punch, orange, and apple) on the floor in front of the juice and coffee preparation table. Observation of the dish machine area revealed the walls were splattered with dried on food debris/drips. The floor of the dish machine area had a sticky residue with food debris throughout. There was a strong odor…

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, the facility failed to ensure the dumpster area was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 123. Findings include: Observation on 12/04/23 at 8:45 A.M. revealed three dumpsters. One dumpster was propped open with a white post. Observation behind and around the sides of the dumpsters revealed significant debris including gloves, boxes, plastic bags, plastic cups, a gas can, a wheelchair, stack of wooden pallets, and an upholstered chair. Interview on 12/04/23 at 8:47 A.M. with Dietitian #817 confirmed the findings. Dietitian #817 indicated she was unsure of who was responsible for keeping the area clean and clear. Review of the facility Waste Disposal Policy dated 06/05/18 revealed trash bags would be sealed prior to removing them from the facility. Trash would be deposited into a sealed container outside the premises. Outside dumpster lids and doors would remain closed and secure when not in use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected four (Residents #4, #52, #93 and #112) of four residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 123. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 09/03/21 with diagnoses including chronic respiratory failure, depression and adult failure to thrive. Review of the physician's orders for November 2023 revealed Resident #4 had an order for a regular diet dated 08/11/23. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #4 revealed under section K0520 that she did not have a feeding tube or parenteral/intravenous feedings. However, section K0710 was documented as receiving 25% or less total calories through parenteral or tube feeding as well as 500 cubic centimeters (cc)/day or less fluid intake per day by IV or tube feeding. Section K0710 stated to complete K0710 only if checked in section…

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, the facility failed to ensure space heaters were not used by residents in the facility. This affected one resident (Resident #116) and had the potential to affect an additional 28 residents (Residents #1, #10, #17, #25, #26, #39, #50, #54, #58, #63, #66, #67, #82, #84, #85, #101, #107, #110, #120, #470, #471, #472, #473, #474, #475, #476, #477 and #670) residing on the 300 hall. The census was 123. Findings include: Observation on 12/05/23 at 9:00 A.M. revealed a space heater in use in Resident #116's room. Interview with Resident #116's wife at the time of the observation revealed the space heater was used to keep the room warm. An interview on 12/05/23 at 1:45 P.M. with the Administrator revealed space heaters were prohibited in the building. The administrator stated the space heater had since been removed. Review of the Census form revealed 29 residents resided on the 300 hall including Residents #1, #10, #17, #25, #26, #39, #50, #54, #58, #63, #66, #67, #82, #84, #85, #101, #107, #110, #116, #120, #470, #471, #472, #473, #474, #475, #476, #477…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #470's call light was available and accessible for the resident's use. This affected one (Resident #470) of 18 residents (Residents #4, #10, #11, #48, #50, #52, #53, #54, #63, #85, #107, #112, #118, #470, #471, #472, #475 and #570) who were observed for call lights within reach. The facility census was 123. Findings include: Review of Resident #470's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, shortness of breath and acquired clubfoot. Review of Resident #470's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #470 exhibited intact cognition. Observation on 12/04/23 at 8:30 A.M. revealed Resident #470's call light was not plugged into the wall for Resident #470 to call the nursing staff for assistance. Interview on 12/04/23 at 8:30 A.M. with Resident #470 revealed they had not had a call…

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 Residents #82's and #470's bathrooms were maintained at a comfortable ambient temperature. This affected two (Residents #82 and #470) of nine residents (Residents #10, #54, #55, #78, #82, #116, #470, #471 and #473) whose bathroom temperatures were checked. The census was 123. Findings include: Interview on 12/04/23 at 9:00 A.M. with Resident #82 revealed the resident's bathroom was cold. Resident #82 was observed in bed across from the bathroom with three blankets on and was wearing a stocking cap. Resident #82 stated cold air blew on them from the bathroom. Upon entering the bathroom it felt cold. Interview on 12/04/23 at 9:15 A.M. with Resident #470 revealed the resident's bathroom was cold. Interview and observation on 12/06/23 at 8:10 A.M. with Maintenance Director (MD) #856 revealed the ambient temperature on the 300 hall was 73.9 degrees Fahrenheit (F). The temperature in resident rooms was controlled by the thermostat in room [ROOM NUMBER].…

