Heights Rehabilitation And Healthcare Center, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidelines for transmission-based precautions, the facility failed to follow infection control standards during wound care, which affected one resident (#9) out of five reviewed for pressure ulcers. In addition, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while providing care to residents on contact isolation, which affected one resident (#81) out of four identified by the facility as having orders for contact isolation. The facility census was 107. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 10/06/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, systemic lupus, aphasia, locked-in syndrome, gastrostomy status, and extended spectrum beta lactamase (ESBL) resistance. Review of the physician's orders for…

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

Based on record review, interview, and review of facility policy for influenza vaccine, the facility failed to administer the influenza vaccine to Resident #3 after consent was given. This affected one resident (#3) out of five reviewed for immunizations. The facility census was 107. Findings include: Review of the medical record for Resident #3 revealed an admission date of 12/29/25 with diagnoses including chronic obstructive pulmonary disease, morbid obesity, anxiety, and tracheostomy status. Review of Resident #3's Vaccine Informed Consent Form (CRNF) - V 3, dated 12/31/25, revealed Resident #3 consented to receive the influenza vaccine. Review of the immunizations section of Resident #3's electronic medical record revealed No data available. On 06/02/26 at 1:06 P.M., an interview with Director of Nursing (DON) confirmed Resident #3 consented to receive the influenza vaccine on 12/31/25. DON said vaccines were documented in the immunizations section of the electronic medical record and verified Resident #3's immunization section indicated there was no data available. On 06/02/26…

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, medical record review, Self-Reported Incident review, review of witness statements, review of police incident report, review of Resident Funds Management Service statement landscape and withdrawal record, review of cashed checks, review of emails, personnel record review, disciplinary action review, policy review and interview, the facility failed to protect residents right to be free from misappropriation of resident property and/or exploitation. This affected 13 residents (#6, #8, #9, #12, #32, #43, #57, #67, #83, #87, #97, #105, and #107) of 66 residents who had a resident funds account during January 2025 and September 2025. The census was 102.Findings Include:Review of the Self-Reported Incident (SRI) dated 09/02/25 revealed an allegation of misappropriation when staff notified the Administrator of suspected misappropriation of resident funds. On 09/02/25, it was identified Business Office Manager (BOM) #120 allegedly purchased items for Resident #97 that were not authorized by 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, medical record review, nursing staff schedule review, disciplinary action review, policy review and interview, the facility failed to implement a person-center care plan to support the behavioral health care needs of Resident #1. This affected one (Resident #1) of three residents reviewed for behavioral health. The census was 102.Findings include: Review of the medical record for Resident #1 revealed an admission date of 04/22/25 with diagnoses which included borderline personality disorder, post-traumatic stress disorder, generalized anxiety disorder, hereditary and idiopathic neuropathy, severe morbid obesity due to excess calories, arthritis, pain in left hip and fibromyalgia. Review of the potential for pain care plan revised on 04/26/25 revealed Resident #1 had potential for pain related to fibromyalgia, neuropathy, osteoarthritis and left hip pain with interventions which included: administer medications per physician orders, notify physician or nurse practitioner if current pain…

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

Based on interview and record review, the facility did not ensure an individualized care plan was developed for Resident #1 to address the diagnosis of post-traumatic stress disorder (PTSD) to identify triggers and interventions to minimize risk of re-traumatization. This affected one resident (#1) of three residents reviewed for care planning. The facility identified one resident (Resident #1) as having PTSD. The facility census was 108. Findings include: Review of the medical record for Resident #1 revealed an admission date of 04/22/25. Diagnoses included generalized anxiety, borderline personality disorder, major depressive disorder, and PTSD. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/29/25, revealed Resident #1 was cognitively intact, exhibited other behavioral symptoms not directed toward others four to six days of the assessment reference period, was independent for transfers and was able to independently maneuver her motorized wheelchair 50 and 150 feet. Walking hadn ' t been attempted during the assessment reference period. Review of PTSD…

