Embassy Of Cambridge

Based on observation and interview, the facility failed to ensure an ice machine was clean and sanitary. This had the potential to affect all residents residing in the facility. The census was 76. Findings include: Observation on 3/19/25 at 12:35 P.M. with Dietary [NAME] # 100 revealed brownish-black, mold-like appearing areas located on the white plastic shield inside of the facility's ice machine. The exterior of the ice machine appeared to have water stains, fingerprints, and dust-like debris. The ice machine was located outside of the kitchen, in a dining room/common area. Interview on 03/19/25 at 12:36 P.M. with Dietary [NAME] #100 confirmed there was brownish-black, mold-like appearing areas located on the white plastic shield located inside of the ice machine, and stated she was unaware of a cleaning schedule or cleaning log for the ice machine. Interview and observation on 03/19/25 at 12:40 P.M. with the Administrator confirmed there was brownish-black, mold-like appearing areas located on the white plastic shield inside of the ice machine and the exterior of the ice machine…

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, review of personal inventory sheets, review of grievance/concern logs, review of email correspondence between a resident representative and the facility, interviews, and policy review, the facility failed to ensure resident representative reports of missing personal items were addressed in a timely manner. This affected one (Resident #2) of three residents reviewed for missing personal items. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, post-traumatic stress disorder, anxiety disorder, age-related macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty in hearing and her speech was clear. She was able to make herself understood and was usually able to understand others. Her cognition was on the high end of being moderately impaired. 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, and interviews the facility failed to ensure a resident, who was dependent on staff for personal care, received appropriate incontinence products needed for proper incontinence care and was assisted up in her chair daily as per her normal routine. This affected one (Resident #2) of three residents reviewed for incontinence care. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, post traumatic stress disorder, gastrostomy status, macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with her hearing and clear speech. She was able to make herself understood and was usually able to understand others. Her cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews the facility failed to ensure administrative staff maintained sufficient supplies to adequately care for the residents residing in the facility. This affected one (Resident #2) of three residents reviewed for incontinence and enteral tube feedings. Findings include: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), obstructive and reflux uropathy, post traumatic stress disorder, gastrostomy status, macular degeneration, and bilateral hearing loss. Review of Resident #2's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with her hearing and clear speech. She was able to make herself understood and was usually able to understand others. Her cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12 (a score of 13-15 was being cognitively intact). She was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility concern log, review of a facility soft file, interviews, and policy review the facility failed to ensure timely and appropriate efforts were implemented to achieve resolution regarding Ombudsman, resident representatives, and/or resident concerns. This had the potential to affect all 72 residents residing in the facility. Finding included: 1. Review of the facility's soft file related to the Ombudsman's concerns revealed on 09/05/24 at 3:00 P.M., the Ombudsman had visited, and she was here two weeks ago and had the same issues she had this day. Today's concerns include a resident was still not getting bologna sandwiches at bedtime, grilled cheese sandwiches and potatoes were burnt, call lights not being answered timely (worse on weekends), residents not getting what they asked for with meals, food over cooked, always available items not always available, and sheets not being changed on shower days. There was no documented evidence who attended the meeting. A…

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

Based on personnel file review, review of the facility Bureau of Criminal Identification (BCI) log, review of employee time sheets, interview, and policy review the facility failed to ensure staff were not permitted to work in a direct care capacity with a disqualifying offense. This had the potential to affect all 72 residents residing in the facility. Findings included: An anonymous concern made on 11/12/24 revealed the Administrator employed staff with criminal backgrounds (felony). This concern was investigated as part of the onsite complaint survey. Review of Certified Nursing Assistant (CNA) #702's application dated 08/12/24 revealed CNA #702 had checked yes to having been convicted or pled guilty to a crime. The CNA documented on the application she had a felony on 07/07/24 in (location) county. The CNA's at the facility work history included she worked as an CNA in a skilled nursing facility from 12/23/23 until 07/03/24. Review of the facility BCI log dated 04/17/24 to 11/11/24 revealed CNA #702 was hired on 08/13/24 and the BCI was submitted on 08/13/24. There was no…

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 review of concern log, review of food committee meeting minutes, observation, interviews, and policy review the facility failed to ensure dietary staff were competent to carry out functions of food delivery. This had the potential to affect all 72 residents, except Resident #51, whom the facility identified as nothing by mouth (NPO). Findings included: Review of the concern log dated 09/06/24 to 10/31/24 revealed 10 concerns were reported regarding food preferences and receiving food items per order. Review of food committee meeting minutes dated 10/02/24 revealed the kitchen was running out of wheat bread and they needed more snacks and more of a variety. Interview on 11/05/24 at 7:07 A.M. and 11/06/24 at 7:42 A.M. with Resident #4 revealed the food was not much better since the last time the kitchen was surveyed in September and received citations. One day he didn't even receive a meal tray. The facility uses the excuse the truck didn't come and that was why they were running out of food, but he heard it was because of the budget, and they can only order so much, and it…

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 review of the concern log, review of the food committee meeting minutes, interview, observation, and policy review the facility failed to ensure meals were provided per menu and resident preferences. This had the potential to affect 71 of 72 residents who receive meals from the facility kitchen. The facility identified one resident(Resident #51)to receive nothing by mouth. Findings included: Review of the concern log dated 09/06/24 to 10/31/24 revealed 10 concerns were reported regarding food preferences and receiving food items per order. Review of food committee meeting minutes dated 10/02/24 revealed the kitchen was running out of wheat bread and they needed more snacks and more of a variety. Review of the breakfast menu for 11/05/24 revealed cream of rice, sausage patty, and apple muffin. Observation on 11/05/24 at 7:37 A.M. of the breakfast meal revealed the residents were to receive a cream of rice, apple muffin and sausage patty, however there was no muffins or sausage patties. [NAME] #200 reported there were no more sausage patties and only the residents in the…

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

Based on review of mealtimes, observation, and interview, the facility failed to ensure meals were delivered timely. This had the potential to affect 71 of 72 residents receiving meals from the facility kitchen. The facility identified one resident (Resident#51) to receive nothing by mouth. Findings included: Interview on 11/05/24 at 7:21 A.M. and 2:22 P.M. with an anonymous staff member #800 revealed meals are late almost every day. Interview on 11/05/24 at 1:52 with Licensed Practical Nurse (LPN) #115 revealed some days meal trays were delivered late. Interview on 11/05/24 at 2:14 P.M., with LPN #114 revealed meals were not delivered timely all the time. Interview on 11/05/24 at 2:40 P.M., with anonymous staff member #801 revealed meals were late a lot of the time. Observation on 11/06/24 at 8:30 A.M. revealed the breakfast treys had just arrived at Southwest Hall. Observation confirmed with DON at 8:30 A.M. on 11/06/24. The DON confirmed the mealtime sheet indicated 7:40 A.M. for breakfast. Interview on 11/06/24 at 12:00 P.M., with Resident #56 revealed meal times vary. Interview…

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, review of controlled drug receipts, review of the medication administration audit report, review of controlled medication shift change logs, review of staff schedules, review of the facility investigation, review of a self-reported incidents (SRI), interviews, and policy review the facility failed to ensure resident narcotics were not misappropriated. This affected four (Resident #7, #12, #51, and #56) of five records reviewed for misappropriation. The facility had identified 46 residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #19, #21, #22, #23, #24, #24, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #48, #51, #52, #53, #54, #55, #56, #57, #58, #500, and #501) that had medication/treatment errors. The facility identified eight residents affected by misappropriation (#7, #12, #13, #16, #21, #22, #31, and #37). Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses…

