Hall Of Fame Rehabilitation And Nursing Center

Based on record review, observation and interview, the facility failed to ensure resident food allergies were honored. This affected one resident (#63) of one resident reviewed for food preferences. This had the potential to affect 47 residents out of 48 who received meals from the facility kitchen. The facility identified one resident (#4) as receiving nothing by mouth (NPO). The facility census was 48.Findings include:A review of the medical record for Resident #63 revealed an admission date of 03/8/26 with diagnoses of pyelonephritis, diabetes mellitus, and major depressive disorder.Review of the physician's orders for March 2026 revealed Resident #63 received a regular diet.Review of Resident #63's diet ticket revealed that she was on a regular diet had onion, peanut butter and strawberry allergies.Interview on 03/23/26 at 9:45 A.M. with Resident #63 revealed that the kitchen does not honor her preferences.Observation and interview of lunch tray line service on 03/25/26 at 12:31 P.M. revealed that [NAME] #451 portioned beef tips over noodles for Resident #63. The lid was placed…

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

Based on record review, observation and interview, the facility failed to ensure Residents #35 and #68 received therapeutic diets as ordered by the physician. This affected two residents (#35 and #63) of three residents (#35, #63, and #68) reviewed therapeutic diets. The facility census was 48.Findings include:1. Review of the medical record for Resident #35 revealed an admission date on 07/13/21 with diagnoses to schizophrenia, bipolar, and diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/26, revealed Resident #35 had severely impaired cognition and was dependent on staff for activities of daily living (ADL) except for eating, Resident #35 required set up assistance only.Review of the physician's orders for March 2026 revealed Resident #35 received a regular diet, dysphagia mechanical soft (Dys Mech) texture and regular fluid consistency diet.Observation of lunch tray line service on 03/25/26 at 12:00 P.M. revealed [NAME] #451 portioned regular textured beef tips over noodles for Resident #35. The lid was placed on top of the plate and put…

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, staff interview and review of the facility policy and procedure, the facility failed to ensure a homelike environment. This affected three residents (#9, #10, and #15) of six residents reviewed for physical environment. The facility census was 48.Findings include:1. Observation on 03/23/36 at 10:42 A.M. of Resident #9's room revealed a hole in the bathroom door. Interview at this time with Housekeeper (HSK) #429 verified the observation. 2. Observation on 03/23/26 at 11:19 A.M. of Resident #15's room revealed a urinal and a pair of scissors were observed on the floor. Interview at this time with Licensed Practical Nurse (LPN) #422 verified the observation. 3. Observation on 03/23/26 at 2:08 P.M. of Resident #10's room revealed long deep gash in the lower part of the bathroom door, and there was a large missing chunk on the rim on trash bin. Interview on 03/23/26 at 3:39 P.M. of Resident #10's room with Director of Maintenance (DOM) #428 verified the observation. Review of the undated policy titled Safe and Homelike Environment revealed housekeeping and…