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 visibly soiled bedding was changed in a timely manner affecting Resident #76. The facility also failed to ensure the south wing shower room wall was maintained in good repair. This had the potential to affect 35 residents (#5, #9, #21, #24, #27, #30, #31, #37, #38, #41, #44, #48, #49, #52, #56, #65, #66, #68, 69, #71, #72, #74, #82, #84, #92, #95, #97, #99, #100, #101, #102, #104, #108, 109, and #114) of 38 residents that use the south wing shower room. The facility census was 115. Findings include: 1. Review of the medical record for Resident #76 revealed an initial admission date of 12/03/24. Diagnoses included quadriplegia, tracheostomy status, dependence on respirator (ventilator), gastrostomy (feeding tube). Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #76 had intact cognition and was dependent on staff for all activities of daily living (ADLs). Observation on 06/24/25 at 11:32…

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 comfortable room temperatures for Resident #20 and Resident #113. This finding affected two residents (Residents #20 and #113) of 115 residents who reside in the facility. Findings include: 1. Review of Resident #113's medical's medical record revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, acute respiratory failure with hypoxia, and tracheostomy status. Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #113's medical record revealed the resident's temperature on 06/20/25 at 11:36 A.M. was 98.0 degrees Fahrenheit; on 06/21/25 at 9:16 A.M. was 98.4 degrees Fahrenheit; on 06/22/25 at 9:25 A.M. was 98.9 degrees Fahrenheit; on 06/23/25 at 9:10 P.M. was 97.7 degrees Fahrenheit; and on 06/24/25 at 5:14 A.M. was 98.6 degrees Fahrenheit. Review of Resident #113's medical record revealed 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, and facility policy review the facility failed to ensure Resident #200's scattered bruises were comprehensively assessed and monitored to include descriptions, measurements, and progression. This finding affected one resident (#200) of three residents reviewed for falls. The facility census was 116. Findings include: Review of Resident #200's medical record revealed the resident was admitted on [DATE] and discharged against medical advice (AMA) on 08/10/24 with diagnoses including cerebral infarction, muscle weakness, and aphasia. Review of Resident #200's admission Evaluation dated 08/02/24 revealed the resident was alert to person, had aphasia, and was sometimes difficult to communicate his needs. The resident did not have skin impairments. Review of Resident #200's Wound Evaluation form dated 08/03/24 revealed the resident had redness and irritation on his buttocks. No other skin conditions were documented. Review of Resident #200's Fall Occurrence Evaluation form dated…

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, interview, and facility policy review the facility failed to ensure resident records were protected and only accessed by authorized individuals. This affected one resident (#3) of three residents reviewed for safe record keeping. The facility census was 125. Findings include: Record review of Resident #3 revealed she was admitted to the facility 11/29/23 and had diagnoses including malignant neoplasm of the lung, cognitive communication deficit, and sheltered homelessness. Review of her minimum data set assessment dated [DATE] revealed she had severe cognitive impairment. Her contact list identified POA #601 and #602 as her powers of attorney and Interview with Power of Attorney (POA) #601 on 04/02/24 at 1:43 P.M. revealed she was a POA for Resident #3 and only her and POA #602 were the only non-providers allowed to access Resident #3's medical information. The resident had a sister (Family Member #603) who was not allowed to access the records due to the resident's wishes…

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, interview, and facility policy review the facility failed to ensure alleged abuse events were reported and investigated appropriately. This affected one resident (#19) of five residents reviewed for abuse prohibition. The facility census was 125. Findings include: Record review of Resident #19 revealed she was admitted to the facility on [DATE] and had diagnoses including hemiplegia, cognitive communication deficit, and anxiety disorder. She was assessed by her minimum data set assessment on 02/28/24 as having severe cognitive impairment. A progress note dated 02/06/24 entered by Licensed Practical Nurse (LPN) #701 revealed Resident #19 called the police and said staff beat her and treated her harshly. The police left the facility after stating they had no concerns regarding resident safety. There was no documentation of any related skin assessment, notification to management, or investigation into the allegation. Interview with Resident #19 on 04/02/24 at 10:06 A.M. revealed…