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, review of concern log and report, interview, and policy review the facility failed to ensure a resident was treated with respect and dignity. This affected one (Resident #4) of three residents reviewed for respect and dignity. Findings included: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including but not limited to lymphedema, diabetes, neuropathy, depression, anxiety, and insomnia. Review of the facility's concern log and report dated 10/31/24 revealed Resident #4 reported to the Ombudsman that Agency Certified Nursing Assistant (CNA) #545 was engaging in a political view conversation and the resident had asked him to stop the conversation during care. The CNA had also stretched the resident's leg too far during care. The Assistant Director of Nursing (ADON) #153 spoke to CNA #545 and he recalled having a conversation months ago about politics but be thought they were just having fun because how blown up it all was now. 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 medical record review, review of controlled drug receipts, review of the medication administration audit report, review of controlled medication shift change logs, review of staff schedules, review of the facility investigation, review of a self-reported incidents (SRI), interviews, and policy review the facility failed to thoroughly investigate an allegation of misappropriation. This affected two resident (#51, #56) of five residents reviewed for misappropriation. The facility census was 72. The facility identified eight residents affected by misappropriation (#7, #12, #13, #16, #21, #22, #31, and #37). Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the mouth and tongue, dysphagia, and gastrostomy. Review of Resident #51's medication administration record (MAR) and orders dated 11/2024 revealed the resident was ordered Oxycodone 10 milligrams (mg) one tablet via nasogastric (NG) tube every four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, review of hospital records, review of hearing results, review of the facility assessment, interviews, and policy review the facility failed to ensure Resident #1 was permitted to return to the facility after an emergency room evaluation. This affected one resident (Resident #1) of three residents reviewed for discharge. Findings included: Closed record review revealed Resident #1 was originally admitted to the facility on [DATE] and discharged with anticipated return on 08/22/24. The resident was re-admitted on [DATE] and discharged [DATE]. The resident's diagnoses included encephalopathy, hallucination, disorientation, hypothyroidism, tension headaches, absence of larynx and history of larynx, thyroid, and brain cancer. Review of Resident #1's preadmission screening and resident review (PASARR) dated 08/26/24 revealed the resident hallucinated that caused functional limitations. The resident was receiving anti-psychotics. A referral was made for a level II evaluation. Review 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 record review, observation, and interview the facility failed to ensure residents received assistance and supervision during lunch dining. This affected one (Resident #62) of three residents reviewed for meal assistance. Findings include: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage, dysphagia, gastrostomy, hypothyroidism, for assistance with personal care, Alzheimer's, dementia, and heart disease. Review of Resident #62's [NAME] Data Set (MDS) dated [DATE] revealed the resident had a feeding tube and was ordered a mechanically alter diet. The resident required substantial/maximal assistance (helper does more than half the effort) with eating. The resident had severe cognition impairment. Review of Resident #62's nutritional plan of care dated 10/17/24 revealed to address any chewing/swallowing/signs of aspiration, assist with feeding needs as needed, monitor weights every month and as needed, and provided diet as…

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, review of concern form, review of pharmacy communication, interview, and policy review the facility failed to ensure medication were readily available and administered as ordered. This affected one (Resident #4) of three residents reviewed for pain management. Findings included 1. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes and neuropathy. a. Review of Resident #4's orders dated 09/2024 revealed the resident was ordered Insulin Glargine Solution 100 units/milliliter (ml) 14 units subcutaneously at bedtime for diabetes. Review of Resident #4's and Medication Administration Record (MAR) dated 09/2024 revealed on 09/18/24 the resident did not receive his Insulin Glargine Solution 100 units/milliliter (ml) 14 units subcutaneously at bedtime for diabetes and to see nurses note. The resident was to have his blood sugar obtained at bedtime and documented with the Administration of the insulin. There was no evidence…

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, review of a facility Self-Reported Incident (SRI) and investigation, interviews with staff and residents, the facility failed to take reasonable precautions, including providing adequate supervision, to prevent a resident-to-resident altercation. This affected one resident (Resident #3) of three residents reviewed for abuse. The facility census was 72. Findings Include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right humerus, asthma, diabetes mellitus, multiple fractures of ribs, fracture of right femur, heart disease, and history of cerebral infarction. The resident was moderately cognitively impaired and was dependent on staff for activities of daily living (ADLs) assistance. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 09 of 15, indicating moderately impaired cognition. Review 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 observation, record review, policy review, and interview, the facility failed to ensure ice water was provided to residents in their rooms, consistent with their preferences, to maintain hydration. This affected one (Resident #3) of three residents reviewed for hydration. The facility census was 72. Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right humerus, multiple fractures of ribs, fracture of right femur, asthma, diabetes mellitus, heart disease, and history of cerebral infarction. The resident was moderately cognitively impaired and was dependent on staff for activities of daily living (ADLs) assistance. Interview on 10/24/24 at 9:39 A.M. with Ombudsman #70 revealed she has received numerous complaints from residents regarding ice water not being provided to them in their rooms. Interview on 10/24/24 at 10:05 A.M. with Resident #7 revealed sometimes ice and water is not provided on a…

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

Based on review of information submitted to the state survey agency, interview, resident council minutes review, review of the concern log, and policy review the facility failed to ensure adequate staffing to answer call lights timely and provide care timely. This had the potential to affect all 69 residents residing in the facility. Findings include: Interview on 08/26/24 at 12:26 P.M. with anonymous staff member #300 revealed the facility was understaffed. The anonymous staff member reported it was difficult to provide incontinence care and answer call lights timely when there was only one aide per hall and by the time she completed the first rounds half of her day was gone. Interview on 08/26/24 at 2:24 P.M. with Resident #3 revealed the facility was understaffed. The resident reported there was only one aide for each unit. The resident reported one aide was not enough for his unit and the facility kept adding residents but not adding staff to care for them. He had to beg for a bed bath daily. It took staff an hour or so to answer call lights. Interview on 08/27/24 at 8:22 A.M.,…

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 review of daily nurse staff posting, review of staffing schedule, review of time sheets, review of the facility assessment, policy review, and interview the facility failed to provide a registered nurse (RN) for at least eight consecutive hours daily on 08/04/24. This had the potential to affect all 69 residents residing in the building. Findings included: Review of the facility's daily staff posting dated 08/04/24 revealed the census was 64. There was no RN or RN hours for dayshift or night shift noted. There was 3.75 Licensed Practical Nurses (LPN) for 44 hours on dayshift and 2.75 LPN for 32 hours on nightshift. Review of the staffing schedule dated 08/04/24 revealed no evidence a RN was scheduled. Review of time sheets dated 08/04/24 revealed no evidence a RN had worked on 08/04/24. Interview on 09/03/24 at 3:45 P.M., with the Director of Nursing (DON) confirmed there was no evidence a RN had worked eight consecutive hours on 08/04/24. The DON reported she had come into the facility on [DATE] 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 review of photos, review of daily food temperature logs, interview, observation, and policy review the facility failed ensure food was palatable. This had the potential to affect all 69 residents residing in the building. Finding includes: 1. Observation on 09/03/24 at 12:31 P.M., of lunch tray line revealed the mechanical soft chicken patty on the steam table temperature was 117.8 degrees Fahrenheit (F) and the pureed chicken patty on the steam table was 115.1 degrees Fahrenheit. At the time of the observation, interview with the Dietary Manager (DM) #212 from a sister facility reported the food should be held at 135 degrees F on the steam table. The DM #212 reported the knobs were missing on the steam table and she didn't know what temperature the steam table was set on. During the observation, [NAME] # 151 made a mechanical soft meal tray for Resident #53 from the steam table without re-heating the mechanical soft chicken patty after the surveyor confirmed the chicken didn't reach holding temperature. The surveyor intervened prior to the dietary aide delivering the meal…

