Astoria Place Of Silverton

Based on observation, resident interview, staff interviews, review of the menu, review of the substitution log, and policy review, the facility failed to ensure they had an adequate supply of food to follow the menu. This affected 67 residents as the facility identified three Residents (#42, #56 and #73) who were nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 70. Findings include:Observation of the dry stock area of the kitchen on 03/04/26 at 11:30 A.M. with Dietary Manager (DM) #64, revealed the facility had a low stock of food. Interview with DM #64 at the same time verified there was a low stock of food and stated the facility received a truck delivery with food once a week and if the facility ran out of food, she would go to the local store and get food. DM #64 verified that there was not an emergency stock of food available. Observation of today's lunch menu on 03/05/26 at 11:32 P.M., revealed the residents would receive beef and noodles, broccoli florets, and two baked cookies. Observation of the food line on 03/05/26 at 12:28 P.M.,…

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

Based on observation, staff interviews, and review of the facility policy, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner to prevent foodborne illness. This affected 67 residents as the facility identified three Residents (#42, #56 and #73) who were nothing by mouth (NPO) and did not receive food from the kitchen. The facility census was 70. Findings include:Observation of the kitchen on 03/04/26 at 9:45 A.M. with [NAME] #67, revealed an air vent in the ceiling leaking water, with droplets falling onto the floor below. Immediately adjacent to this location was a food preparation table that was actively being used. Below the preparation table, clean dishes were stored and water droplets were splashing off the floor and onto the dishes. Interview at the time of the observation with [NAME] #67 verified that the air vent was leaking next to the preparation area and near the clean dishes. During an interview on 03/02/26 at 9:47 A.M., Maintenance Supervisor (MS) #91 stated the air vent was connected to the air conditioning unit and it 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 staff interview, record review and policy review, the facility failed to ensure care conferences were conducted. This affected two Residents (#107 and #117) of the three residents reviewed for care conferences. The facility census was 70.Findings include:1) Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] and discharged on 02/09/26 as Against medical Advice (AMA). Diagnoses included chronic viral hepatitis-c, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression and venous insufficiency. The resident had no Guardian at the time of discharge. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #107 had moderately impaired cognition, independent with eating, partial assistance with toileting, substantial assistance with bathing, and set up for personal hygiene. On 02/09/26, the resident was reassessed to have a Brief Interview Mental Status (BIMS) of 13 indicating the 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 record review, staff interview and policy review, the facility failed to notify the Medical Director/ Provider of residents leaving the facility Against Medical Advice (AMA). This affected two Residents (#105 and #107) of the three reviewed. The facility census was 70.Findings include: 1) Review of the medical record revealed Resident #107 was admitted to the facility on [DATE] and discharged on 02/09/26 as AMA. Diagnoses included chronic viral hepatitis c, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression and venous insufficiency. The resident had no Guardian at the time of discharge. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #107 had moderately impaired cognition, independent with eating, partial assistance with toileting, substantial assistance with bathing, and set up for personal hygiene. On 02/09/26, the resident was reassessed to have a Brief Interview Mental Status (BIMS) of 13, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure physician orders were following when administering medications to residents. This affected three Residents (#53, #54, and #55) of the four residents reviewed for medication administration. The facility census was 70. Findings include: 1) Review of the medical record for Resident #53 revealed an admission date of 02/03/25 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominate side, gastro esophageal reflux disease (GERD), and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 was cognitively intact. Review of the physician orders for Resident #53 dated 07/01/25, revealed the resident was ordered to receive a Pain Relief Maximum Strength external topical pain patch (Lidocaine) to be applied at 9:00 P.M. (bedtime), diclofenac Sodium external gel (pain relief) one percent four times daily (8:00 A.M., 11:00 A.M., 4:00 P.M. and 9:00 P.M.,…