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 closed medical record review, video/audio footage review, review of a facility self-reported incident, policy review and interview, the facility failed to ensure allegations of neglect were timely reported to the State agency. This affected one resident (#118) of two residents reviewed for death. The census was 112. Findings include: Review of Resident #118's closed medical record revealed an admission date of 06/08/23 and a discharge date of 09/17/23. Resident #118 had diagnoses including dysphagia (difficulty swallowing), muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic congestive heart failure, hypertension, and obstructive sleep apnea. Record review of the care plan for Resident #118 dated 06/08/23 revealed the resident's advance directives were for a full code status. Record review revealed the resident also had a care plan for impaired respiratory status related to asthma, sleep apnea, and chronic respiratory failure. Interventions included administering medications as ordered, assist with activities 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 closed medical record review, review of the audio/video footage, interview and policy review, the facility failed to accurately document Resident #118's condition change and care provided in the resident's medical record. This affected one resident (#118) of two residents reviewed for death. The facility census was 112. Findings include: Review of Resident #118's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Resident #118 had diagnoses including dysphagia (difficulty swallowing), muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic congestive heart failure, hypertension, and obstructive sleep apnea. Review of Resident #118's physician orders revealed an order dated [DATE] indicating Resident #118 was to have nothing by mouth (NPO). An order dated [DATE] indicated Resident #118 was a full code. Review of a nurse's note, dated [DATE] timed 12:00 P.M. and completed by LPN #221 revealed during morning…

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, policy review, and staff interview, the facility failed to ensure an allegation of physical abuse was reported to the state agency as required. This affected one resident (#9) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 113. Findings include: Record review for Resident #9 revealed an admission date of 08/17/22. Diagnoses included personal history of traumatic brain injury, anxiety disorder, dementia unspecified severity with mood disturbance, and muscle weakness. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed Resident #9 was rarely or never understood. Resident #9 required extensive assistants of one for bed mobility, transfers, dressings, eating, and personal hygiene. Resident #9 used a wheelchair for mobility. Resident #9 had no behavior towards others such as hitting, kicking, pushing, etc., and had no rejection of care. Record review of the care plan for Resident #9 dated 08/14/23 revealed Resident #9…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to ensure consistent safe storage of smoking materials. This affected two residents (Resident #4 and #52) of two residents reviewed for smoking with the potential to affect all 16 Residents who are independent smokers (Residents #4, #12, #31, #35, #52, #82, #89, #90, #96, #99, #104, #112, #116, #118, #141 and #277). The facility census was 116. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 01/30/20 and a readmission date of 09/18/23. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, interstitial pulmonary disease, and type two diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition. Resident #52 required extensive two-person physical assistance for mobility; total dependence of two-persons for transfer, locomotion on and off the unit,…

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 pureed foods were prepared to the appropriate consistency. This affected eight residents (Residents #11, #29, #55, #58, #59, #60, #84 and #105) receiving a pureed diet. The facility census was 116 residents. Findings include: Review of the diet spreadsheet for week three, day 17 corresponding to 09/12/23 revealed a meal consisting of pork tips in gravy, steamed rice, broccoli, dinner roll and melon cubes. Beef tips were substituted for the pork tips at the lunch meal. Observation on 09/12/23 starting at 12:00 P.M. with [NAME] #328 revealed a pan of beef tips were ready to be pureed. [NAME] #328 indicated she needed nine portions and used a #8-scoop and placed five scoops into the food processor. The food was blended and tasted by [NAME] #328, Dietary Manager (DM) #325 and the surveyor at 12:05 P.M. and the mixture was not smooth with pieces of meat still palpable on the tongue. [NAME] #328 continued to blend and taste the mixture at 12:15 P.M., 12:22 P.M. and 12:29 P.M., adding five ounces of beef broth to the mixture…