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 review of submitted concerns to the state survey agency, interviews, and policy review the facility failed to ensure residents were treated with respect and dignity. This affected four residents (#3, #33, #41, and #49) of nine residents reviewed for respect and dignity. Findings included: Review of submitted concerns to the state survey agency, dated 07/16/24 to 09/03/24 revealed several concerns with staff not treating residents with respect and dignity. On 07/16/24 a submitted concern indicated staff had extremely cold manners, 08/02/24 aides had bad attitudes, very disrespectful towards residents, and talked about other residents to residents. On 08/05/24 a submitted concern revealed staff were yelling at residents and rough with care. On 08/22/24, a submitted concern revealed Licensed Practical Nurse (LPN) #145 was rude to residents and 09/03/24 LPN #145 told a male resident who fell Are you kidding me. I don't have time for this. I have a family emergency. Interview on 08/26/24 at 2:24 P.M., with Resident #3 revealed he has concerns with staff not treating him with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure resident narcotics were not misappropriated. This affected two residents (#42 and #51) of three records reviewed. Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including anxiety, insomnia, dementia, depression, and senile degeneration of the brain. Review of Resident #51's orders dated 08/2024 revealed the resident was ordered Ativan 0.5 milligrams (mg) every four hours for anxiety/agitation. There was an additional order to administer an additional 0.5 mg at bedtime with the other 0.5 mg scheduled Ativan. Review of Licensed Practical Nurse (LPN) #198's timecard revealed on [DATE] the LPN clocked in at 2:36 P.M. and clocked out at 2:00 A.M. on [DATE]. Review of Resident #51's Ativan 0.5 mg control drug receipt form dated [DATE] revealed on [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure misappropriation of resident narcotics was reported to the state survey agency within the required timeframe. This affected two residents (#42 and #51) of three records reviewed. Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including anxiety, insomnia, dementia, depression, and senile degeneration of the brain. Review of Resident #51's orders dated 08/2024 revealed the resident was ordered Ativan 0.5 milligrams (mg) every four hours for anxiety/agitation. There was an additional order to administer an additional 0.5 mg at bedtime with the other 0.5 mg scheduled Ativan. Review of Licensed Practical Nurse (LPN) #198's timecard revealed on [DATE] the LPN clocked in at 2:36 P.M. and clocked out at 2:00 A.M. on [DATE]. Review of Resident #51's Ativan 0.5…

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, review of timecards, review of the facility investigation, review of self-reported incidents (SRI), interviews, and policy review the facility failed to ensure misappropriation of resident narcotics was thoroughly investigated. This affected two residents (#42 and #51) of three records reviewed. Findings included: 1. Medical record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including anxiety, insomnia, dementia, depression, and senile degeneration of the brain. Review of Resident #51's orders dated 08/2024 revealed the resident was ordered Ativan 0.5 milligrams (mg) every four hours for anxiety/agitation. There was an additional order to administer an additional 0.5 mg at bedtime with the other 0.5 mg scheduled Ativan. Review of Licensed Practical Nurse (LPN) #198's timecard revealed on [DATE] the LPN clocked in at 2:36 P.M. and clocked out at 2:00 A.M. on [DATE]. Review of Resident #51's Ativan 0.5 mg control drug receipt form dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interview, and policy review the facility failed to ensure all required information upon transfer was communicated and/or documented in the resident's medical record. This affected one resident (#74) of three residents reviewed for transfer and discharge. Findings include: Closed record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including hallucinations, disorientation, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #74's progress note dated 08/22/24 revealed the resident was transferred to the emergency room. Review of Resident #74's Psych 360 note dated 08/22/24 revealed the resident's behaviors have continued to escalate. The resident was sent to the emergency room and returned to the facility. The facility called requesting a pink slip to send him to another emergency room. Offered to find bed placement, however per the facility, transport was currently at the facility 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 closed medical record review, staff interview, and policy review the facility failed to ensure the resident and resident representative received a transfer notice as soon as practicable prior to being transferred to the hospital. This affected one resident (#74) of three residents reviewed for transfer and discharge. Findings include: Closed record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including hallucinations, disorientation, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #74's progress note dated 08/22/24 revealed the resident was transferred to the emergency room. Review of Resident #74's Psych 360 note dated 08/22/24 revealed the resident's behaviors have continued to escalate. The resident was sent to the emergency room and returned to the facility. The facility called requesting a pink slip to send him to another emergency room. Offered to find bed placement, however per the facility, transport was currently…

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, staff interview, and policy review the facility failed to ensure the resident and resident representative received a bed hold notice when the resident was transferred. This affected one resident (#74) of three residents reviewed for transfer and discharge. Findings include: Closed record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including hallucinations, disorientation, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #74's progress note dated 08/22/24 revealed the resident was transferred to the emergency room. Review of Resident #74's Psych 360 note dated 08/22/24 revealed the resident's behaviors have continued to escalate. The resident was sent to the emergency room and returned to the facility. The facility called requesting a pink slip to send him to another emergency room. Offered to find bed placement, however per the facility, transport was currently at the facility and waiting on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, review of information submitted to the state survey agency, staff interview, and policy review the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) documents accurately reflected the resident's diagnoses. This affected one resident (#74) of three residents reviewed for PASARR assessment. Findings include: Closed record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including hallucinations, disorientation, and other symptoms and signs involving cognitive functions and awareness. Review of a neurology note dated 07/31/24 (prior to admission) revealed the resident had intermittent hallucinations and was still having bizarre behaviors. Review of Resident #74's PASARR dated 08/08/24 indicated the resident had no serious mental illness. Review of Resident #74's progress note dated 08/10/24 revealed the resident was agitated and entered an empty room at the end of the hall and removed a wooden bar from…

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 policy review the facility failed to ensure fall interventions were implemented for a resident at risk of falls. This affected one resident (#51) of three residents reviewed for falls. Findings included: Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses included history of falls, history of healed traumatic fracture, and muscle weakness. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had two or more falls with no injuries since the last admission/entry, reentry, or prior assessment. Review of Resident #51's fall plan of care initiated 12/04/21 and revised on 03/19/24 revealed the resident required a soft call light, ensure call light was in reach at all times, low bed, and a full mattress on the floor beside the bed. Review of Resident #51's activity of daily living (ADL) plan of care initiated on 05/12/21 and revised on 03/19/24 revealed to call light in reach when in bed. Observation on…