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

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 70 out of 71 residents in the facility. One resident (#67) was unable to consume food from the kitchen per diet order. The census was 71.Observation on 07/07/25 at 10:15 A.M. of the kitchen revealed the floor of the walk-in refrigerator had a pooling of water with a brownish tint. Interview on 07/07/25 at 10:15 A.M. with Dietary Manager (DM) #710 verified the pooling of water on the floor in the walk-in refrigerator. DM #710 stated she was newer to the position and had no information regarding the issue in the walk-in refrigerator. This deficiency represents non-compliance investigated under Complaint Number 1308977.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and policy review, the facility failed to maintain a clean, safe, and homelike environment. This affected one resident (#72) and had the potential to affect all residents residing in the facility. The census was 71.Findings include:1. Observation on 07/07/25 at 8:24 A.M. revealed an area of the handrail on the 200 hall was missing. There was a wooden box between the two sections of handrail that was half-way secured to the wall. At the time of the observation, Maintenance Director (MD) #990 verified the missing section of handrail. MD #990 stated there was a water fountain that was removed from the wall, and the wooden box contained some plumbing parts. MD #990 expressed the plan was to remove the plumbing parts and replace the handrail. 2. Observation on 07/07/25 at 9:55 A.M. revealed a broken handrail on the 400 hall. The front portion of the handrail was cracked and separated from the rest of the handrail and had a sharp edge, which was verified by State…

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, staff interview, and review of facility policy, the facility failed to ensure care and services to prevent falls were implemented timely and appropriately. This affected one resident (#13) of 23 residents reviewed for falls. The facility census was 71. Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Alzheimer's disease, dementia with behavioral disturbances, and hypertension. Review of the facility Fall Risk Assessment, dated 04/15/25, revealed the resident was assessed to be at moderate risk for falls. Review of the facility incident log revealed Resident #13 experienced a fall in the facility on 05/10/25. Review of the plan of care for Resident #13 revealed a plan of care and interventions to reduce the risk of falls had not been implemented for the resident until 05/14/25, four days after the resident experienced a fall at the facility. Interview with Minimum Data Set (MDS) Nurse #390 on 07/08/25 at 3:08 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and review of the medication administration policy the facility failed to provide medications while adhering to proper infection control procedures during administration. This affected one resident (Resident #53) out of three observed during medication administration. The facility census was 71.Findings include:Record review of Resident #53 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: Alzheimer's disease, seizures, depression, dysphagia, supraventricular tachycardia, atrial fibrillation, and benign prostatic hyperplagia. Review of the Minimum Data Set(MDS) assessment completed on 06/05/25 revealed this resident had minimal cognitive impairments. Review of Physician Orders revealed this resident was receiving the following medications observed during administration: Vitamin B12 100 milligrams (mg) 1 tablet, Zinc 50 mg 1 tablet, Sertraline 50 mg 1 tablet, Multivitamin 1 tablet, Folic Acid 800 mg 1 tablet,…

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, family interview, staff interview, and policy review, the facility failed to provide evidence of a refund being issued within thirty days of discharge. This affected one (110) of the two residents reviewed for personal accounts. The facility census was 59. Findings include: Review of the medical record of Resident #110 revealed an admission date of 06/26/24. The resident passed away in the facility on 08/12/24. Diagnoses included lung cancer and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had moderately impaired cognition. The resident required partial/moderate assistance with activities of daily living (ADLs). Interview on 04/07/25 at 3:54 P.M., Resident #110's daughter stated she had not received a refund from the funds paid in advance for August 2024. Resident #110's daughter stated she had reached out to the facility multiple times and had not received any answers as to why she had not been refunded approximately $3900.00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to allow a resident to remain in the facility and not transfer or discharge the resident without justification and proper documentation. This affected one (#61) resident out of three residents reviewed for transfer and discharge. The facility census was 53. Findings include: Review of the closed medical record for Resident #61 revealed an admission date of 05/27/21 and a discharge date of 08/20/24. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, bipolar disorder, and alcohol use, unspecified with alcohol-induced persisting dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/24, revealed Resident #61 had moderately impaired cognition. Resident #61 was assessed to be independent for eating, oral hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to give proper notice before a transfer or discharge. This affected one (#61) resident out of three residents reviewed for transfer and discharge. The facility census was 53. Findings include: Review of the closed medical record for Resident #61 revealed an admission date of 05/27/21 and a discharge date of 08/20/24. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, bipolar disorder, and alcohol use, unspecified with alcohol-induced persisting dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/24, revealed Resident #61 had moderately impaired cognition. Resident #61 was assessed to be independent for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Review of…

