Astoria Skilled Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff the facility failed to ensure transportation was set up for a postoperative appointment for Resident #52. This affected one resident (#52) of three reviewed for appointments. Findings included: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses included cervical disc disorder, spinal stenosis, diabetes, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, osteoarthritis of the hip, injury to the cauda equina, benign prostatic hyperplasia, sleep apnea, depression, asthma, anxiety disorder, alcohol abuse, gout, fracture of the cervical vertebrae, fusion of the spine and fluid overload. Review of the hospital discharge paperwork provided to the facility dated 03/28/25 revealed Resident #52 had a post operative appointment with the surgeon on 04/07/25 at 9:30 A.M. Review of the physician's order dated 03/28/25 revealed Resident #52 had a post operative appointment with the surgeon…

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 the medical record, interview, and review of facility policy, the facility failed to implement individualized and effective pressure ulcer interventions timely. This affected one resident (Resident #42) out of three reviewed for pressure ulcers. Findings included: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included hemiplegia of the left side after cerebrovascular disease, contractures of the left arm, major depressive disorder, bipolar disorder, hypertension, pressure ulcers to the left and right heel, hypertensive retinopathy, insomnia, age related cataract, drusen of the left eye, and xerosis cutis. Review of the admission Braden Scale (pressure ulcer risk assessment) dated 04/11/25 revealed Resident #42 was at a high risk for the development of pressure injuries. Review of the admission assessment dated [DATE] revealed Resident #42 had an unstageable (full thickness tissue loss where the base of the ulcer was obscured by slough (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 review of the medical record and interview with staff the facility failed to set up a dental appointment as ordered for Resident #39. This affected one resident (#39) of three reviewed for appointments. Findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, diabetes, obstructive sleep apnea, schizoaffective disorder, personality disorder, lymphedema, paranoid personality, kidney disease, congestive heart failure, edema, hypertension, depression, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had moderately impaired cognition and had no behaviors. Review of the nursing progress note dated 03/27/25 at 11:30 A.M. revealed Resident #39 notified the nurse his tooth fell out. Resident #39 did not complain of any pain associated with the area, however he was concerned because there was no blood. The physician was notified, 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 review of the medical record, observation, interview with staff, and review of facility policy, the facility failed to maintain appropriate infection control measures during incontinence care for Resident #41. This affected one resident (Resident #41) of three reviewed for incontinence care. Findings included: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of the colon, duodenal ulcer, dementia, retention of urine, depression, chronic pain syndrome, gastritis, and moderate protein-calorie malnutrition. Observation of incontinence care on 05/27/25 at 9:45 A.M. revealed Certified Nursing Assistant (CNA) #219 provided incontinence care to Resident #41. CNA #219 brought into the room, two washcloths and a bath towel to provide care to Resident #41. CNA #219 washed the perineal and rectal area of Resident #41 and got feces on the washcloth. CNA #219 continued to wash the perineal area with the same washcloth, but used a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and manufacturer guidance review the facility failed to ensure distilled water was replaced as required to prevent infection associated with respiratory therapy tasks and equipment. This affected one out of one resident reviewed for the use of bilevel positive airway pressure (BiPAP) (A mechanical breathing device with a mask that is used to treat sleep apnea and other health conditions that affect breathing.). The facility census was 63. Findings include: Medical record review revealed Resident #40 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with chronic respiratory failure, morbid obesity with alveolar hypoventilation, diabetes mellitus, obstructive sleep apnea, schizoeffective disorder, paranoid personality disorder, lymphedema, high cholesterol, anemia, chronic kidney disease, heart failure, high blood pressure, gastroesophageal reflux disease, and depression, Review of Resident #40's physician order dated 01/29/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure a medication error rate of less than five percent. Two errors were made within 25 opportunities for error resulting in a medication error rate of eight percent. This affected two (Residents #3 and #50) of three residents observed during medication administration. Facility census was 63. Findings include: 1. Medical record review revealed Resident #50 was re-admitted on [DATE] with diagnoses including colitis with irritable bowel syndrome, methicillin susceptible staphylococcus aureus infection, fractured left ischium, quadriplegia, cervical disc myelopathy (Severe compression of the spinal cord.), gastroesophageal reflux disease, ovarian cysts, sacral pressure ulcer, sepsis, and rhabdomyolysis ( Disorder of skeletal muscle breakdown [necrosis] caused by muscle injury or myocyte membrane damage that leads to the release of myocyte contents into the bloodstream.) Resident #50's physician orders dated 02/01/25 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, interview, policy review and Center for Disease Control guidance for hand hygiene, the facility failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #3's and Resident #31's medication administration and failed to ensure staff disinfected the glucometer prior to obtaining Resident #3's and Resident #31's blood sugar. This affected two out of three residents observed for medication administration. The facility census was 63. Findings include: Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including hypertensive heart disease with heart failure, high cholesterol, anxiety , hypothyroidism, depression, gout and diabetes mellitus. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including progressive neurological conditions, anemia, coronary artery disease, high blood pressure, and kidney disease. An observation on 02/11/25 at 7:22 A.M. of Registered Nurse (RN) #65 administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #54's medications were administered as ordered. This affected one (Resident #54) of four residents reviewed for medications. The facility census was 57. Findings include: Review of Resident #54's medical record revealed the resident was readmitted on [DATE] with diagnoses including pneumonia, depression and acute respiratory failure with hypoxia. Review of Resident #54's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #54's physician orders revealed an order dated 11/27/24 for hydrocodone/Tylenol (Percocet) 5-325 milligrams (mg) give one tablet by mouth every six hours as needed for up to five days (discontinued 10/01/24). Review of Resident #54's Controlled Drug Record form revealed the resident was ordered Percocet narcotic pain medication every six hours up to five days with a total Percocet on the narcotic card of 19. One entry was documented by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected one resident ( Resident #42) of three reviewed for staffing however it had the potential to affect all 60 residents residing in the facility. Findings included: Review of the closed medical record for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, dysphagia, gastrostomy, peptic ulcer disease, Huntington's disease, diabetes, epilepsy, benign prostatic hyperplasia, dyskinesia, hypothyroidism, malignant neoplasm of the thyroid, hypertension, metabolic encephalopathy, severe protein calorie malnutrition, kidney failure, and cystitis with hematuria. Resident #42 was discharged to the hospital on [DATE] and subsequently passed away on [DATE]. Review of the plan of care dated [DATE] and revised on [DATE] revealed Resident #42 was at risk for falls and potential injury 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.