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

Based on review of narcotic control sheets, interview, and policy review the facility failed to ensure staff followed the systems in place for managing narcotic medications to assist in the prevention of narcotic diversion. This had the potential to affect all 69 residents residing in the facility. Finding included: Review of the Northwest controlled medication form dated 07/30/24 to 08/07/24 revealed no evidence a second nurse witnessed/signed when a narcotic medication count sheet was added or removed from the inventory. Interview on 08/27/24 at 12:57 P.M., with Registered Nurse (RN) #206 and the Director of Nursing (DON) confirmed nurses were not ensuring a second nurse was witnessing when narcotic count sheets were added or removed from the narcotic inventory. The facility recently had nine oxycodone missing. The resident's blister card and control sheet were both removed and not documented on the control sheets per staff. The staff reported the only reason the missing medication was discovered was the nurse that had worked the prior day noticed the resident's new blister pack…

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, observation, and interview the facility failed to ensure a resident received their diet as ordered. This affected one resident (#41) of three records reviewed. Findings included: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Parkinson's, dysphagia, and gastro-esophageal reflux disease. Review of Resident #41's nursing note dated 08/26/24 revealed the resident returned from the hospital with new orders for six small mechanical soft meals daily and aspiration precautions due to the resident had failed a swallowing evaluation. Review of Resident #41's orders dated 08/26/24 revealed the resident's diet order was changed to six small mechanical soft texture meals daily. Interview and observation on 08/28/24 at 11:41 A.M., of Resident #41 with Registered Nurse (RN) #206 revealed the resident had only received one meal thus far today and it was breakfast. Observation of the resident's meal ticket from breakfast revealed no…

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, observation, and interview the facility failed to ensure a resident received fluids as ordered. This affected one resident (#41) of three records reviewed. Findings included: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Parkinson, dysphagia, and gastro-esophageal reflux disease. Review of Resident #41's nursing note dated 08/26/24 revealed the resident returned from the hospital with new orders for nectar thickened liquids and aspiration precautions due to the resident had failed a swallowing evaluation. Review of Resident #41's orders dated 08/26/24 revealed the resident's diet order was changed to nectar thickened liquids. Observation on 08/28/24 at 5:31 P.M. of Resident #41's dinner meal revealed the resident had a red juice on her meal tray that was thin consistency. The resident had no other fluids on her tray except the red juice. The resident's meal ticket was handwritten with the resident's name, mechanical…

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, observation, interview, and policy review the facility failed to ensure resident medical records including medication administration records and narcotic administration records were complete and accurate. This affected three residents (#31, #37, and #42) of 28 residents residing on Northwest. Findings included: 1. Record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome and presence of a neurostimulator. Observation on 09/03/24 at 1:02 P.M. of Northwest medication cart revealed Resident #37 had a blister package of 51 Oxycodone (15 milligram (mg) tablets). Review of Resident #37's controlled drug receipt form revealed the resident had 52 Oxycodone (15 mg) remaining. 2. Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including knee pain, diabetes, and lymphedema. Observation on 09/03/24 at 1:02 P.M. of Northwest medication cart revealed Resident #31 had a blister package of 15…

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 policy review the facility failed to ensure a resident's call light was functional at the resident's bedside. This affected one resident (#51) of three residents reviewed for falls. Findings included: Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses included history of falls, history of healed traumatic fracture, and muscle weakness. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had two or more falls with no injuries since the last admission/entry, reentry, or prior assessment. Review of Resident #51's fall plan of care initiated 12/04/21 and revised on 03/19/24 revealed the resident required a soft call light and to ensure call light was in reach at all times. Review of Resident #51's activity of daily living (ADL) plan of care initiated on 05/12/21 and revised on 03/19/24 revealed to have call light in reach when in bed. Observation on 09/03/24 at 8:26 A.M. revealed the surveyor…

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 staff interview, the facility failed to ensure the laundry room was maintained in a safe, functional and sanitary conditon. This had the potential to affect all the residents in the facility. The facility census was 68. Findings include: Observation in the laundry room with Laundry Aide #120 on 05/14/24 at 1:10 P.M. revealed the eyewash station was not functioning and was in pieces, the front of the washing machine was off and leaning up against the side of the washing machine, there was a large hole in the wall beside the hot water tank from a metal railing which was separating the laundry barrels from the hot water heater, the dry wall behind the washing machine was crumbling and had large holes in it, the water facet behind the washing machine was leaking into a bucket and the bucket was overflowing onto the floor, the four air vents in the ceiling were covered with a greyish substance and debris. Additionally, one of the air vents had a leaf sticking out of it, there was a drainage pipe coming out of the wall to the left of the washing machines and there…

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, staff interview and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene while distributing meal trays to the residents. This affected eight (Resident #3, #20, #30, #37, #38, #52, #57, and #65) out of the 26 residents (#3, #13, #15, #20, #21, #25, #30, #35, #37, #38, #41, #43, #44, #46, #48, #50, #51, #52, #54, #57, #58, #60, #61, #65, #67, and #224) residents residing on the Northwest Unit who ate their meals in their rooms. Additionally, the facility failed to ensure residents were not provided milk that was past the best by date. This affected one resident (Resident #3) out of 67 residents who received food from the facility kitchen. Resident #270 was identified as not receiving meals from the kitchen. The facility census was 68. Findings include: 1. Observation of staff delivering meal trays on 05/13/24 at 12:35 P.M. revealed State Tested Nursing Assistant (STNA) #119 started to pass out the trays on the Northwest Unit. She went into 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.

Based on medical record review, staff interview and review of the facility policy, the facility failed to notify physicians of significant weight changes. This affected one (Resident #50) of five residents reviewed for nutrition. The facility census was 68. Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/10/22 with diagnoses including anoxic brain injury damage, adult failure to thrive, unspecified protein-calorie malnutrition, gastrostomy, aphasia, dysphagia, contracture of left and right hand, drug induced dyskinesia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #50 dated 03/20/24 revealed the resident had severely impaired cognition and was dependent on the assistance of staff for eating. Resident #50 had symptoms of a swallowing disorder including loss of liquids or solids from mouth when eating or drinking, holding food in mouth or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents accurately reflected resident diagnoses. This affected one (Resident #27) of two residents reviewed for PASARR documents. The facility census was 68 residents. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with agitation, bipolar disorder, cognitive communication deficit, and alcohol abuse with encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #27 dated 03/09/24 revealed the resident had severely impaired cognition, and had diagnoses of dementia, anxiety disorder, depression, and bipolar disorder. Review of the PASSAR document for Resident #27 dated 04/11/17 revealed diagnoses of schizophrenia and mood disorder were listed. Review of the cumulative diagnosis list for Resident #27 revealed the diagnoses of anxiety…

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 medical record review and staff interview, the facility failed to develop a care plan that addressed palliative care. This affected one (Resident #43) out of one resident reviewed for hospice. The facility census was 68. Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/24/23 with diagnoses including unspecified protein-calorie malnutrition, depression, atherosclerotic heart disease, spinal stenosis, adult failure to thrive, low back pain, cognitive communication deficit, osteoarthritis, anxiety disorder, and unspecified dementia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/18/24, revealed Resident #43 was severely cognitively impaired. Review of the hospice visit, dated 12/04/23, revealed Resident #43's initial palliative assessment was completed. Review of Resident #43's physician order, dated 03/05/24, revealed an order for hospice palliative care. Review of Resident #43's plan of care, last reviewed 03/31/24, revealed Resident #43 receiving palliative care was not addressed in the care plan.…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure comprehensive resident care plans were updated with changes in treatment. This affected two (Residents #32 and #33) of 24 residents reviewed for care plans. The facility census was 68. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 11/30/22 with diagnoses including paraplegia, hypertensive heart disease, history of transient ischemic attack and cerebral infarction, hypoxemia, diabetes mellitus, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #32 dated 04/10/24 revealed the resident had moderate cognitive impairment. Review of the care plan for Resident #32 dated 09/03/22 revealed the resident experienced pain/discomfort related to paraplegia, wounds, and immobility. Interventions included the following: administer pain medications as ordered, observe for side effects and effectiveness. The care plan was not updated to reflect the resident's order for methadone. Review 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.