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

Based on review of the facility menu, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide palatable food to meet resident nutritional needs. This had the potential to affect all residents residing in the facility. The facility census was 55 residents. Findings include: Review of the menu for lunch dated 06/27/24 revealed the menu items included the following: creamy Maryland chicken with mushroom sauce, egg noodles, yellow squash, chilled peach, choice of cold beverage. Observation on 06/27/24 at 11:44 A.M. of the test tray revealed the meal included creamy Maryland chicken with mushroom sauce, penne noodles, yellow squash, and peaches. The squash was sliced and green in color and was mushy to the touch with no taste or flavoring. The creamy Maryland chicken had pieces of cut up chicken breast in a crem sauce over noodles. There was a hard substance which appeared to be a chicken bone mixed in with the sauce and pieces of chicken. The chicken dish was bland and had no flavor. Observations on 06/27/24 from 11:50 A.M.…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to accurately and timely document resident wound treatments. This affected one (Resident #48) resident of three residents reviewed for treatments. The facility census was 55 residents. Findings include: Review of the medical record for Resident #48 revealed an admission date of 02/08/24 with diagnoses including chronic obstructive pulmonary disease (COPD), cellulitis, lymphedema, and type two diabetes mellitus. Review of the care plan for Resident #48 dated 02/15/24 revealed the resident had actual impairment to skin integrity. Interventions included staff were to perform wound treatments with documentation to include measurements, type of tissue, and any exudate noted. Review of the Minimum Data Set (MDS) assessment for Resident #48 dated 05/17/24 revealed the resident had intact cognition and required supervision with bathing. Review of the physician's orders for Resident #48 revealed an order dated 06/04/24 to cleanse the bilateral lower extremities (BLE) with normal saline,…

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 interviews, record review and review of facility policy, the facility failed to maintain an effective pest control program. This had the potential to affect all 53 residents who resided at the facility. The facility census was 53. Findings include: Interview on 05/29/24 at 4:00 P.M. with Resident #35 revealed the facility has had an on-going issue with various bugs. Resident #35 stated she observed several bugs in her room recently. Interview with Resident #42 on 05/29/24 at 11:40 P.M. revealed she has observed various bugs in her room recently. An interview with an unknown Visitor #51 on 05/29/24 at 11:22 A.M. revealed she was very upset with the conditions of the facility. Visitor #51 took out her phone and showed Surveyor several pictures of large bugs she had observed in the facility. Interview with Resident #47 on 05/29/24 at 11:28 A.M. revealed she had large bugs in her room. Observed at the same time revealed a dead, large, black hard-shelled bug approximately one inch inside her door frame and a live one underneath the resident's sink. 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 record review, staff interviews, and review of the facility policy, the facility failed to ensure a written discharge notice with provision of the discharge was provided to resident upon discharge to the community. This affected one resident (#56) out of three residents reviewed. The facility census was 53. Findings include: Record review for Resident #56 revealed the resident was admitted on [DATE] and discharged on 05/14/24. His diagnoses included, spondylosis, chronic obstructive pulmonary disease, coronary artery dissection, major depressive disorder, insomnia, hypertension, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #56, revealed the resident was cognitively intact. Resident #56 was dependent on facility staff for medication administration and independent with all other activities of daily living. Review of the nursing progress notes for Resident #56 dated 05/14/24 at 4:12 P.M. revealed the resident was discharged to a local hotel'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, staff interviews, and review of the facility policy, the facility failed to ensure a safe and orderly discharge. This affected one resident (#56) out of three residents reviewed. The facility census was 53. Findings include: Record review for Resident #56 revealed the resident was admitted on [DATE] and discharged on 05/14/24. His diagnoses included, spondylosis, chronic obstructive pulmonary disease, coronary artery dissection, major depressive disorder, insomnia, hypertension, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #56, revealed the resident was cognitively intact. Resident #56 was dependent on facility staff for medication administration and independent with all other activities of daily living. Review of the nursing progress notes for Resident #56 dated 05/14/24 at 4:12 P.M. revealed the resident was discharged to a local hotel's address with all of his personal belongings, a courtesy bag, a list of medications 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 record review, observation, staff interviews, and review of facility policy, the facility failed to provide a clean, safe, and sanitary environment. This directly affected three residents (#14, #25, and #42) but had the potential to affect all 18 residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #25 and #42) who resided on the memory care unit. The facility census was 53. Findings include: 1) Record review for Resident #14 revealed he was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic respiratory failure with hypercapnia, diabetes mellitus (DM)2, Alzheimer's disease, depression, insomnia, and anxiety disorder. Review of Resident #14's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had impaired cognition. Observation of Resident #14's room on 05/29/24 at 11:20 A.M. revealed the following: a. The cove base around the outside of the bathroom wall was hanging off the wall. b. There was white…