Based on observations, interview and record review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 58 residents that received meals from the facility. Two residents (Resident #3 and #5) were identified as receiving nothing by mouth. The facility census was 60. Findings include: Observation of the kitchen on 05/21/24 at 2:15 P.M. with Dietary Manger (DM) #400 revealed underneath the sink the extra dish racks were stored on top of four old milk crates. When Dietary aide #402 pulled the dish racks and milk crates out many gnats flew out from under the sink. There were approximately five feet of missing tile along the baseboard for water damage, the drywall was crumbling, and water damaged with a large hole in the wall. The gnats were coming from the hole in the wall. An interview at this time with the Dietary Manger #400 confirmed there was a hole in a wall and there were many gnats. He was not sure how long the wall had been like that since he had just started a couple months ago. DM #400 verified finds at time of observation.…

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 the medical record, review of the facility's investigation, interviews with staff and family, and review of facility policy, the facility failed implement their abuse policy to thoroughly investigate and report all allegations of resident-to-resident abuse. This affected two residents (#51, and #61) of five reviewed for abuse. The facility census was 60. Findings Include: 1. Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, history of falling, hypertension, hearing loss, dysthymic disorder, protein-calorie malnutrition, dementia, Alzheimer's disease, depression, and anxiety. The resident was discharged to another facility on 04/05/24 at the request of her family. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had severely impaired cognition. Review of the plan of care dated 03/05/24 revealed Resident #61 had alterations in mood and behaviors 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 record review, interview, and review of the facility policy, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency. This affected two resident (Resident #51, and #61) of five reviewed for abuse. The facility census was 60. Findings included: 1. Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, history of falling, hypertension, hearing loss, dysthymic disorder, protein-calorie malnutrition, dementia, Alzheimer's disease, depression, and anxiety. The resident was discharged to another facility on 04/05/24 at the request of her family. Review of the progress note dated 03/26/24 at 9:10 P.M. and authored by the DON revealed Resident #61 was in the bathroom with another resident (#61), both residents were noted with their pants down. They were immediately separated and placed on one-on-one (1:1) supervision with staff. The note indicated Resident #61 was assessed with no signs 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 review of the medical record, review of the facility's investigation, interviews with staff and family, and review of facility policy, the facility failed to thoroughly investigate all allegations of resident-to-resident sexual abuse. This affected two residents (#51, and #61) of five reviewed for abuse. The facility census was 60. Findings Include: 1. Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, history of falling, hypertension, hearing loss, dysthymic disorder, protein-calorie malnutrition, dementia, Alzheimer's disease, depression, and anxiety. The resident was discharged to another facility on 04/05/24 at the request of her family. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had severely impaired cognition. Review of the plan of care dated 03/05/24 revealed Resident #61 had alterations in mood and behaviors related to anxiety, depression and wandering.…