Based on medical record review, observation, staff interview, resident interview and review of the facility policy, the facility failed to provide proper nail care to dependent residents. This affected two (Residents #23 and #32) of five residents reviewed for activities of daily living (ADL) care. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 03/28/24 with diagnoses including diabetes mellitus, obsessive compulsive personality disorder, moderate intellectual disabilities, and muscle weakness. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/08/24 revealed the resident had severely impaired cognition and was dependent on staff assistance with bathing and personal hygiene. Review of the care plan for Resident #23 dated 04/29/24 revealed the resident was totally dependent and did not participate in any aspect of the tasks of personal hygiene. Interventions included staff would assist the resident as needed with daily hygiene. Observations on 05/13/24 at 9:58 A.M., 05/14/24…

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 medical record review, review of a tray ticket, observation, staff interview, and policy review, the facility failed to ensure residents who were not supposed to receive liquids by mouth were not provided liquids by mouth and failed to ensure nutritional supplements were provided as ordered. This affected one resident (#50) out of five residents reviewed for nutrition. The facility census was 68. Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/10/22 with diagnoses including anoxic brain injury damage, adult failure to thrive, unspecified protein-calorie malnutrition, gastrostomy, aphasia, dysphagia, contracture of left and right hand, drug induced dyskinesia, and cognitive communication deficit. Review of Resident #50's quarterly Minimum Data Set 3.0 assessment, dated 03/20/24, revealed the resident had severely impaired cognition and was dependent on staff for eating. Resident #50 had symptoms of a swallowing disorder including loss of liquids or solids from mouth when eating or drinking, holding food in mouth or residual…

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 medical record review, observation, staff interview and review of the facility policy, the facility failed to label, date, and initial an enteral formula for a resident receiving enteral nutrition. This affected one (Resident #62) of three facility-identified residents who received tube feedings. The facility census was 68 residents. Findings include: Review of the medical record for Resident #62 revealed an admission date of 03/08/24 with diagnoses including acute dilation of stomach, partial intestinal obstruction, iron deficiency anemia, esophagitis with bleeding, dysphagia, bipolar disorder, and gastroesophageal reflux disease. Observation on 05/13/24 at 9:12 A.M. of Resident #62 revealed a bag of tube feeding was infusing via pump at a rate of 60 milliliters per hour (ml/hr.) The disposable enteral feeding bag was not labeled, dated, or initialed. Interview on 05/13/24 at 9:32 A.M. of Licensed Practical Nurse (LPN) #125 confirmed she had hung the tube feeding bag for Resident #62 on 05/13/24 at 6:00 A.M. but she had not labeled, dated, or initialed the bag to indicate…

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, observation, staff interview, and review of the facility policy the facility failed to ensure resident oxygen flow rates were set as ordered by the physician and failed to ensure the humidifier bottles were emptied and changed weekly. This affected one (Resident #32) of three residents reviewed for respiratory care. The facility identified seven residents receiving oxygen therapy. The facility census was 68 residents. Findings include: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included paraplegia, hypertensive heart disease, history of transient ischemic attack and cerebral infarction, hypoxemia, diabetes mellitus, and chronic kidney disease. Review of the care plan for Resident #32 dated 12/12/22 revealed the resident had an alteration in cardiac output with the intervention to administer oxygen as ordered by the physician. Review of the physician's orders for Resident #32 revealed an order dated 08/04/23 for oxygen at…

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

Based on medical record review, staff interview and review of the facility policy the facility failed to residents were assessed for the safe use of bed rails prior to implementation. This affected one (Resident #50) of two residents reviewed for skin impairment. The facility census was 68 residents. Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/10/22 with diagnoses including anoxic brain injury damage, adult failure to thrive, unspecified protein-calorie malnutrition, gastrostomy, aphasia, dysphagia, contracture of left and right hand, drug induced dyskinesia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #50 dated 03/20/24 revealed the resident had severely impaired cognition. Review of the plan of care for Resident #50 dated 10/16/23 revealed the resident required assistance for activities of daily living (ADLs) related to cognitive impairment, poor safety awareness, and contracture to bilateral hands. Interventions included the following: assist with oral care per…

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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were not left at the bedside unattended. This affected two (Resident #3 and #37) of six residents reviewed for accidents. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 12/26/22 with diagnoses including human immunodeficiency virus disease, atrial fibrillation, hypertension, major depressive disorder, chronic pain syndrome, and chronic obstructive pulmonary disease (COPD.) Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 03/22/24 revealed the resident had intact cognition. Review of the May 2024 physician's orders for Resident #3 revealed an order dated 03/22/24 for an Incruse Ellipta inhaler. Resident #3 did not have an order to self-administer the inhaler nor to leave it at the bedside. Observation of Resident #3's room on 05/13/24 at 9:30 A.M. revealed there was an Incruse inhaler unattended by staff on the resident's bedside stand.…

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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents received timely dental care. This affected one (Resident #15) of one residents reviewed for dental services. The facility census was 68 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 12/26/22 with diagnoses including cerebral infarction, major depression, epilepsy, hemiplegia of the right side, and dementia with psychotic disturbance. Review of the progress note for Resident #15 dated 10/13/23 timed at 5:36 P.M. revealed the resident requested to see the dentist. Review of the dentist report for Resident #16 dated 10/23/23 revealed the resident lost his partial for his front teeth and the dentist recommended extraction of tooth number seven so they could make a new partial for teeth numbers seven, eight, and nine. There was no pathology, but the resident had extensive decay. Review of the plan of care for Resident #15 dated 01/13/24 revealed the resident had impaired dental status related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a meal ticket, observation, and staff interview, the facility failed to ensure residents received adaptive equipment with meals as ordered. This affected one (Resident #48) of five residents reviewed for nutrition. The census was 68. Findings include: Review of Resident #48's medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, diabetes, acute kidney failure, dysphagia, anxiety disorder, depression, obstructive sleep apnea, hypertension, metabolic encephalopathy, and atherosclerotic heart disease. Review of the quarterly Minimum Data Set assessment, dated 03/02/24, revealed Resident #48 had moderately impaired cognition and required set up assistance with eating. Review of the Resident #48's physician order, dated 03/16/24, revealed an order to have built up utensils and a divided plate with meals. Review of the plan of care, dated 03/16/24, revealed Resident #48 had a potential alteration in nutrition…

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 medical record review and staff interview, the facility failed to ensure medications were accurately documented as administered. This affected one resident (#50) of six residents reviewed for behaviors and/or medications. The facility census was 68. Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/10/22 with diagnoses including anoxic brain injury damage, adult failure to thrive, unspecified protein-calorie malnutrition, gastrostomy, aphasia, dysphagia, contracture of left and right hand, drug induced dyskinesia, and cognitive communication deficit. Review of Resident #50's quarterly Minimum Data Set 3.0 assessment, dated 03/20/24, revealed the resident had severely impaired cognition. Review of Resident #50's physician orders revealed an order, dated 10/10/22, for Bromcriptine Mesylate 2.5 milligrams (mg) two times a day. Review of Resident #50's physician orders revealed an order, dated 10/10/22, for Melatonin (used to regulate sleep/wake cycles) 10 mg at bedtime. Review of Resident #50's physician orders revealed an order,…