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, observations, staff interviews and policy review, the facility staff failed to perform hand washing/hand hygiene after providing incontinence care and before applying barrier cream, repositioning, and clothing adjustments. This affected two (#4 and #26) of three residents review for incontinence care. The facility census was 52. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 01/16/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, excoriation (skin-picking) disorder, and functional urinary incontinence. Review of the Minimum Data Set (MDS) for Resident #26, dated 03/13/24, revealed the resident was cognitively intact, required partial assistance with toileting hygiene and personal hygiene. Review of the physician's orders for Resident #26 revealed an order dated 01/16/24 to apply barrier cream as needed. Observation of incontinence care on 04/29/24 at 10:00 A.M., on Resident #26, was provided by State Tested Nursing Assistant (STNA) #256. 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 observations, staff and resident interviews, and policy review, the facility failed to ensure the residents were provided a clean, functional, homelike environment. This affected two residents (#37 and #40) and had the potential to affect 34 residents (#18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #38, #39, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, and #53) of 53 residents residing in the facility. Findings include: Observation was conducted in the facility on 03/28/24 from 8:42 A.M. to 9:10 A.M. revealed: • The 100-hall outside of room [ROOM NUMBER] had bugs and dust in the ceiling light. Outside of room [ROOM NUMBER], there were bugs and dust in the ceiling lights and the shield was broken. Outside of rooms [ROOM NUMBER], there were bugs, dust, and lights burned out. Throughout the 100-hallway, the walls and handrails had scuff marks. On the entrance to the 100-hall, there was a missing strip of flooring. • The bathroom on the 100-hall…

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, record review and staff interviews, the facility failed to ensure the dishwasher temperature and water temperatures in the kitchen were maintained in manner to promote kitchen sanitation. This affected 54 of the 54 residents who the facility identified as receiving food from the kitchen. The facility census was 54. Findings include: Observation of Maintenance Director #72 taking water temperatures in the facility on 02/07/24 at 10:51 A.M. revealed the handwashing sink in the kitchen was 72 degrees Fahrenheit, the dishwasher registered 71 degrees Fahrenheit for the wash and rinse, and the three-compartment sink was 87 degrees Fahrenheit. Dietary Aide #13 was actively washing pans in the three-compartment sink. Interview with Maintenance Director #72 on 02/07/24 at 10:51 A.M. verified the handwashing sink in the kitchen was 72 degrees Fahrenheit, the dishwasher registered 71 degrees Fahrenheit for the wash and rinse, and the three-compartment sink was 87 degrees Fahrenheit. Maintenance Director #72 also verified Dietary Aide #13 was actively washing pans in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to provide a comfortable, safe, and homelike environment by ensuring the residents had water. This affected 23 (#01, #03, #05, #07, #10, #12 #14, #16, #19, #24, #27, #29, #32, #33, #34, #37, #38, #39, #40, #44, #45, #46 and #52) of the 54 residents who resided at the facility. Findings include: Review of Resident #05's chart revealed Resident #05 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, anemia, muscle weakness and dysphagia. Review of Resident #05's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #05 was dependent on staff for oral hygiene, toileting, showering, personal hygiene, and transfers. Review of Resident #07's chart 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 observations, resident and staff interviews and review of facility policy, the facility failed to maintain essential equipment to provide hot water to the residents. This directly affected 23 (#01, #03, #05, #07, #10, #12 #14, #16, #19, #24, #27, #29, #32, #33, #34, #34, #34, #37, #38, #39, #40, #44, #46 and #52) of the 54 residents reviewed for safe and comfortable hot water temperatures. This also had the potential to affect all 54 residents who resided in the facility. Findings include: Interview on 02/07/24 at 9:35 A.M. with Housekeeper #42 revealed the water was cold in the facility. Interview on 02/07/24 at 9:37 A.M. with Registered Nurse (RN) #66 revealed the center unit was the only unit with hot water in the facility. RN #66 stated all other units did not have hot water. Interview with Resident #07 on 02/07/24 at 9:39 A.M. revealed the water at the facility was cold and she wanted a warm shower. Interview on 02/07/24 at 9:46 A.M. with Resident #05 revealed the water in the facility was cold…