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 timely incontinence care for residents. This affected one (Resident #4) of one resident reviewed for incontinence care. The facility census was 123. Findings include: Review of the medical record for Resident #4 revealed an admission date of 09/03/21 with diagnoses including adult failure to thrive, need for assistance with personal care, and muscle weakness. Review of the care plan for Resident #4 dated 05/11/23 revealed she was incontinent of bladder. Staff were to provide incontinence care as needed. Review of the physician's orders for December 2023 revealed Resident #4 had an order for staff to check and change Resident #4 every two to three hours and as needed dated 08/11/23. Review the Treatment Administration Record (TAR) for October 2023 revealed staff had not documented that they had checked and changed Resident #4 every two to three hours on 10/05/23 and 10/15/23 for the 7:00 P.M. shift. Review of the TAR for November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #107's tube feeding was infused per the physician's orders. This affected one resident (Resident #107) of one resident reviewed for tube feedings. The facility census was 123. Findings include: Review of Resident #107's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, gastrostomy status and cognitive communication deficit. Review of Resident #107's physician orders revealed an order dated 08/01/23 for Isosource 1.5 at 60 cubic centimeters (cc) via a percutaneous endoscopic gastrostomy tube (PEG) for 20 hours per day. Turn off the tube feed solution at 12:00 P.M. and turn back on at 4:00 P.M. Review of Resident #107's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Observation on 12/07/23 at 9:45 A.M. revealed Resident #117 in bed. The tube feeding pump was turned off. The end of the tube was…

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

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and were administered as ordered. This affected one (Resident #48) of three residents reviewed for pain medications being administered as ordered. The facility census was 123. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/28/23 with diagnoses including anxiety disorder, epilepsy, restlessness/agitation, polyneuropathy, and diffuse traumatic brain injury (TBI) with loss of consciousness. Review of the physician's order dated 06/29/23 revealed an order for hospice services related to TBI with loss of consciousness. Review of the plan of care dated 06/29/23 revealed Resident #48 had chronic pain related to TBI and polyneuropathy. Interventions included to administer pharmacological interventions as ordered. Review of the physician's order dated 06/30/23 revealed an order for Hydromorphone Hydrochloride (HCl) eight milligrams (mg) every four hours for pain. Review of the plan of care dated 07/02/23 revealed Resident #48…

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 dispose of medications when they expired. This affected two (Residents #30 and #69) of four residents reviewed for medication storage. The facility census was 123. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of [DATE] with diagnoses including stroke, diabetes mellitus and depression. Review of the physician's orders for [DATE] revealed Resident #30 had an order for Humalog KwikPen 100 units/milliliter (mL), inject six units with meals for diabetes dated [DATE]. Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #30 had received Humalog medication at meals on [DATE], [DATE], [DATE], [DATE] and [DATE]. Observation and interview on [DATE] at 11:10 A.M. with Licensed Practical Nurse (LPN) #919 of the medication cart for the 200 hall revealed Resident #30's Humalog Kwik Pen to be expired as it stated on the pen date opened on [DATE]. LPN #919 verified the insulin…

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, the facility failed to ensure Resident #10's medical record was complete and accurate. This affected one resident (#10) of two residents reviewed for antibiotic use. The facility census was 123. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes, neuromuscular dysfunction of the bladder and osteomyelitis. Review of Resident #10's physician orders revealed an order dated 11/04/23 for Vancomycin intravenous solution (antibiotic) infuse 1.5 grams intravenously every 12 hours for osteomyelitis until 11/20/23 and an order dated 11/04/23 for piperacillin sod-tazobactam intravenous solution (antibiotic) 3.375 grams infuse 3.375 grams every eight hours for osteomyelitis until 11/20/23. Review of Resident #10's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #10's medication administration records (MARS) from 11/04/23 to…