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, policy review, and interview, the facility failed to initiate enhanced barrier precautions as required. This affected one resident (#48) of three residents sampled. The census was 70. Findings include: Medical record review revealed Resident #48 was admitted on [DATE] and readmitted on [DATE] with diagnoses including dementia, aortic artery aneurysm, sepsis, urinary tract infection, Vancomycin Resistant Enterococci (VRE) infection and percutaneous endoscopic gastrostomy (an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). Review of Certified Nurse Practitioner #116's Progress Note dated 03/19/24 revealed Resident #48 was seen at a local hospital from [DATE] to 03/19/24 for altered mental status and fever. The hospital course included an acute workup in which his urine culture was positive for VRE. He was initiated on Zyvox…

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 and interview, the facility failed to ensure dependent residents received assistance with personal hygiene. This affected one resident (#27) of three residents sampled. The census was 70. Findings include: Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including dementia, muscle weakness, syncope, collapse and cerebral infarction. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 was moderately impaired for daily decision-making, required set-up/clean-up assistance with oral care, substantial/maximal assist with shower/bathe self, and partial/moderate assist with personal hygiene. Review of the Head-to-Toe Skin Observation sheets and Task Shower/Bathe documentation revealed Resident #27 had not received or been offered a shower between 03/16/24 and 03/23/24 or between 03/27/24 and 04/04/24. Review of the care plan: Assistance Needed with ADL's (activities of daily living) revised 12/11/23…

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 observation, medical record review, manufacturer guideline review, policy review and interview, the facility failed to ensure medications were administered as ordered. This affected two residents (#10 and #17) of five residents observed, four observed errors during 38 medication opportunities resulting in a medication error rate of 10.52%. The facility census was 70. Findings include: 1. Medical record review revealed Resident #10 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact for daily decision-making and received insulin injections daily. Review of the monthly Physician Orders dated April 2024 revealed Resident #10 was ordered Lantus (long acting insulin to treat diabetes) 60 units subcutaneous at bedtime. On 04/03/24 at 6:59 P.M., observation of Resident #10's medication administration revealed Registered Nurse (RN) #100 dispensed the resident's oral medications…

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, policy review and interview, the facility failed to ensure residents were free of significant medication errors when a resident was administered intravenous antibiotics not in accordance with physician orders. This affected one resident (#1) of four sampled residents. The census was 70. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including osteomyelitis of thoracic spine, diarrhea of presumed infectious origin, type II DM, cardiomyopathy, and status post placement of cardiac pacemaker. Review of the hospital admission orders revealed Resident #1's physician was to be asked about medications including ozempic, Sertraline, sodium bicarbonate, topiramate, tuberculin and vancomycin. The vancomycin was to given every 24 hours for 41 days intravenously (IV). Review of the medical record revealed no documented evidence the hospital admission orders were addressed by Resident #1's physician or follow-up with the infectious disease…

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, policy review, transportation calendar review and interview, the facility failed to be administered in a manner to ensure residents were able to be transported to scheduled appointments. This affected one resident (#1) of four residents sampled. The census was 70. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including osteomyelitis of thoracic spine, type II DM, cardiomyopathy, and status post placement of cardiac pacemaker. Review of Resident #1's after-visit hospital Discharge Instructions dated 03/29/24 revealed future appointments included a cardiology appointment at 10:40 A.M. on 04/01/24. Review of the eMAR (electronic Medication Administration Record) Note dated 04/01/24 revealed Resident #1's Follow up appointment with Cardiology on 04/01/24 was rescheduled for 04/11/24. There was no explanation or reason for rescheduling the appointment. On 04/11/24 at 7:23 A.M., interview with Transporter #120 stated the facility bus…

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 and interview, the facility failed to ensure treatments were completed as ordered. This affected two residents (#123 and #141) of three residents reviewed for treatments. The facility census was 73. Findings include: 1. Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including end stage renal disease, right knee amputation (BKA) on 12/26/23 and an I&D with revision on 02/06/24. Surgical culture of the site revealed vancomycin-resistant enterococci (VRE) and Methicillin-resistant staphylococcus aureus (MRSA). The resident was discharged back to facility on 02/12/24. Review of the Discharge summary dated [DATE] revealed Infectious Disease recommended zyvox (antibacterial drug used to treat susceptible Gram-positive infections) and augmentin (penicillin class of antibiotics) with an end of treatment being 02/20/24 for the treatment of VRE and MRSA. Review of the Medication Administration Record dated February 2024 revealed Resident #141 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, transportation calendar review, dialysis contract review, policy review and interview, the facility failed to ensure residents were transported to dialysis as scheduled. This affected one resident (Resident #141) of three residents reviewed for transportation to appointments. The facility census was 73. Findings include: Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including end stage renal disease, renal dialysis dependent and diabetes mellitus. Review of the hospitalist Discharge summary dated [DATE] revealed Resident #141 received hemodialysis every Monday, Wednesday and Friday. Review of the 2024 Transportation Calendar revealed no evidence transportation was scheduled for 01/01/24. Review of the Progress Notes dated 01/01/24 at 5:30 A.M. revealed the nurse notified the dialysis center that Resident #141 would not be able to make his 6:00 A.M. dialysis treatment due to a transportation problem. Review of the care plan: Potential for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure medications were administered as ordered. This affected two of two residents (#127 and #130), three observed errors during 28 medication opportunities resulting in a medication error rate of 10.71%. Findings include: 1. Medical record review revealed Resident #130 was admitted on [DATE] with diagnoses including chronic lymphocytic leukemia, hypertension and total retinal detachment of both eyes. Review of the monthly Physician Orders dated February 2024 revealed Resident #130 was to receive magnesium chloride delayed release 64 milligrams (mg) daily. On 02/21/24 at 9:36 A.M., observation of Registered Nurse (RN) #1 administration of Resident #130's medications revealed the resident was administered magnesium chloride 400 milligrams. 2. Medical record review revealed Resident #127 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, allergic rhinitis and anxiety. Review 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 medical record review, policy review, transportation calendar review, and interview, the facility failed be administered in a manner to ensure residents were able to be transported to scheduled appointments. This affected two residents (#25 and #141) of three residents reviewed for transportation. The census was 73. Findings include: 1. Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including end stage renal disease, dependent on renal dialysis and diabetes mellitus. Review of the hospitalist Discharge summary dated [DATE] revealed Resident #141 was to receive hemodialysis every Monday, Wednesday and Friday. Review of the 2024 Transportation Calendar revealed no evidence transportation had been arranged for Resident #141's dialysis on 01/01/24. Review of the Progress Notes dated 01/01/24 at 5:30 A.M. revealed the nurse called the dialysis center to notify them Resident #141 would not be able to make his 6:00 A.M. appointment today due to transportation problems. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to maintain accurate resident records. This affected one resident (#141) of three individuals reviewed for treatments. The census was 73. Findings include: Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including end stage renal disease, renal dialysis dependent and diabetes mellitus. Review of the hospitalist Discharge summary dated [DATE] revealed Resident #141 had a below the knee right stump surgical incision. Review of the Order Summary dated February 2024 revealed Resident #141 had a daily wound treatment to the left stump. Review of the Treatment Administration Record (TAR) dated February 2024 revealed staff had been documenting the surgical site was the left not right stump since 02/13/24. On 02/29/24 at 10:30 A.M., interview with the Administrator verified the amputation extremity was not accurately identified on the TAR. This deficiency represents non-compliance investigated under Complaint 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.