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 staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect all 62 residents who received food from the kitchen. The facility census was 62. Findings include: Observation of the kitchen on 12/27/23 from 8:47 A.M. to 9:03 A.M. revealed the following: a) The high temperature dishwasher temperature gauge was stuck at 90 degrees Fahrenheit, the clear covering on the gauge was cracked, and the gauge was broken. There was white and brown debris on the top of the dishwasher and all around the openings of the dishwasher. b) The reach in refrigerator's seal around the door was broken. The reach in refrigerator did not have a thermometer inside and the temperature gauge outside the refrigerator was broken and stuck at 17 degrees Fahrenheit. c) There were two packages of expired buns in the dry storage room that were dated 12/13/23. One of the packages of buns…

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 resident and staff interview, the facility failed to ensure a safe, clean comfortable and homelike environment. This affected 23 residents (#03, #09, #12, #14, #16, #19, #27, #32, #34, #36, #37, #40, #41, #42, #45, #48, #50, #52, #53, #57, #60, #62, and #63) of 61 residents reviewed for a homelike environment. The facility census was 61. Findings include: 1. Observation on 04/10/23 and 04/11/23 from 11:00 A.M. to 6:00 P.M., revealed the hallway railings had dark brown and black particles of dirt and crumbs on them. There was a slice of bread from a mealtime left on the hallway railings. There was toilet paper, an empty milk container, bread and paper fragments were in between the wall and the hallway railings. The hallway railings had chipped paint exposing the wood and the white painted railings were dirty and dingy in appearance. The vent in the hallway outside of room [ROOM NUMBER] was caked with dirt and debris and the turning knob of the vent was missing. Interview on 04/11/23 at…

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

Based on observation, resident and staff interviews, the facility failed to ensure residents were given the correct grievance official during monthly resident council meetings and aware of the designated grievance official. This directly affected six (#13, #18, #22, #31, #37, and #48) residents interviewed during the resident council meeting and had the potential to affect all 61 residents in the facility. The Facility census was 61. Findings include: Interviews during the resident group meeting on 04/12/23 12:59 P.M., revealed Residents #13, #18, #22, #31, #37, and #48 expressed a concern they were reporting their grievances to the Activity Director (AD) #43 during council meetings and outside of council meetings and don't believe anything was being done. The residents were not aware of a posting which revealed the Grievance Official in the center, back, and or front of the facility. Interview on 04/12/23 at 1:38 P.M., revealed AD #43 reported residents can come to her about a grievance. She took those concerns to the department heads to address the concerns. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents and representatives had the opportunity to participate in care conferences. This affected one resident (#09) out of one resident reviewed for care conferences participation. The facility census was 61. Findings include: Medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included dementia, attention and concentration deficit following cerebral infarction, paranoid schizophrenia, peripheral vascular diseases, and chronic kidney disease stage two. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 had intact cognition and required supervision of one staff for bed mobility, transfers, and ambulation. The record review revealed no evidence of residents participating in care conferences. Further record review revealed no documentation from other interdisciplinary team members was invited. There is no documentation whether resident 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 and interview, the facility failed to ensure meals served were palatable. This had the potential to affect all 82 residents who received meals from the kitchen. The census was 82. Findings include: Observation on 12/16/19 at 2:15 P.M. revealed dietary services preparing to serve dinner that consisted of diced chicken and dumplings, diced carrots, wheat bread and [NAME] dump cake. Dietary [NAME] (DC) #20 was cooking the chicken dumplings which consisted of diced chicken, frozen dumpling pieces, concentrated chicken flavored base, pepper and garlic powder. DC #20 placed canned apples in the pan and placed cinnamon on top along with melted butter. DC #20 sprinkled yellow cake mix on top of the apples. During interview on 12/16/19 at 2:16 P.M., DC #20 and Dietary Assistant Manager (DAM) #23 was unable to find the recipe for the dinner menu. DC #20 reported she has never used a recipe when cooking meals. During interview on 12/16/19 at 2:30 P.M., Dietician (DT) #87 stated a copy of the dinner…