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, maintenance log review, and staff interview the facility failed to maintain resident rooms in a safe and functional condition. This affected four residents (Resident #11, #23, #42, #55) of 116 residents observed for environment. Findings include: A tour of the facility was conducted on 09/11/19 from 9:10 A.M. to 4:36 P.M. and the following environmental conditions were identified: 1. The room walls next to Resident #11, #23, and #55 had damage from peeled paint with dry wall showing. 2. The back wall was filled with white spackles on top of colored paint. Resident #42 stated it has been like that for three months. 3. Resident #55 room had a cracked electrical outlet plate with wires exposed on the wall next to resident bed while resident #55 was in bed. Review of the facility maintenance log revealed the above environmental concerns were not in the log. Interview of Licensed Practical Nurse (LPN) #389 on 09/11/23 at 10:24 A.M. confirmed the electric outlet plate was cracked next to resident #55's bed and stated I don't think it is safe, I will have maintenance…

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

Based on interview, record review and facility policy review, the facility failed to provide spend-down letters for each month the resident was over the resource limit. This affected three residents (Residents #9, #13 and #93) of five residents reviewed for resident funds. The facility census was 116 residents. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 08/02/22 and diagnoses including end stage renal disease, type two diabetes, chronic obstructive pulmonary disease, depression, anxiety and anemia. Review of nurses' notes from 04/25/23 to 09/12/23 revealed no notes indicating the need to spend-down funds. Review of Resident #9's quarterly resident funds statement revealed balances of $3564.92 on 04/01/23, balances of $5363.79 on 05/01/23, and $7161.82 on 06/01/23. Review of supporting resident funds documentation revealed a spend-down letter was issued on 07/18/23. Interview on 09/13/23 at 11:24 A.M. with Senior Business Office Manager (SBOM) #360 and the Administrator revealed the facility provided quarterly-spend down letters 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 interview, record review and facility policy review, the facility failed to ensure advanced directives were consistent across electronic and paper medical records. This affected two residents (Resident #23 and Resident #105) of two residents reviewed for advanced directives. The facility census was 116 residents. Findings include: 1. Review of Resident #23's medical record revealed an admission date of 03/18/22 with diagnoses including senile degeneration of brain, dysphagia, muscle weakness, falls, hypertension and chronic kidney disease stage three. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a memory problem and received hospice care. Review of Resident #23's paper chart revealed no advanced directive information was available. Review of Resident #23's electronic medical record (EMR) revealed a code status of Do Not Resuscitate Comfort Care (DNR-CC) on the gray bar below Resident #23's photo. Review of a physician's order dated…

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 to Resident #22. This affected one resident (Resident #22) of three residents reviewed for incontinence care. The facility census was 116. Findings include: Review of the medical record for Resident #22 revealed an admission date of 12/24/21. Diagnoses included morbid obesity, type two diabetes mellitus, and polyneuropathy. Review of the facility care plan for Resident #22 dated 08/08/23 revealed she had episodes of bowel and bladder incontinence related to depression, diabetes, and obesity. Interventions included to assist her with toileting needs and to provide peri care after each incontinent episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 revealed she had intact cognition. Resident #22 required extensive two-person assistance for bed mobility; total dependence of two persons for transfers; extensive assistance of one person for dressing, toilet use, 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, the facility failed to provide catheter care in a manner to prevent infection. This affected one (Resident #44) of two residents reviewed for catheters. The facility census was 116. Findings include: Review of the medical record for Resident #44 revealed an admission date of 03/08/23. Diagnoses included non-displaced fracture of the right tibial tuberosity, hemiplegia affecting right dominant side, and neuromuscular dysfunction of the bladder. Review of the physician's order dated 01/05/23 for Resident #44 revealed orders to clean his suprapubic catheter with soap and water, pat dry, and cover with gauze every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #44 revealed he had intact cognition. Resident #44 required extensive two-person physical assistance for bed mobility and toilet use; total dependence of two-persons for transfers; extensive one-person physical assistance for dressing and personal hygiene; 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 the facility failed to provide nutritional juice supplement to Resident #79 that was ordered due to a significant weight loss. This affected one resident (Resident #79) of eight residents reviewed for nutrition. Findings include: Review of the medical record for Resident #79 revealed an admission date of 08/06/21. Diagnoses included hyperlipidemia, atrial fibrillation, and major depressive disorder. Review of physician's order dated 08/06/21 for Resident #79 revealed an order for a regular diet with regular texture and thin consistency. Resident #79 was also to receive double potions. Review of Resident #79's recorded weights dated 02/07/23 revealed he weighed 165 pounds. Resident #79 weighed 152 pounds on 06/05/23 and 146 pounds on 09/03/23. Review of dietary note dated 07/07/23 for Resident #79 revealed during the annual nutritional assessment he had a history of weight loss and fluctuations. Resident #79 was ordered to receive orange nutritional drink three…