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

Based on observation, interview, and review of facility policy, the facility failed to serve foods in a manner to prevent contamination, failed to have a sufficient supply of foods in case of emergency, and failed to ensure expired foods were discarded timely. This had the potential to affect all 45 residents in the facility.Findings include:1.On 12/03/25 from 11:25 A.M. to 12:11 P.M., an observation of the lunch meal tray line service revealed [NAME] #146 was wearing gloves while plating foods for the lunch meal. [NAME] #146 used his gloved hands to handle all serving utensils, to hold the baked potatoes on each plate as he cut them open, he used his gloved fingers to open each baked potato after he cut it, and he used his gloved fingers to move and position the meat and creamed spinach after he put those items on the plates. [NAME] #146 did not change or dispose of his soiled gloves at any point during the observed meal service. At 11:36 A.M., Regional Dietary Director #126 told [NAME] #146 to use tongs when handling the baked potatoes. At 11:39 A.M., [NAME] #146 obtained 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 observation and interview the facility failed to ensure a clean and sanitary environment. This affected one resident (#21) and had the potential to affect twenty five residents (#5, #6, #8, #9, #13, #14, #15, #16, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #33, #37, #38, #44, #45 and #47) who resided on the second floor. The facility census was 45. Findings include:Observation on 12/03/25 at 10:01 A.M. revealed Resident #21's bathroom had a large area of what appeared to be mold or mildew underneath his bathroom sink. Resident #21 was not present in his room during observation.Observation of shower room located on the second floor on 12/03/25 at 10:34 A.M. with Housekeeper #137 revealed a large hole behind the toilet with exposed pipes and a large hole in the ceiling also with exposed pipes. Further observation revealed toilet in shower room had a large amount of dried stool inside the bowl and stool on the outside of bowl and lid. Interview with Housekeeper #137 at time of observation confirmed the observation and Housekeeper #137 stated the water may have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the activities calendar, resident interview, and staff interview, the facility failed to provide activities to meet the needs and interests of all residents in the facility. This affected three residents (#2, #16, and #40) of six interviewed regarding activities. The facility census was 45.Findings include:Review of the facility's activities calendar for December 2025 revealed the planned activities were repetitive, no activities were provided later than 3:00 P.M., and staff led activities on the weekends and on holidays were lacking. The following were the activities listed on the calendar for December 2025:-On Mondays 12/01/25, 12/08/25, 12/15/25, 12/22/25, and 12/29/25, the scheduled activities were True or False at 10:45 A.M. and Crafts at 2:00 P.M. No other activities were planned for Mondays in December.-On Tuesdays 12/02/25, 12/09/25, 12/16/25, 12/23/25, and 12/30/25, the scheduled activities were Book Club at 1:00 P.M. and Bingo at 2:00 P.M. No other activities were planned 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, interview and record review the facility failed to ensure adequate foot care had been provided. This affected one resident (#45) of two reviewed for foot care. The facility census was 45.Findings include:Review of Resident #45's medical records revealed an admission date of 07/01/16. Diagnoses included traumatic brain injury, aphasia (difficulty speaking) and cognitive deficits.Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had no cognition score due to being rarely understood. Resident #45 was independent with toileting and required set up assistance with bathing.Review of care plan dated 11/10/25 revealed Resident #45 had self care deficits related to impaired cognition and had been combative when trying to trim facial hair. Interventions included encourage resident to participate to fullest extent possible and reapproach when resistive to care. Resident #45 had behaviors that included yelling out and physical behaviors when she did not want to participate in task.…

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 ensure social services staff was adequately trained and performed duties as required. This affected one resident (#45) of three reviewed for social services duties. The facility census was 45. Findings include:Review of Resident #45's medical records revealed an admission date of 07/01/16. Diagnoses included traumatic brain injury, aphasia (difficulty speaking) and cognitive deficits.Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had no cognition score due to being rarely understood. Resident #45 was independent with toileting and required set up assistance with bathing.Review of care plan dated 11/10/25 revealed Resident #45 had self care deficits related to impaired cognition and had been combative when trying to trim facial hair. Interventions included encourage resident to participate to fullest extent possible and reapproach when resistive to care. Resident #45 had behaviors that included yelling out and physical behaviors when…

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 staff interview the facility failed to ensure supplemental oxygen delivery devices were changed weekly and stored properly. This affected three residents (Residents #12, #24 and #28) of three residents reviewed for supplemental oxygen use. The facility identified 10 residents currently utilizing supplemental oxygen (Residents #4, #11, #12, #14, #22, #24, #28, #30, #34 and #37). Findings include: 1. Review of Resident #12's medical record revealed an admission date of [DATE] with diagnoses that included pneumonia, congestive heart failure and hypertension. Physician's orders on [DATE] indicated the use of supplemental oxygen at two liters per minute (lpm) per nasal canula by oxygen concentrator. Additional orders indicated to change nasal canula every night shift on Sunday. An additional order on [DATE] identified the use of DuoNeb (aerosolized medication for shortness of breath) 0.5-2.5 milligrams (mg) per milliliter (ml) via nebulizer every six…