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

Based on observation, staff interview, and policy review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. This had the potential to affect all 82 residents. The census was 82. Findings include: On 12/15/19 at 8:05 A.M., an initial tour of the kitchen was conducted with Dietary Assistant (DA) #23, the following was observed: 1. In the refrigerator there was a large bowl of mixed salad was covered with no preparation date or use by date; two 20 pound portions of ground beef and two 34 pound hams were thawing on a cookie sheet, one shelf up from the bottom; two dozen eggs were stored one shelf up from the bottom; a container of country steak and a container of corn were dated 12/14 and a container of sliced potatoes with a date of 12/6, but it was not specified if this was an open date or use by date; three large pans of macaroni and cheese with no opened date or use by date; three large storage bags of shaved ham with no date; a plastic container beef with no opened date or use by date; and a large pan of green beans 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.

Based on observation and interview, the facility failed to keep rooms clean and in proper repair. This affected one resident on the 400 hall (Resident #45), and 11 (Resident #14, #21, #23, #37, #38, #44, #52, #53, #59, #60, and #281) residents on the dementia unit. The facility census was 82. Findings include: 1. Observation on 12/15/19 at 2:56 P.M. of Resident #45's room, the string to turn on the resident's room light was broken; the assist rails in the bathroom were loose; the wall was separated from the air vent used for heat in the bathroom; and there was a handrail that was detaching from the the wall, which was being used as a shelf. A tour on 12/17/19 at 4:04 P.M. with the Maintenance Director #79 verified the above observations. 2. On 12/15/19 at 11:05 A.M., an observation of Resident #52 and #281's room revealed paint peeling over Resident #281's bed and the toilet was clogged with feces. 3. On 12/15/19 11:27 A.M., an observation of Resident #21's and Resident #38's room revealed the call light in bathroom was broken. 4. On 12/15/19 at 11:48 A.M., an observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care planning conferences were being held. This affected four (Residents #17, #26, #33 and #57) of six residents reviewed for care planning conferences. The facility census was 82. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 06/23/14. Review of care plan conference sheets revealed Resident #26 had two conferences at the family request on 04/15/19 and again on 08/26/19. There were no other care plan conference records provided for the resident for the year. Interview on 12/15/19 at 3:29 P.M. with Resident #26's mother and sister revealed they did not recall any care conferences being offered recently. 2. Review of the medical record for Resident # 57 revealed an admission date of 03/28/14. Review of care plan conference sheets revealed Resident #57 had one conference at the family request on 09/08/19. There were no other care plan conference records provided for the resident for the year.…