Based on observation, policy review and interview, the facility failed to utilize appropriate handwashing and gloving during medication administration. This affected two residents (#127 and #130) of two residents observed for medication administration. The census was 73. Findings include: On 02/21/24 observation of medication administration revealed the following: a. Between 9:25 A.M. and 9:36 A.M., Registered Nurse (RN) #1 was observed using hand sanitizer and then pulled medication pouches from the cart to administer Resident #130's morning medications. RN #1 was observed breaking the following tablets in half with her bare hands including: Vitamin C 1000 milligrams (mg), Phospha 250 Neutral Tablet and two tablets of potassium chloride extended release 20 miliequivalents and placed the broken tablets into the medication cup. RN #1 then entered Resident #130's room and administered the medications to the resident. b. Between 9:44 A.M. and 10:16 A.M., RN #1 was observed using hand sanitizer and then pulled a medication pouch containing Resident #127's oral medications. RN #1 reached…

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, staff interview, and policy review, the facility failed to ensure appropriate signage was posted at the main entrance to notify residents, families, and visitors of active Covid-19 cases in the building, what symptoms of Covid-19 were, encouragement not to visit if having symptoms of those symptoms, importance of hand hygiene, and respiratory/ cough etiquette to follow when in the facility. This had the potential to affect all residents residing in the facility. The facility's census was 71. Findings include: On 02/01/24 at 8:40 A.M., an observation upon entrance to the facility revealed there was no signs posted that identified the facility as having active Covid-19 cases in the facility. An employee that was present at the front reception desk area confirmed they had active Covid-19 cases in the building. There was also no signs posted that informed visitors of the symptoms common with Covid-19 or encouragement for families/ visitors not to visit if any of those symptoms were present. Furthermore, there were no signs posted that encouraged visitors 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Tuberculin and insulin were discarded once the vials were open greater than 30 days. The facility also failed to ensure the Southwest medication cart was locked when unattended to prevent unauthorized access. This affected one resident (#21) who had insulin that was outdated, had to potential to affect all residents who could require the use of Tuberculin for Mantoux/TB testing and had the potential to affect eight residents (#7, #8, #9, #15, #21, #31, #40, and #197) who were independently mobile, cognitively impaired and who did not reside on the locked memory care unit. The facility census was 52. Findings Include: 1. On 08/08/22 at 2:40 P.M. observation of the Southwest medication cart revealed it was unlocked and unattended by staff located by the South nurses' station with the front of the cart facing out toward the hallway. There were no staff near the cart. State Tested Nursing Assistant (STNA) #123 was sitting at the nurses' station desk. On 08/08/22 at 2:43…

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, facility policy and procedure review and interview the facility failed to ensure the Medical Director (MD) attended Quality Assurance and Performance Improvement (QAPI) meetings as required. This had the potential to affect all 52 residents residing in the facility. Findings Include: Review of an undated QAPI member list revealed the MD was a member of the facility QAPI committee. Review of the staff sign in sheets for the facility QAPI meetings, dated 05/24/22, 06/24/22 and 07/28/22 revealed no signature for the MD to indicate the MD was in attendance at any of the meetings held during this time period. On 08/15/22 a 2:51 P.M. interview with the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #200 revealed the following facility staff/positions were part of the QAPI committee: The Administrator, DON, Medical Director (MD), Pharmacy, Laboratory, Dietitian, Social Services, Therapy, Human Resources, Medical Records, Activities, Maintenance and Business Office Manager. On 08/15/22 at 2:56 P.M. interview with the Administrator verified the MD…

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 review of time card punches, staff COVID-19 testing logs, review of website data and information communicated from the facility, facility policy and procedure review and interview the facility failed to provide timely notification of positive COVID-19 cases to staff, residents and family/esponsible parties. This had the potential to affect all 52 residents. Findings Include: Review of [NAME] #158's time card punches revealed on 07/25/22 she clocked in for work at 6:30 A.M. and out (on 07/25/22) at 12:38 P.M. Review of staff COVID-19 testing logs revealed [NAME] #158 tested positive for COVID- 19 on 07/25/22. On 08/09/22 9:00 A.M. interview with Director of Nursing (DON) revealed staff tell residents personally when there were positive or suspected cases of COVID-19 and families were notified through Care Feed. Human Resources (HR) tracked notifications. Review of the website for Care Feed indicated the company would broadcast texts, emails, voicemails to the facility's entire community, provide templates for all types of communications and could automatically upload…

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, review of medication information, review of the Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual, review of facility policy and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for all residents. This affected six residents (#4, #15, #33, #40, #41, and #43) of 17 residents whose assessments were reviewed. Findings Include: 1. Review of Resident #4's medical record revealed diagnose including atrial fibrillation, heart disease and diabetes mellitus. Review of the physician's orders revealed an order, dated 04/30/22 for delayed release Aspirin 81 milligrams (mg) once a day. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/22 revealed the assessment was coded the resident received an anticoagulant all seven days of the assessment reference period. On 08/09/22 at 5:13 P.M. during an interview with MDS Coordinator/Licensed Practical Nurse (LPN) #102, the coordinator revealed she had learned on 08/09/22…

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 a call light to accommodate Resident #193's needs and ability to obtain staff assistance upon his request. This affected one resident (#193) of 24 residents reviewed for call light function/accessibility. Findings Include: Record review revealed Resident #193 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, essential hypertension, type two diabetes mellitus with hypoglycemia with coma, acute respiratory distress syndrome and Lennox-Gastaut syndrome. Resident #193's admission Minimum Date Set (MDS) 3.0 assessment, dated 08/03/22 revealed the resident's cognition was not assessed but Resident #193 had a problem with short-term and long-term memory. The admission MDS revealed Resident #193 was totally dependent or needed extensive assistance from staff for bed mobility, transfers, and personal hygiene and he had functional limitation in range of motion on both sides of us upper extremities (shoulder,…

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 Resident #21's physician was notified when blood glucose (sugar) results were outside ordered parameters (blood sugar less than 60 or greater than 500). This affected one resident (#21) of five residents reviewed for medication administration. Findings include: Review of Resident #21's medical record revealed a diagnosis of diabetes mellitus. A physician's order, dated 12/24/21 revealed to obtain blood glucose (sugar) levels before meals and at bedtime and notify the physician if results were below 60 or above 500. Review of the June 2022 Medication Administration Record (MAR) revealed on 06/29/22 at 4:00 P.M. the resident's blood sugar was 511. There was no documented evidence of physician notification. Review of the July 2022 MAR revealed on 07/06/22 the resident's blood sugar reading was 49 upon rising. There was no documented evidence of Resident #21's physician being notified when the reading was obtained. The MAR revealed gvoke (used to treat hypoglycemia) was administered at 6:30 A.M. On 08/10/22 at 10:09 A.M.…