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

Based on observation, interview, record review, review of the facility policy and review of Centers for Disease Control (CDC) guidance, the facility failed to develop and implement a water management program to prevent the potential growth of legionella as required. Additionally, the facility failed to maintain infection control during medication administration for one resident (Resident #31) out of two residents observed for medication administration. The facility census was 38. Findings include: 1. Review of available facility documentation relative to legionella revealed the CDC toolkit titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, dated 06/05/17. The documentation included a section, Identifying Buildings at Increased Risk, which instructed staff to survey the building or property to determine if they needed a water management program to reduce the risk of Legionella growth and spread and this section was blank and not filled out. There was no attached water management diagram and no water management plan written for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure smoking assessments were completed. This affected four (Residents #15, #35, #38 and #192) of 12 residents who smoked at the facility. The facility census was 38. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 07/31/21 with diagnoses including vascular dementia, history of traumatic brain injury and nicotine dependence. Review of Resident #15's assessments revealed his last smoking safety screen was completed on 05/23/23. At that time, Resident #15 was safe to smoke with supervision. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was moderately cognitively impaired. Observation on 08/12/24 at 10:00 A.M. revealed Resident #15 smoking in the designated smoking area with staff. Interview on 08/14/24 at 12:15 P.M. with Licensed Practical Nurse (LPN) #523 verified a smoking assessment had not been completed quarterly and was last completed…

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 policy review the facility failed to ensure advanced directives were present in the electronic chart. This affected one (Resident #37) of 16 (Residents #3, #4, #5, #10, #15, #19, #20, #23, #25, #26, #30, #35, #37, #38, #191, and #192) reviewed for advanced directives. The facility census was 38. Findings include: Review of the medical record for Resident #37 revealed an admission date of 06/20/24. Diagnoses included but were not limited to type II diabetes with ketoacidosis, dementia, cardiomyopathy, congestive heart failure, and Alzheimer's dementia. Review of the physician's orders located in the electronic medical record for Resident #37 revealed no evidence of an order for advance directives. Review of the admission packet which included the baseline care plan dated 6/20/24 for Resident #37 revealed the code status was Do Not Resuscitate Comfort Care Arrest (DNR CCA). Interview on 08/13/24 at 8:50 A.M. with the Director of Nursing (DON) confirmed the DNR CCA was signed and in a pile of unfiled papers and was not in the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and facility policy review, the facility failed to ensure a comprehensive care plan was created related to behavioral health needs. This affected one (Resident #192) of nineteen residents reviewed for care plans. The facility census was 38. Findings include: Review of the medical record for Resident #192 revealed an admission date of 07/31/24. Diagnoses included but were not limited to rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) acute kidney failure, anxiety disorder, other psychoactive substance abuse and bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #192 revealed he was cognitively intact, was noted to be feeling down, depressed, little interest in doing things, trouble falling asleep, tired, and had little energy seven to eleven days of the last fourteen days during the assessment period. Resident #192's Patient Health Questionnaire (PHQ-9) score of 10 indicated moderate…

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 adequately monitor residents on anti-anxiety medications. This affected one resident (#10) of five residents reviewed for unnecessary medications. The facility census was 38. Findings include: Review of Resident #10's medical record revealed an admission date of 04/28/23 and diagnoses including anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension and suicidal ideations. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and received anti-psychotic, anti-depressant and anti-anxiety medications as well as a diuretic. Review of Resident #10's physician's orders as of 08/15/24 revealed an order dated 11/09/23 for Ativan (anti-anxiety medication) oral tablet 0.5 milligrams (mg) give by mouth twice a day for anxiety. No orders were in place to monitor side effects relative to Resident #10's anti-anxiety medication. An…