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 the medical record and staff interviews, the facility failed to ensure Resident #63 had an adequate supply of narcotic medications to ensure a safe discharge until her post-discharge physician appointment. This affected one resident (Resident #63) of three residents reviewed for safe discharge. Findings included: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including attention deficit hyperactivity disorder, generalized anxiety disorder, arthritis, history of transient ischemic attack, major depressive disorder, intervertebral disc degeneration, fibromyalgia, hypertension, restless leg syndrome, malignant neoplasm of ovary, insomnia, and migraines. She was discharged to home on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #63 had moderately impaired cognition. Review of the April 2024 Physician's orders revealed Resident #63 had narcotic order for Adderall 10 milligrams every morning 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 review of Notice of Medicare Non-Coverage letters and staff interview, the facility failed to inform the residents of the appeal agency and their phone number. This affected five (Resident #22, Resident #28, Resident #29, Resident #49, and Resident #62) of five residents reviewed for liability notices. The census was 61. Findings include: 1. Review of Resident #22's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 11/10/23. The letter did not contain the name and phone number of the agency to send an appeal. 2. Review of Resident #28's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice of Medicare Non-Coverage letter revealed services were ended on 02/21/24. The letter did not contain the name and phone number of the agency to send an appeal. 3. Review of Resident #29's medical record revealed they were admitted to the facility on [DATE]. Review of a Notice 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 there was a full-time dietary manager to oversee daily kitchen operations. This had the potential to affect all 58 residents (except Residents #9, #54 and #212) who received food from the kitchen. The facility census was 61. Findings include: Review of the dietary staff schedules and punch detail for February 2024 through March 2024 revealed [NAME] #811 worked part-time, less than 35 hours per week. On 03/04/24 at 7:30 A.M., interview with [NAME] #810 revealed there was no dietary manager and that [NAME] #811 was overseeing kitchen operations. On 03/05/24 at 3:04 P.M., interview with Registered Dietitian (RD) #819 revealed she was part time at the facility and was only in the building for eight to ten hours per week, spending most of her time on clinical work. On 03/05/24 at 3:33 P.M., interview with Regional Quality Assurance Nurse #920 revealed [NAME] #811 was a Certified Dietary Manager and that [NAME] #811 had no interest in being a manager. On 03/06/24 at 2:57 P.M., interview with Regional Director 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 observation, interview, and review of the dietary schedules, the facility failed to ensure there was sufficient competent staff to work in the kitchen. This had the potential to affect all 58 residents (except Residents #9, #54, and #212) who received food from the kitchen. The facility census was 61. Findings include: Review of the dietary staff punch detail revealed there was no morning dietary aide and no evening cook on 02/22/24; no dietary aide all day and no evening cook on 02/23/24; no morning dietary aide on 02/24/24; no morning dietary aide and no evening cook on 02/26/24; no morning dietary aide on 02/27/24; no morning dietary aide on 02/28/24; no evening cook on 03/01/24; no morning dietary aide on 03/02/24, and no morning dietary aide on 03/04/24. On 03/04/24 at 7:30 A.M., interview with [NAME] #810 revealed there was not enough dietary staff and staff from other departments had to help in the kitchen. On 03/05/24 at 10:48 A.M., observation of the resident activity occurring in the dining room revealed Activities Director #802 ended the activity early to assist…