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 policy review, the facility failed to implement their policy for abuse by not reporting to the State Agency or investigating an allegation of abuse. This affected one (Resident #15) of two residents reviewed for abuse. The census was 82. Findings include: Record review revealed Resident #15 was admitted on [DATE] with diagnosis including diabetes, bipolar II disorder, psychoactive substance abuse, insomnia, encephalopathy, hypertension, benign neoplasm of pituitary gland, depression, personality disorder, chronic viral hepatitis C, vitamin D deficient, anemia, anxiety, chronic obstructive pulmonary disease, thrombocytopenia, post traumatic stress disorder, and accidental overdose. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 has no cognitive deficits, requires limited assist with bed mobility, transfers, extensive assistance with personal hygiene, dressing, toileting, is frequently incontinent of urine, and always continent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to report allegations of abuse to the State Agency. This affected one (Resident #15) of two residents reviewed for abuse. The facility census was 82. Findings include: Record review revealed Resident #15 was admitted on [DATE] with diagnosis including diabetes, bipolar II disorder, psychoactive substance abuse, insomnia, encephalopathy, hypertension, benign neoplasm of pituitary gland, depression, personality disorder, chronic viral hepatitis C, vitamin D deficient, anemia, anxiety, chronic obstructive pulmonary disease, thrombocytopenia, post traumatic stress disorder, and accidental overdose. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 has no cognitive deficits, requires limited assist with bed mobility, transfers, extensive assistance with personal hygiene, dressing, toileting, is frequently incontinent of urine, and always continent of bowel. During interview on [DATE] at 11:33 A.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to thoroughly investigate an allegation of abuse. This affected one (Resident #1) out of two residents reviewed for abuse. The census was 82. Findings include: Record review revealed Resident #15 was admitted on [DATE] with diagnosis including diabetes, bipolar II disorder, psychoactive substance abuse, insomnia, encephalopathy, hypertension, benign neoplasm of pituitary gland, depression, personality disorder, chronic viral hepatitis C, vitamin D deficient, anemia, anxiety, chronic obstructive pulmonary disease, thrombocytopenia, post traumatic stress disorder, and accidental overdose. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 has no cognitive deficits, requires limited assist with bed mobility, transfers, extensive assistance with personal hygiene, dressing, toileting, is frequently incontinent of urine, and always continent of bowel. During interview on [DATE] at 11:33 A.M., Resident #15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to provide an individualized activity program designed to meet the interests and total care needs of the residents on the dementia unit. This affected two (#21 and #49) out of 29 residents reviewed for activities. The facility census was 82. Findings include: 1. Review of Resident #21's care plan, dated 10/08/19, revealed Resident #21 was dependent on staff for meeting emotional, intellectual, physical and social needs and would attend/participate in activities of choice two to three times weekly. Review of Resident #21's activity assessment dated [DATE] revealed the resident's current interests included newspapers, magazines, listening to music, puzzles and participation in religious services was very important. Review of Resident #21's Daily Participation Record for October 2019, November 2019 and December 2019 revealed Resident #21 was not offered to play bingo, puzzles or participate in music any time it was scheduled. Observation on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure all resident call lights were in working order. This affected three (rooms [ROOM NUMBER]) of 26 resident rooms. The facility census was 82. Findings include: Observation made on 12/15/19 at 10:01 A.M. revealed call light in room [ROOM NUMBER] was not in working condition. Observation made on 12/15/19 at 2:12 P.M. revealed call light in room [ROOM NUMBER] was not in working condition. Observation made on 12/15/19 at 4:07 P.M. revealed call light in room [ROOM NUMBER] was not in working condition. A tour conducted on 12/17/19 at 3:49 P.M. with Maintenance Director #79 verified call lights were not functioning.

Based on observation, test tray trial, and interview, the facility failed to ensure meals were served in a palatable manner This had the potential to affect all 85 residents who received meals from the kitchen. Census was 85. Findings include: Interviews were conducted on 11/13/18 throughout the day with 10 residents, who wished to remain anonymous. The residents complained about the taste of the food. Observation on 11/14/18 from 5:15 P.M. to 5:55 P.M., revealed dietary services served dinner that consisted of Hungarian goulash, buttered noodles, Capri vegetables and peanut butter cookies. Several residents sent the served meal back to the kitchen and requested for the substitution dinner which consisted of hamburger, fries and soup. There were white noodles with brown meat on top of the noodles, and next to the noodles was a mixture of cauliflower, broccoli and one or two carrot slices. At 5:45 P.M., after all the residents received their meal trays, the surveyor, Dietary Manager (DM) #31 and Dietary [NAME] (DC) #47 tasted tested the meal. The surveyor tasted the food 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.