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

Based on observation, interview and policy review, the facility failed to ensure proper sanitation for resident refrigerators for two residents (Residents #9 and #17) of eight (Residents #9, #14, #15, #16, #17, #28, #34 and #36) reviewed for in room refrigerators. The facility census was 38. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/11/18. Diagnoses included but were not limited to chronic congestive heart failure, encephalopathy, chronic obstructive pulmonary disorder, type II diabetes mellitus with neuropathy, and dementia with behaviors. Review of the 07/01/24 Minimum Data Set (MDS) 3.0 assessment revealed Resident #9 had severe cognitive impairment. Review of the medical record for Resident #17 revealed an admission date of 01/10/18. Diagnoses included but were not limited to chronic and mild intellectual disabilities. Review of the 05/29/24 MDS 3.0 assessment revealed Resident #17 had severe cognitive impairment. Observations or resident room refrigerators on 08/14/24 at 3:19 P.M. with Registered Dietitian (RD) #564 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 record review, interview and review of the facility policy, the facility failed to maintain a complete and accurate record. This affected one resident (#10) of 19 resident records reviewed. The facility census was 38. Findings include: Review of Resident #10's medical record revealed an admission date of 04/28/23 and diagnoses including anxiety, schizoaffective disorder bipolar type, depression, falls, hypertension and suicidal ideations. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and received routine antipsychotic medications. Review of a pharmacy recommendation dated 12/01/23 revealed Resident #10 received Abilify (antipsychotic) which could cause involuntary movements but an Abnormal Involuntary Movement Scale (AIMS) or other appropriate assessment was not documented in the medical record within the previous six months. Review of a pharmacy recommendation dated 06/03/24 revealed Resident #10 received Geodon…

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 facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 40 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. The facility census was 40. Findings Include: Tour of the dietary department with [NAME] #239 on 02/23/24 from 7:15 A.M. through 7:25 A.M. revealed that Dietary Aide #262 was not wearing a hair restraint while in the kitchen. There was a large hole in the wall under the prep sink. [NAME] #239 stated that the leak was just fixed yesterday, but they did not patch the hole. Under the dish machine, there were missing tiles along the wall, mold along the baseboard, and garbage debris on the floor. The walk-in freezer located in the hallway had black mold on the curtain strips and along the floor and wall in the corner of the freezer. This was verified by [NAME] #239 at the time of the observation. Interview on 02/23/24 at 10:40 A.M. with Dietary Manager #228 verified the kitchen findings from earlier in the day and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure essential equipment was working in a safe operating condition. This had the potential to affect all 40 residents residing in the facility. Findings Include: On 02/23/2024 during the facility tour between 8:00 A.M. to 10:45 A.M with Maintenance Director (MD) #209 revealed the following: • The toilet in room [ROOM NUMBER] had a leak that followed pipes and channels down causing leaks on the first floor and basement. Maintenance Director #208 stated the leak was repaired on 02/22/24. • In the basement there was a clean linen room that had a current domestic water leak with five ceiling tiles missing. • The supply closet next to the basement linen room had visible signs of domestic water leaks. • There were visible signs of domestic water line leaks to include stained tiles and two ceiling tiles missing in the hallway near dialysis storage. • There were visible signs of domestic water leaks to include multiple water-stained tiles and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of cleaning schedules, and interview the facility failed to ensure a clean and sanitary environment for Residents #1, #3, #7, #9, #10, and #16. This affected six residents (#1, #3, #7, #9, #10, #16) and the potential to affect all 40 residents residing in the facility. Finding Include: An observation on 02/23/24 at 9:58 A.M. revealed Resident #7's wheelchair was soiled. The wheelchair had dried food spills, dust and crumbs on the seat cushion, footrests, on wheels and the arm rests. Interview with Activity Director #241 confirmed the soiled wheelchair at the time of the observation. An environmental tour on 02/23/24 from 11:04 A.M. through 11:15 A.M. with the Director of Nursing (DON) revealed the following: • Resident #10's room had a urine odor, there was a bath sheet along the wall behind the toilet, and the bathroom floor was sticky. • Resident #9's privacy curtain was stained and there was mold in the bathroom. • Resident #16's privacy curtain was stained, the toilet had a red…