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, the facility failed to maintain adequate infection control practices during administration of medications to residents. This affected one (Resident #6) of six residents observed during medication administration. The facility census was 123. Findings include: Review of the medical record for Resident #6 revealed an admission date of 12/02/22 with diagnoses including hypertension (high blood pressure), anxiety and altered mental status. Review of the physician's orders for December 2023 revealed Resident #6 had orders for venlafaxine (medication for depression) 150 milligrams (mg), furosemide (diuretic) 40 mg, clonazepam (medication for anxiety) 1 mg and oxybutynin chloride (medication for overactive bladder) 5 mg. Observation on 12/05/23 at 8:05 A.M. of the medication administration to Resident #6 by Licensed Practical Nurse (LPN) #917 revealed LPN #917 pulled the clonazepam medication card from the narcotic drawer, popped the pill in her hand and placed the card back in the narcotic drawer. When asked to see the medication card 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.

Based on record review, observation and interview the facility failed to store and prepare foods under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen except eight residents (#9, #25, #26, #35, #38, #45, #105 and #109) who did not receive food/nutrition by mouth. The facility census was 109. Findings include: An initial tour of the kitchen was conducted on 11/15/21 at 6:10 A.M. with [NAME] #417 revealing multiple sanitation concerns. In the large, walk-in cooler there was a large, steam-table pan of cooked, breaded chicken loosely covered with tin foil leaving it open to air and dated 11/07/21. The breading on the chicken looked like it was partially hardened on top yet the bottom pieces appeared to be decomposing in a liquid substance throughout the pan. A soft ball sized chuck of white meat was dated 11/04/21 and the bag was open to air. Two rotting half onion pieces were inside a bag with ham floating in cloudy water and random tomato slices dated 11/06/21. An approximate one pound block of yellow cheese was open to air 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.

Based on record review, observation and interview the facility did not ensure menus were posted in a highly visible area and/or ensure residents received a copy of the menu to support individual food choices each day. This affected four residents (#19, #52, #68, and #95) of 24 residents who were reviewed for choices. The facility census was 109. Findings include: Record review was conducted of the facility's four week cycle menu titled Spring/Summer 2021 Week 3 for the date range of 11/14/21 to 11/20/21. For each lunch and dinner there was one meal being prepared without a second entree option. For lunch on 11/16/21 the menu read Celebration Day, starch of choice, vegetable of the day, margarine, dessert of the day and beverage of choice. Observations and interviews were conducted on 11/15/21 from 9:00 A.M. to 9:30 A.M. on the 200 unit and 400 unit of the facility and in the adjoining common areas. There was no evidence of a posted menu in the common areas nor in resident rooms. Interviews revealed Resident #68 had no idea what food was going to be served to her each day because…