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 maintain a clean and sanitary kitchen and nursing unit refrigerators, as well as ensure hair restraints were worn in the kitchen. This had the potential to affect all but three residents (Residents #14, #74 and #88) who received nothing by mouth. Findings include: Brief initial tour of the kitchen on 01/27/20 at 8:15 A.M. with Registered Dietitian (RD) #85 revealed staff in the kitchen serving breakfast. A contracted staff was observed without any form of hair restraints repairing the juice machine. The walk-in freezer revealed a box of frozen pie crust that was wide open with the frozen pie crust exposed. In the walk-in cooler there was a stack of cheese wrapped in saran wrap that wasn't labeled or dated. All findings were verified by RD #85. Second tour of the kitchen on 01/28/20 at 8:50 A.M. with Dietary Manager (DM) #147 revealed the bottom portion of the stove had grease stains and various food crumbs. The wall and floor behind and adjacent to the stove had various grime and food stains.…

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 pureed chicken was prepared according the recipe. This had the potential to affect seven residents (Residents #3, #10, #47, #75, #79, #93 and #305) who received pureed diets. Findings include: Observation on 01/29/20 at 9:32 A.M. of the preparation of the pureed baked rosemary chicken revealed Dietary Staff (DS) #100 added cooked rosemary chicken breast with rosemary seeds on top into the blender. DS #100 then added thickener and chicken broth and then started blender. DS #100 stopped the blender and added more thickener, blended it again, and stopped the blender. DS #100 stated the baked rosemary chicken was done. The pureed rosemary chicken appeared smooth with specks in it. During the taste test a whole rosemary seed was observed. At this time DS #100 verified there were whole rosemary seeds in the pureed meat. Interview on 01/29/20 at approximately 9:40 A.M. with DS #100 revealed she did not have the recipe for the ground baked rosemary chicken. Interview on 01/29/20 at 9:41 A.M. with DS #151…

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 accurate portion sizes were served for the mechanical soft chicken. This had the potential to affect 29 residents (Residents #2, #4, #7, #8, #11, #15, #20, #24, #25, #28, #29, #31, #36, #38, #50, #58, #59, #63, #69, #70, #73, #81, #86, #89, #96, #100, #101, #105 and #156) who received a mechanical soft diet. Findings include: Observation on 01/29/20 at 11:33 A.M. of the tray line meal service revealed Dietary Staff (DS) #100 plate a mechanical soft diet using a black handled scoop for the ground baked rosemary chicken. Interview at this time with DS #100 revealed the black handled scoop used to serve the ground baked rosemary chicken was three ounces. Registered Dietitian (RD) #85 picked up the black handled scoop from the ground chicken and verified it was a three-ounce serving. RD #85 stated it should be four ounce serving scoop. Review of the Diet Spreadsheet revealed the serving for the soft baked rosemary chicken was four ounces.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure call lights were within reach and accessible for Residents #46 and #51. This affected two Residents (#46 and #51) of 32 residents reviewed for call light placement. The facility census was 104. Findings include: 1. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, anxiety disorder and diabetes mellitus. The most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was cognitively intact and required extensive assistance of one person for activities of daily living. Review of Resident #46's care plan dated 05/18/19 revealed the call light should be within reach. Observation of Resident #46 on 01/27/20 at 10:01 A.M. revealed Resident #46 was lying in bed with her eyes open. The call light was noted to be on the floor behind the headboard of the bed and out of reach of Resident #46.…