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

Based on record review, observation, interview, and review of facility policy, the facility failed to store foods in a manner to prevent contamination, monitor sanitizer solution concentration, monitor dishwasher temperatures, and ensure staff working in the kitchen had their hair secured and covered. This had the potential to affect all 58 residents (except Residents #9, #54, and #212) who received food from the kitchen. The facility census was 61. Findings include: On 03/04/24 at 7:30 A.M., tour of the kitchen revealed there were 10 boxes of food stored on the floor in the walk in freezer, which was verified by [NAME] #810 at the time of observation. In the walk-in refrigerator, there was one bag of shredded cheese that was open to air and not sealed, one bag of shredded carrots that was open to air and not sealed, and one container of pasta salad that was open to air and not sealed, all of which were verified by [NAME] #810 at the time of observation. During the tour, Business Office Manager (BOM) #807 entered the kitchen with her hair unsecured. BOM #807 proceeded to walk…

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 to provide a dignified dining experience for residents. This affected three residents (#8, #19, and #38) observed during meals in the dining room. The facility census was 61. Findings include: On 03/04/24 at 1:00 P.M., observation of the dining room revealed Resident #19 was seated at a table with three other residents and Resident #19 was the only one without food at her table. Resident #19 asked staff repeatedly where her food was and stated she was hungry. Resident #8 was seated at a table with two other residents and Resident #8 was the only one without food at her table. Resident #8 repeatedly told staff she was hungry. Resident #38 was seated at a table with two other residents and Resident #38 was the only one without food at her table. On 03/04/24 at 1:00 P.M., interview with State Tested Nurse Aide (STNA) #867 verified Residents #8, #19, and #38 were the only residents at their tables without food. STNA #867 stated facility staff distributed the trays as they were delivered to the units and it was not unusual some residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide timely notification to the state ombudsman of 30 day discharges for Resident #33 and Resident #41. This affected two residents of four reviewed for discharge notices. The facility census was 61. Findings include: 1. Review of Resident #33's medical records revealed the Resident was admitted on [DATE] with diagnoses including diabetes mellitus, fracture of the vertebrae (spine), lack of coordination, chronic obstructive pulmonary disease, and moderate cognitive impairment. Review of the Resident #33's Notice of 30-day Discharge for non-payment dated 02/09/24 indicated the Ohio Department of Health and Ombudsman were notified via postal mail. The proposed discharge date was 03/10/24. An interview on 03/06/23 at 2:42 P.M. with Business Office Manager #807 revealed the Notice of 30-day Discharge for Resident #33 was mailed via postal carrier on 02/09/24, however verified there was no evidence the notice was mailed on that date. An interview 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 record review and interview, the facility failed to ensure Resident #56 was provided adequate supervision to prevent an attempted elopement, and failed to investigate a fall and re-assess the resident to determine if current fall interventions remained appropriate to prevent future falls. This affected one (Resident #56) of five residents reviewed for accidents and hazards. Findings include: 1. Review of Resident #56's medical record revealed the resident was admitted on [DATE] with diagnoses including major depressive disorder, aphasia, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Review of Resident #56's Wandering Risk assessment dated [DATE] revealed the resident was low risk for wandering. Review of Resident #56's Elopement Risk Assessment form dated 01/26/24 revealed the resident was a low risk for elopement. Review of Resident #56's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive…

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, review of the medical record and interview with the staff and resident, the facility failed to ensure Resident #5 had his fingernails trimmed and Resident #8 was shaved. This affected two residents ( Resident #5 and #8) of 12 residents who required assistance by staff for activities of daily living (ADLS). The facility census was 61. Finding included: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included protein-calorie malnutrition, cerebral infarction, dysphagia, transient ischemic attack, ataxia, arthritis, epilepsy, spastic paraplegia, Huntington's disease, need for assistance with personal care, major depressive disorder, and aphasic. Review of the plan of care dated 08/10/22 with a revision date of 12/18/23 revealed Resident #5 had a self-care deficit, and ADL decline may be expected related to his disease process. Resident #8 required extensive to total assistance for most ADLs and he required staff assist for feeding. Review…