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 Resident #10 was treated in a dignified manner. This affected one resident (#10) of three residents reviewed for dignity. The facility identified 12 residents (#3, #4, #8, #10, #11, #13, #15, #16, #25, #30, #34, and #39) as smokers. The facility census was 40. Findings Include: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and tobacco use. Review of Resident #10's care plan dated 12/08/22 with a revision date of 12/14/22 revealed Resident #10 is a smoker. Interventions included but were not limited to instructing the resident about the facility policy on smoking, location, times, safety concerns. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and was independent for activities of daily living (ADL). Review of Resident #10's progress notes 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 record review and interview, the facility failed to ensure Resident #34's urine specimens were sent to the laboratory and the results of the laboratory testing were acted upon to timely treat Resident #34's urinary tract infection. This finding affected one (Resident #34) of three residents reviewed for urinary tract infections (UTIs). Findings include: Review of Resident #34's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia, cerebral infarction and muscle weakness. Review of Resident #34's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited moderate cognitive impairment. Review of Resident #34's progress note dated 07/13/23 at 4:42 P.M. authored by Licensed Practical Nurse (LPN) #808 indicated the resident reported issues with urinary frequency and denied pain. A urine was sent for a urinalysis (UA) lab test to rule out a UTI. Review of Resident #34's laboratory form dated 07/13/23 at 4:56 P.M. indicated the sample was canceled 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 observation, interview, and record review, the facility failed to ensure trash was properly contained on the facility grounds. This had the potential to affect all 47 residents currently residing in the building. Findings include: An observation with the Administrator on 04/26/23 at 9:23 A.M. of the grounds around the parking lot and fence line revealed styrofoam cups, used surgical masks, water bottles, empty beer cases, and stray socks. The Administrator explained there were tarps down along the fence line to smother the weeds so they can lay mulch down, but he did confirm there was a lot of refuse along the fence. An interview on 04/26/23 at 9:23 A.M. with the Administrator verified the facility did not contain their garbage around the facility grounds. Review of the facility policy titled Disposal of Garbage and Refuse, undated, indicated areas surrounding dumpsters shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe discarding of cigarettes, and failed to ensure Resident #40 had his physician ordered soft helmet while up in the wheelchair. This finding had the potential to affect seventeen residents (Residents #5, #6, #11, #12, #13, #15, #16, #17, #19, #21, #26, #27, #28, #34, #45, #46 and #47) the facility identified as smokers, and one resident ( Resident #40) of four reviewed for accidents. Findings include: 1. Observation on 04/24/23 at 4:05 P.M. with Activity Director #802 revealed the smoking patio had greater than thirty cigarette butts on the cement portion of the patio and cigarette butts lying in the rocks surrounding the cement patio. A fire proof receptacle was located on the patio and two fire proof ash trays were located on the tables on the patio. Interview on 04/24/23 at 4:10 P.M. with Activity Director #802 confirmed the patio had a large amount of cigarette butts lying on the grounds. She stated the facility was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). A total of 28 medications were administered with four errors for a medication error rate of 14.29%. The finding affected four (Residents #11, #25, #43, and #47) of four residents observed for medication administration. Findings include: 1. Review of Resident #47's medical record revealed she was admitted on [DATE] with type two diabetes, muscle weakness and depression. Review of Resident #47's physician orders revealed an order dated 02/23/23 for Lispro (fast acting insulin) inject 18 units subcutaneously (SQ) before meals for diabetes. Observation on 04/24/23 at 4:44 P.M. with Registered Nurse (RN) #826 of Resident #47's morning medication administration revealed she checked the resident's blood sugar using a glucometer blood sugar machine with a result of 144. She then administered the Lispro fast acting insulin to the resident. Further observation revealed the resident was in 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 and interview, the facility failed to ensure a safe, comfortable, homelike environment. This finding affected three (Residents #27, #33 and #40) of 47 residents residing in the facility observed for environment. Findings include: 1. Observation on 04/24/23 at 11:58 A.M. with Maintenance Director #818 revealed Resident #33's bathroom door had a large hole in it; the upper right side of the wall had wires hanging out of the wall where the light fixture was removed; the floor appeared scuffed and blackened; and the bathroom wall had several holes below the mirror and above the sink. Interview on 04/24/23 at 12:00 P.M. with Maintenance Director #818 confirmed Resident #33's room was not maintained in good repair and in a clean and sanitary manner. 2. Observation on 04/24/23 at 12:02 P.M. with Maintenance Director #818 revealed Resident #27's phone jack plate was out of the wall and hanging down near the floor causing a hole in the wall and wires to be exposed. A phone cord was observed to be plugged into the phone jack plate which was hanging from the wall and 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, review of the medical record and interview with staff, the facility failed to ensure Resident #31 was properly assessed to ensure the resident was free from physical restraint. This affected one resident (Resident #31) of one reviewed for physical restraints. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, anorexia, fatigue, dementia, repeated falls, hypertension and COVID-19. Review of the plan of care dated 07/09/19 revealed Resident #31 was at risk for fall related injury and falls related to weakness, dementia, history of falls, impaired mobility, chooses not to use a walker, incontinence of bowel and bladder, impaired range of motion to the right shoulder. Interventions included to be up in the Broda chair with self releasing seatbelt when not in wheelchair and self release seatbelt in applied in the wheelchair. Review of the Annual Minimum Data Set assessment dated [DATE] 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, medical record review, shower sheet review, and interview, the facility failed to ensure Resident #36 who was dependent on staff assistance for activities of daily living (ADL) was shaved per his preference. This affected one resident (Resident #36) of two resident reviewed for (ADL). Findings included: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included Guillain-Barre syndrome, neuromuscular dysfunction of the bladder, cerebral infarction, vitamin B12 deficiency, anemia, seizures, mild cognitive impairment, hypertension, and weakness. Review of the quarterly Minimum Data set assessment dated [DATE] revealed Resident #36 had moderately impaired cognition. He required extensive assistance of one staff member for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of the progress notes from 02/24/23 through 04/25/23 revealed no documentation Resident #36 refused to be shaved. Review of the shower…