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 review of the Skilled Nursing Facility Beneficiary Protection Notification Review Sheet and staff interview the facility failed to ensure residents who received Medicare Part A Services, did not exhaust skilled days and remained in the facility received a Centers for Medicare and Medicaid Services (CMS)-10055 form as required. This affected three residents (#4, #7 and #19) of three residents reviewed for beneficiary notices. Findings Include: Review of the Skilled Nursing Facility Beneficiary Protection Notification Review Sheet for Resident #4, #7 and #19 revealed all three residents were discharged from Medicare Part A Services, had not exhausted their skilled days and remained in the facility. The facility marked each residents did not receive a CMS-10055 form related to the discontinuation of skilled services, however, did not give any explanation why the residents did not receive the form. On 08/09/22 at 3:27 P.M. interview with Registered Nurse (RN) #200 revealed the social worker, who was responsible for providing residents with beneficiary notices, did not know what…

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 the ombudsman was notified of Resident #2's transfer to the hospital as required. This affected one resident (#2) of one reviewed for hospitalization. Findings Include: Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation and kidney stones. Review of Resident #2's progress note, dated 04/12/22 revealed the resident was admitted to the hospital with atrial fibrillation with rapid ventricular rate and chest pain. Further review of Resident #2's progress note, dated 07/24/22 revealed the resident was admitted to the hospital for kidney stones. On 08/08/22 at 2:54 P.M. interview with Resident #2 confirmed she had been admitted to the hospital twice in the last four to five months for atrial fibrillation and kidney stones. On 08/15/22 at 9:05 A.M. interview with the Director of Nursing (DON) revealed the facility had no evidence the Ombudsman received a copy of the transfer…

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 staff interview the facility failed to ensure the admission Pre-admission Screening and Resident Review (PASARR) form for Resident #4 was accurate to reflect the resident's mental health and psychotropic medication use in the last six months. This affected one resident (#4) of two residents reviewed for PASARR. Findings Include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, depression, anxiety and substance abuse. Review of Resident #4's PASARR, dated 04/29/22 indicated the resident had no mental health disorders and had not taken any prescribed psychotropic (anti-depressants or anti-anxiety) medications in the past six months. Review of Resident #4's hospital admission orders, dated 04/29/22 revealed the resident was to continue psychoactive medications, Buspar 15 milligrams (mg) twice daily and Paxil to 20 mg daily, however there was no indication for either medication use. The hospital records indicated 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, record review, review of ancillary service records of resident visits and interview the facility failed to ensure Resident #6's hearing aid was in working condition and Resident #12 received new glasses timely. This affected two residents (#6 and #12) of two residents reviewed for hearing/vision. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of hearing deficit. The resident's payor source was Medicaid. Review of Resident #6 ancillary consent, dated 05/13/22 revealed the resident had Medicaid and signed a consent for audiology services. Review of Resident #6's admission orders, dated 05/12/22 and current orders (for 08/2022) revealed orders for ancillary services including hearing (audiology) services. Review of Resident #6's admission assessment, dated 05/12/22 revealed the resident had a left hearing aid device. Review of Resident #6's progress note, dated 05/12/22 revealed the hospital called report and indicated 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, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place for Resident #16 as care planned to prevent falls and failed to ensure the resident's responsible party was notified timely of a fall. This affected one resident (#16) of two residents reviewed for accidents. Findings include: Record review revealed Resident #16 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, personal history of healed traumatic fracture, essential hypertension, repeated fall,and encounter for other orthopedic aftercare. Review of quarterly Minimum Date Set (MDS) 3.0 assessment, dated 03/18/22 revealed Resident #16 was cognitively impaired, required extensive assistance from two staff for bed mobility, total assistance from two staff for transfers and extensive assistance from one staff for toileting. Review of Resident #16's nursing progress note,…

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, facility policy and procedure review and interview the facility failed the ensure oxygen tubing was dated and changed per physician order, failed to ensure residents who were receiving oxygen had a physician's order for use and/or failed to ensure a resident's oxygen saturation was maintained above 92% as ordered. This affected three residents (#13, #17, and #193) of four residents reviewed for respiratory care. Findings Include: 1. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, hypertensive heart disease without heart failure, atherosclerotic heart disease of native coronary artery and legal blindness. Review of Resident #13's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/07/22 revealed the resident had moderately impaired cognition and did not use oxygen. Review of Resident #13's current physician orders revealed no physician order for oxygen use or oxygen tubing change. Review 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.

Based on record review and interview the facility failed to ensure medication orders were accurately transcribed upon admission and failed to obtain laboratory testing for medication monitoring to ensure all medications were justified and administered at the most effective dose. This affected two residents (#21 and #194) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #21's medical record revealed diagnoses including type 2 diabetes mellitus, hyperlipidemia, and bipolar disorder. Record review revealed Resident #21's medication regimen included physician's orders for Lipitor (antihyperlipidemic), Novolog insulin per sliding scale, Basaglar insulin, Depakote (bipolar therapy agent) and Trulicity insulin. On 06/23/21 an order was written for a laboratory testing, Hemoglobin A1c (Hgb A1c) (a test used to measure a three month average of blood glucose levels). No laboratory testing results were available between 07/19/21 and 12/23/21. Review of a pharmacy medication regimen review, dated 12/15/21 revealed the pharmacist was unable 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of axillary service records and interview, the facility failed to ensure residents received routine dental services. This affected two residents (#6 and #12) of three residents reviewed for dental care. Findings Include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including nicotine dependence and gastric reflux disease. The resident's payer source was Medicaid. Review of Resident #6's progress note, dated 05/12/22 revealed the hospital called report and indicated the resident had no teeth or dentures. Review of Resident #6's admission orders, dated 05/12/22 and current orders dated 08/2022 revealed orders for ancillary services including dental services. Review of Resident #6 oral assessment, dated 05/15/22 revealed the resident had no natural teeth and had one tooth on the bottom of his mouth. The assessment revealed the resident indicated he would like dentures. Review of Resident #6's admission assessment, 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure pureed food was the correct consistency for Resident #296. This affected one resident (#296) of one resident identified to receive a pureed diet. Findings Include: Review of a list of resident diets, dated 08/08/22 revealed Resident #296 was the only resident identified to receive a pureed diet. On 08/11/22 at 9:40 A.M. observation of pureed meal preparation revealed Dietary [NAME] (DC) #154 attempted three times to prepare pureed chicken. Following the first two attempts there were chunks of chicken still visible and after the third attempt the chicken was stringy. When tasting the chicken after the third attempt, the chicken balled up in the surveyor's mouth when placed on the roof of the pallet. On 08/11/22 at 10:10 A.M. interview with Dietary Manager (DM) #145 confirmed the pureed chicken was not the correct consistency after all three attempts. The DM tasted the third attempt and confirmed the chicken was stringy and not smooth to the roof of the palate. The DM…

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 maintain a sanitary and comfortable environment and failed to ensure a mold like organism was not growing in a resident room. This affected one resident (#22) of three residents whose rooms were observed on the Northwest hall of the facility. The facility census was 52. Findings Include: On 08/15/22 at 9:33 A.M. observation of Resident #22's closet nearest the corner revealed a dark spotted substance on the ceiling and approximately 24 inches down the walls. An interview with Resident #22 at the time of the observation revealed he was unaware of the substance. On 08/15/2022 at 9:37 A.M. interview with Maintenance Director (MD) #128 revealed the facility had a problem with the sprinkler system and there had been leaking water from the system. MD #128 revealed the mold like substance in this area was re-occurring issue from the leak. Observation of Resident #22's closet nearest to the corner with MD #128 during the interview, verified the black mold like spots on the ceiling and coming down the walls. MD #128 reported he would…

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.