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 review and interview the facility failed to ensure fall interventions were in place for Resident #40 as ordered/care planned. This affected one resident (#40) of three residents reviewed for fall interventions. Findings include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, dysphagia, congestive heart failure, diabetes, anemia, shortness of breath, atrial fibrillation, dementia, and hypertension. Review of the physician's orders revealed Resident #40 had ordered (dated 11/28/22) for a Dycem to the recliner chair for safety (every day) and an order (dated 12/29/22) for a Dycem to be placed under the fitted sheet (every day). Review of the plan of care with a revision date of 09/28/23 revealed Resident #40 was at risk for falls and potential injury related to debilitation, weakness, dementia, impaired balance, and unsteady gait. Interventions included having her bed against…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Resident #20 and Resident #53. This affected two residents (#20 and #53) observed during random observations. The facility census was 66. Findings include: 1. Record review revealed Resident #20 was admitted on [DATE] with diagnoses that included but were not limited to pain in right lower leg, need for assistance with personal care, anxiety disorder and spinal stenosis. Review of care plans dated 06/23/23 revealed Resident #20 was at risk for falls related to diagnoses. Interventions included but were not limited to call light within reach. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired and required extensive assistance of two staff for mobility, transfer, and toilet use. Observation on 10/02/23 at 9:41 A.M. revealed Resident #20 was lying in bed. Resident #20's call light was on the floor underneath the bed.…

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 facility policy the facility failed to ensure medication delivered from the pharmacy were locked in a secure location. This affected three residents (Resident #52, #319, and #468) who were cognitively impaired and independently mobile in the facility. The facility census was 70. Findings include: Observation on 03/16/22 at 9:20 A.M. revealed the door to the [NAME] unit communication center was open and inside on the counter was an open gray tote with medication which was delivered from the pharmacy. There were no staff members present. Interview on 03/16/22 at 9:25 A.M. Registered Nurse #565 verified the medications were not secured in a locked room. She stated she did not even know they were there because the midnight shift usually puts them away. Review of the medication in the delivery tote were as followed; four patches of scopolamine one milligrams (mg), 16 tablets of pantoprazole 40 mg, eight tablets of amitriptyline 50 mg, 24 tablets of cyclobenzaprine 10 mg, 24 tablets of gabapentin 400 mg, 24 tablets of gabapentin 600 mg, 16 tablets…

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 record review, the facility failed to ensure transmission-based precautions were implemented for four of seven residents (Resident #471, #472, #473 and #475) in the facility that were presumed Covid-19 positive and infection control signs were not posted outside of all isolation rooms. The facility had no positive Covid-19 residents. The census was 70. Finding Include: 1. Review of the medical record for Resident #471 revealed an admission date on 03/11/22. Review of the orders revealed droplet isolation orders per admission protocol for 10 days. Observation on 03/14/2022 at 8:06 A.M. of License Practical Nurse (LPN) #512 revealed LPN #512 entered Resident #471 to deliver breakfast tray, Resident #471 was on droplet precautions for new admission. LPN #512 was only wearing a surgical mask and goggles and not wearing appropriate personal protective equipment (PPE). There were no isolation signs outside of Resident #471's room. 2. Review of the medical record for 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 record review and interview, the facility failed to ensure residents or resident representatives received a written copy of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). This affected two (Residents #22 and #38) of four residents reviewed for beneficiary protection notification. The facility census was 70. Findings include: 1. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #22 dated 02/23/22 revealed the resident's skilled services would end on 02/25/22. There was no signature by the resident or resident representative indicating they received and understood the notice. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) for Resident #22 dated 02/23/22 revealed the resident would be responsible for paying for skilled nursing services, physical therapy, and occupational therapy. There was no signature by the resident or resident representative indicating they received and understood the notice. On 03/16/22 at 9:31 A.M., interview 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 observation and staff interview the facility failed to trim and clean the fingernails for Resident #49 and failed to provide routine hand hygiene for Resident #46, both who required staff assistance for activities of daily living. This affected two residents (Resident #46 and #49) of three reviewed for activities of daily living. Findings include: 1. Review of the medical record revealed Resident #49 was admitted on [DATE]. Diagnoses included hypoxemia, dementia without behaviors, personal history of COVID-19, hypertension, atherosclerotic heart disease, hypothyroism, hemiplegia and hemiparesis affecting left side, major depression, and anorexia. Review of the plan of care dated 07/12/21 revealed Resident #40 had hemiparesis related to a stroke. She needed assistance with activities of daily living due to her limitations. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #49 had severely impaired cognition and required extensive assistance with activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to implement supervision and smoking interventions for Resident #12 to smoke safely. This affected one of five residents identified as smokers in the facility (#6, #32, #47 and #56). The facility census was 70. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, incomplete quadriplegia and a history of falls. Review of the comprehensive assessment (MDS 3.0) dated 12/25/21 indicated she was alert, oriented and independent in daily decision-making ability. Review of the smoking assessment dated [DATE] indicated she smoked two to five cigarettes per day, liked to smoke in the evenings, able to light her own cigarette, required no adaptive equipment and the facility did not need to store her lighter and cigarettes. Review of the care plan dated 02/14/22 indicated Resident #12 was at risk for injury due to smoking. The interventions indicated…