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 did not ensure medications were properly stored in the second-floor medication cart. This affected six residents (Resident #5, #13, #16, #43, #44 and #100) and had the potential to affect the other 15 residents (Resident #2, #15, #25, #28, #30, #40, #46, #101, #102, #104, #105, #106, #107, #108 and #152) whose medications were stored in the second-floor medication cart. The facility census was 48. Findings included: Observation of the medication administration on 06/05/23 at 9:15 A.M. with Registered Nurse (RN) # 200 revealed in the top drawer of the second-floor medication cart there were six, individual plastic medication cups each containing loose pills and did not have appropriate instructions nor labels for each medication because the pills had been removed from the original packaging. Each plastic medication cup was marked with the first names of six residents who RN #200 identified as Residents #5, #13, #16, #43, #44 and #100. Resident #43's cup had eight pills, Resident #44's cup had seven pills, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview, the facility failed to ensure the Resident #40 had physician ordered adaptive devices to assist with meals. This affected one resident (Resident #40) of three reviewed for nutrition. Finding include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses include cerebral infarction, hemiplegia of the left side, acute respiratory failure, intracerebral hemorrhage, schizoaffective disorder, cannabis use, cocaine abuse, viral hepatitis C, viral hepatitis B, malignant neoplasm prostate, major depressive disorder, hypertensive urgency, anxiety disorder, hypertension, and COVID-19. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #40 had moderately impaired cognition and required extensive assistance for activity of daily living. Review of the physician orders revealed Resident #40 had an order for a regular diet, double entrees, sectioned plate and handled cup dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the ice machine in the kitchen and the refrigerator on the second floor were in a clean and sanitary condition. This had the potential to affect all 47 residents currently residing in the building. Findings include: 1. An observation on 04/26/23 at 11:25 A.M. with Dietary Manager #812 revealed mildew and a red substance inside the ice machine. Dietary Manager #812 confirmed the mildew and a red substance inside the ice machine. He stated he would clean it before the end of shift. Another observation on 04/26/23 at 2:40 P.M. with Dietary Aide (DA) #811 revealed the inside of the ice machine still had mildew and a red substance. DA #811 cleaned it with a clean washcloth. Interview on 04/26/23 at 2:40 P.M. with DA #811 revealed the inside of the ice machine still had mildew and a red substance. Review of facility policy titled Ice Machine, dated 04/2010, indicated ice machines shall be free of rust and mildew at all times. 2. 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.