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, observation and interview the facility failed to serve meals in a timely manner. This affected 21 residents (#2, #3, #5, #11, #16, #19, #23, #28, #31, #46, #52, #59, #65, #68, #76, #86, #88, #89, #99, #100 and #114) residing on the 200 unit and had the potential to affect all residents in the facility except eight residents (#9, #25, #26, #35, #38, #45, #105 and #109) who did not receive food/nutrition by mouth. The facility census was 109. Findings include: Observation was conducted on 11/15/21 beginning at 9:00 A.M. on the 200 unit. Patient Care Aide (PCA) #423 was working on the unit and said the meals were often late due to staffing problems in the kitchen. PCA #423 said breakfast should come to the unit around 8:30 A.M. Resident #68 said they sometimes don't get breakfast until 9:30 A.M. to 10:00 A.M. The tray cart arrived to the unit at 9:14 A.M. and PCA #423 was passing all the trays by herself. Residents #76 and #100 were sitting in their doorways asking where breakfast was. Both said breakfast was supposed to be served at 8:30 A.M. but had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure the call light was in reach at all times for Resident #89 who had limited mobility. This affected one of 24 residents reviewed for accommodation of needs. The facility census was 109. Findings include: Record review was conducted for Resident #89 who was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, heart failure, major depression and memory deficit related to cerebrovascular disease. The Minimum Data Set Assessment (MDS) dated [DATE] revealed she had difficulty hearing unless the speaker raised voice volume, was totally dependent on staff for transfers and toileting, did not walk, needed extensive assistance of one staff person for bed mobility and hygiene and could feed herself after tray set up. Review of the plan of care with a date initiated of 06/19/15 indicated she had self care deficits related to weakness and being nonambulatory and her call light should be kept within reach so she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review the facility failed to conduct predialysis and postdialysis blood pressure checks and assessments for Resident #2 and Resident #56. This affected two of nine residents reviewed for dialysis. The facility census was 109. Findings include: 1. Record review was conducted for Resident #2 who admitted to the facility on [DATE] with diagnoses including adult failure to thrive, protein-calorie malnutrition, heart failure, primary hypertension, atrial fibrillation and chronic kidney disease with dependence on hemodialysis. The Minimum Data Set assessment dated [DATE] revealed he was independent for his activities of daily living, had no cognitive impairment, no significant weight gain or loss and was receiving hemodialysis treatments. Review of a physician order dated 07/20/21 revealed he would receive dialysis treatments three times a week on Tuesday, Thursday and Saturday. A physician order dated 09/24/21 revealed he was to have vital signs taken daily.…

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 policy review the facility failed to ensure narcotics were reconciled every shift. The facility also failed to ensure accurate accounting of narcotics were maintained in one of four medication carts reviewed. This affected one (Resident #55) of eight (Residents #32, #53, #55, #70, #73, #74, #91 and #117) residents who had narcotics in the 100 hall medication cart. The facility census was 109. Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/16/21 with diagnoses including hypertension, schizophrenia and burns involving 40-49% of his body surface. Resident #55's physician's order dated 09/09/21 for Methadone HCl (a narcotic used for pain) 5 milligrams (mg) stated to give three tablets via peg-tube (a tube inserted into the stomach for providing nutrition and medications) four times a day (qid) for pain. The resident's Medication Administration Record (MAR) for 11/16/21 revealed the resident did receive three tablets of Methadone as prescribed. Observation on 11/16/21 at 10:43 A.M. 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 record review, observation and interview the facility failed to provide a therapeutic diet as ordered for Resident #2 who was receiving hemodialysis treatments. This affected one of 23 residents reviewed for therapeutic diets. The facility census was 109. Findings include: Record review was conducted for Resident #2 who admitted to the facility on [DATE] with diagnoses including adult failure to thrive, protein-calorie malnutrition and chronic kidney disease with dependence on hemodialysis. The Minimum Data Set assessment dated [DATE] revealed he was independent for his activities of daily living, had no cognitive impairment, no significant weight gain or loss and was receiving hemodialysis treatments. Review of a physician order dated 07/20/21 revealed he went to hemodialysis three times a week. On 07/23/21 a renal, regular texture diet with a 2000 cubic centimeter (CC) fluid restriction was ordered. On 07/27/21 large portions was added to the diet orders. Review of the plan of care with a date…

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, interview and policy review the facility failed to ensure administered medications were consistently documented on the Medication Administration Record (MAR). This affected one (Resident #55) of 13 (Residents #21, #25, #27, #30, #36, #51, #52, #55, #102, #106, #112, #120 and #320) residents whose MARs were reviewed. The facility census was 109. Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/16/21 with diagnoses including hypertension, schizophrenia and burns involving 40-49% of his body surface. Resident #55's physician's order dated 09/09/21 for Methadone HCl (a narcotic used for pain) five milligrams (mg) stated to give three tablets via peg-tube (a tube inserted into the stomach used to provide nutrition and/or medications) four times a day for pain. Review of the Controlled Drug Receipt Record Disposition Form revealed Methadone was administered on 11/06/21 at 6:00 A.M., 11/13/21 at 6:00 P.M. and 11/14/21 at 6:00 P.M. However, staff did not sign off on the MAR indicating the medications were given.…

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.