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

Based on observation, record review and interview the facility failed to ensure nutritional supplements were dated upon opening to ensure they were used timely and failed to provide appropriate temperature controls for packed lunches for Resident #56. This had the potential to affect ten residents (Resident #42, Resident #19, Resident #8, Resident #223, Resident #14, Resident #48, Resident #54, Resident #65, Resident #44, and Resident #9) of ten residents that were ordered a Med Pass 2.0 nutritional supplement and one resident (Resident #56) of one resident who received a packed lunch for dialysis. The facility census was 69. Findings include: 1. Observation on 03/21/19 at 10:10 A.M. of the two snack refrigerators, with Licensed Practical Nurse (LPN) #451 present, revealed there were six opened and undated 32 ounce Med Pass 2.0 nutritional supplement cartons. Interview with LPN #451 confirmed they were opened and undated. LPN #451 was unsure the facility policy on dating opened nutritional supplements. Review of the Med Pass 2.0 nutritional supplement manufacture guideline revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure infection control practices were maintained related to the disposal of an insulin syringe for Resident #27. This affected one resident (Resident #27) and had the potential to affect 16 residents (Resident #1, #2, #3, #4, #11, #23, #25, #27, #30, #34, #35, #42, #51, #55, #61 and #119) identified as receiving insulin injections. The facility census was 69. Findings include: Record review for Resident #27 revealed an initial admission into the facility on [DATE] with diagnoses including stroke with residual paralysis, type 2 diabetes mellitus, hepatitis C, hypertension, dysphagia or trouble swallowing and insomnia. Resident #27 was not able to be interviewed due to the recent effects of a stroke and was reliant upon the staff for all of his care. The physician had orders written to obtain a glucose level or blood sugar four times a day, before each meal and at the hour of sleep. The nursing staff would administer insulin according 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 record review and interview the facility failed to issue Resident #64 and Resident #62 the proper notification of liability when skilled nursing services ended. This affected two residents (Resident #62 and Resident #64) of three residents reviewed for beneficiary protection notification. Findings include: 1. Resident #64 was admitted on [DATE] and received a Notice of Medicare Non-Coverage (NOMNC) on 12/05/18 that skilled services would end on 12/07/18. Resident #64 remained in the facility. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted and Resident #64 did not receive a Skilled Nursing Advanced Beneficiary Notice (SNABN). Interview on 03/20/19 at 1:34 P.M. with Social Services Designee (SSD) #100 revealed the facility does not issue residents an SNABN when Medicare Park A serviced ended if the resident remained in the facility under…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #66, who required staff assistance for activities of daily living received timely and adequate nail care. This affected one resident (Resident #66) of three residents reviewed for activities of daily living. Findings include: Resident #66 was admitted on [DATE] with diagnoses including cerebral infarction, need for assistance with personal care, hemiplegia affected right dominant side, and osteoarthritis. Resident #66's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/22/19 revealed the resident's cognition was severely impaired and the resident required supervision with personal hygiene. Resident #66's comprehensive care plan, revised 03/19/19 revealed the resident was at risk for decline activities of daily living function due to cognitive deficits. Resident #66 was admitted with long fingernails that were and are difficult to cut and he sees the podiatrist for cutting his fingernails. Interventions on the care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #25 received the correct amount of fluids via a percutaneous gastronomy tube for nutrition/hydration according to physician orders. This affected one resident (Resident #25) of seven residents identified to receive nutrition/hydration via gastrostomy tube. Findings include: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with a primary diagnosis for admission of hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting the non-dominate left side. Additional diagnoses included respiratory failure, pulmonary embolism, anemia, gastrointestinal bleeding, type two diabetes mellitus, hypertension, dysphagia and slurred speech. Record review revealed Resident #25 had a percutaneous gastronomy (PEG) tube place in the abdomen for total nutritional needs following a stroke which left Resident #25 with the inability to take food or drink by mouth. 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 observation, record review and interview the facility failed to ensure Resident #5 received routine tracheostomy care. This affected one resident (Resident #5) of two residents reviewed for respiratory care. Findings include: Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE] and expired at the facility on [DATE] with diagnoses including respiratory failure, cardiac arrest, dependent on respirator ventilator status, edema, neuromuscular dysfunction of bladder, and ventricular tachycardia. Resident #5's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed her cognition was intact and she received tracheostomy care. Resident #5's comprehensive care plan for ventilator dependence due to respiratory failure, revised [DATE], revealed the resident should receive routine tracheostomy change by respiratory care. No other information regarding tracheostomy care was included on the care plan. Review of Resident #5's physician orders from [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 observation, record review and interview the facility failed to ensure Resident #44's medications were securely stored. This affected one resident (Resident #44) of 69 residents reviewed for accident hazards. Findings include: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including gangrene, peripheral vascular disease, atrial fibrillation, hypertension, and major depressive disorder. Resident #44's 60-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was moderately impaired. Observation on 03/18/19 at 10:58 A.M. with Licensed Practical Nurse (LPN) #101 revealed Resident #44 was lying in bed in his room and there was a cup of unidentified medications at his bedside table. LPN #101 removed the cup of medication from the resident's room. Interview with LPN #101 at this time revealed she administered his morning medications in the dining room. LPN #101 revealed there were eight medications in the cup, and after reviewing Resident #44's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure laboratory blood work was completed as ordered for Resident #5, Resident #9 and Resident #27. This affected three residents (Resident #5, #9 and #27) of nine residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. The primary diagnosis for admission was malaise and fatigue. Additional diagnoses included osteoporosis, cardiac pacemaker, high cholesterol, high blood pressure, depression and acid reflux. Review of the physician orders, dated [DATE] revealed an active order for complete blood count (CBC), comprehensive metabolic panel (CMP) and a lipid panel to have been obtained every six months starting on [DATE]. Review of the hard charting and electronic medical record for Resident #9 was void of any evidence of the completed laboratory work as per the physician's orders. The facility had evidence of the most recent CBC and CMP…