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 code status matched in both the electronic medical record and the hard chart. This affect one Resident (#88) of 34 residents reviewed for advance directives. Findings include: Record review of Resident #88 revealed an admission date of [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease and tracheostomy. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had an intact cognition. Review of the [DATE] physician's orders for Resident #88 revealed Full Cardiopulmonary Resuscitation (CPR) dated [DATE]. Review of Resident #88's hard chart located at the nursing station revealed under the Advanced Directives tab Do Not Resuscitate Comfort Care (DNRCC) form signed but undated by Resident #88's Power of Attorney (POA) and the Nurse Practitioner (NP). Interview on [DATE] at 5:20 P.M. with Licensed Practical Nurse (LPN) #2 verified the code statuses in the electronic medical…

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 Residents #39 and #94's toilets were cleaned and Resident #88's respiratory suction machine and stand were cleaned. This affected three residents (Residents #39, #94 and #88) but had the potential to affect all 104 residents. Findings include: 1. Observation on 01/27/20 at 9:48 A.M. of Resident #94's bathroom revealed there was dried bowel movement on the toilet seat and bathroom floor. This was verified by Licensed Practical Nurse (LPN) #109 at the time of the observation. 2. Observation on 01/27/20 at 10:09 A.M. of Resident #39's toilet seat revealed it was dirty with brown specks on it. This was verified by LPN #41 at the time of the observation. Interview on 01/30/20 at 10:25 A.M. with Director of Environmental Services #9 revealed rooms are cleaned daily, and she does rounds frequently. Review of the Housekeeping policies, dated 08/2014, revealed that resident rooms should be maintained in a clean, safe and sanitary. 3. Observation on 01/27/20 at 10:12 A.M. of Resident #88'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.

Based on observation, interview and record review, the facility failed to develop and implement specific policies and procedures for maintaining oxygen concentrators. The facility failed to ensure oxygen filters were in place for Resident #10 and failed to ensure filters were clean for 10 residents (Residents #3, #21, #28, #40, #42, #48, #50, #66, #80 and #92). This affected 11 residents of 19 residents observed with oxygen concentrators. Findings include: During an interview with Resident #28 on 11/05/18 at 11:44 A.M. the resident was observed to be using oxygen from a concentrator set at four liters. The filter (which filters air being pulled into the concentrator for the person to breath) on the oxygen concentrator was observed covered with a layer of thick gray dust. The oxygen concentrator for her roommate, Resident #50, was observed and the filter was observed with a layer of thick gray dust. An environmental tour was conducted on 11/08/18 beginning at 9:36 A.M. with the Administrator, Housekeeping/Laundry Director #301 and Environmental Director #302. They observed 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, record review, and interview the facility failed to provide or obtain routine dental services to meet the needs of the Resident #38. This affected one (Resident #38) of two residents reviewed for dental services. Finding include: Review of Resident #38's medical record revealed admission dated of 06/06/16. Diagnosis included end stage renal (kidney) disease and dependence on renal dialysis. Review of the annually minimum data set (MDS) assessment dated [DATE] revealed Resident #38 was alert and oriented with intact cognition and had no concerns with dentures or teeth. Observation on 11/06/18 at 9:53 A.M. of Resident #38 during interview revealed Resident #38 had one upper tooth and three bottom teeth. Resident #38 stated he had requested dentures and the facility had not done anything yet. Resident #38 stated he goes to dialysis three days a week and that is when the dentist is scheduled at the facility. Interview on 11/06/18 at 1:54 P.M. with Licensed Social Worker (LSW) #300 verified…

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.