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 laboratory results were reported to the physician timely for Resident #27 and Resident #5. This affected two residents (Resident #27 and #5) of nine residents whose laboratory results were reviewed. Findings include: 1. Record review revealed Resident #27 was initially admitted to the facility on [DATE] with diagnoses including stroke with residual paralysis, Type 2 diabetes mellitus, hepatitis C, hypertension, dysphagia or trouble swallowing and insomnia. Resident #27 was not able to be interviewed due to the recent effects of a stroke and was reliant upon the staff for all care. Review of the medical nutrition therapy note, dated [DATE] revealed Resident #27 had a low prealbumin (lab frequently used to assess nutritional requirement in the diet) value at 12 milligrams/deciliter (mg/dl) (normal result range 16 to 45 mg/dl) and requested a nutritional supplement be provided twice a day and requested repeat prealbumin in a week to assess success.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #44's Medication Administration Record (MAR) was accurate. This affected one resident (Resident #44) of 18 residents reviewed for complete and accurate medical records. Findings include: Record review revealed Resident #44 was admitted to the faciliy on 10/22/18 with diagnoses including gangrene, peripheral vascular disease, atrial fibrillation, hypertension, and major depressive disorder. Resident #44's 60-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was moderately impaired. Review of Resident #44's March 2019 MAR revealed his medications were documented as administered on the evening of 03/17/19. Observation on 03/18/19 at 10:58 A.M. with Licensed Practical Nurse (LPN) #101 revealed Resident #44 was lying in bed in his room and there was a cup of unidentified medications at his bedside table. LPN #101 removed the cup of medication from the resident's room. Interview with LPN #101 at this…

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.