Based on observation, staff interview, and policy/procedure review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. The facility also failed to serve food in a sanitary environment. This had the potential to affect all 85 residents. Facility census was 85. Findings include: On 11/13/18 from 9:22 A.M. to 9:45 A.M., an initial tour of the kitchen was conducted with Registered Dietician (RD) #42. During the observation the following concerns were observed and all the concerns were verified by RD #42. a) In the refrigerator there was a container of chili was covered but had no date or use by date. b) In the refrigerator there was a 12-pack of assorted donuts with one donut missing and had no opened date or use by date. c) In the refrigerator there were seven ½ pints of milk dated 11/10/18 and five containers of 4.0 fluid ounces of reduced fat free milk dated 11/06/18. d) In the refrigerator there were two-gallon bags of Ziploc baggies that consisted of bologna with no date and no used by date. e) In the freezer there were rib…

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

Based on review of monitoring measures, interview and policy review the facility failed to have appropriate Legionella monitoring. This has the potential to affect all residents residing in the facility. Facility census was 85. Findings include: Review of the facility's Monitoring Control Measures to Prevent Growth and Spread of Legionella revealed no evidence of water temperatures being done in rooms or water heaters, no evidence of flushing of resident rooms/unused rooms, and no evidence of wash basins aerators or shower heads being cleaned or replaced. Interview on 11/15/18 at 5:12 P.M. with Maintenance Director (MD) #36 verified there was no evidence of water temperatures being done in rooms or water heaters, no evidence of flushing of resident rooms/unused rooms, and no evidence of wash basins aerators or shower heads being cleaned or replaced. Review of the facility's policy entitled Legionella Hazard Risk Analysis (not dated) revealed all resident rooms and other areas in the facility that have not had use in the past week will have the appropriate output devices flushed for…

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

Based on observation, resident and staff interview and review of pest control records the facility failed to provide an environment free of insects in the kitchen and in the residents' rooms. This had the potential to affect all 85 residents. Facility census was 85. Findings include: Observation on 11/13/18 from 9:22 A.M. and on 11/15/18 at 8:28 A.M., revealed gnats in the kitchen near the dry storage area, near the stove, near the dishwasher, near the serving table and around the trash can. Interview on 11/13/18 at 10:58 A.M., Resident #4 complained about gnats and ants in his room and in the dining area. Interview on 11/14/18 at 10:28 A.M., Dietary Manager (DM) #31 stated the kitchen had some problems with gnats about two months ago, but it was getting better. DM #31 verified there were still gnats in the kitchen. Interview on 11/14/18 at 6:30 P.M., Maintenance Director (MD) #36 reported the exterminator sprays the facility twice a month for bugs. MD #36 reported some residents had reported gnats in their rooms. Review of local pest control company records revealed the company 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 3. Observation on 11/13/18 at 12:01 P.M. revealed scrapes to the wall, the entire length of Resident #62's bed, the laminate was peeling off the front of the sink counter leaving exposed wood, and the bottom of the corner wall, next to the sink. Resident #72's bed, was crumbling with a visible hole. Observation on 11/15/18 at 2:30 P.M. with MD #36 verified the scrapes to the wall and reported they were the result of Resident #62's bed being raised and lowered during care. MD #36 also verified the exposed wood to the front of the sink, reported the laminate was sliding down, and the crumbling lower corner wall near Resident #72's bed was a five inch area of exposed drywall where the cove base was off. The measurement was obtained by MD #36. 4. Observation on 11/13/18 at 3:54 P.M. revealed Resident #28's bathroom ceiling was cracked, peeling, with a large piece hanging down. Observation on 11/15/18 at 2:26 P.M. with MD #36, measured and reported it was a 13 inch by seven inch piece of peeling paint hanging off…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review,review of Facility Reported Incidents (FRI) and witness statements, interviews, and review of facility Abuse Prevention Program and Abuse Investigation and Reporting Policies the facility failed to ensure abuse policies were implemented for allegations of abuse including injuries of unknown origin. This affected four (#22, #33, #69, #83) of five residents reviewed for abuse. The facility census was 85. Findings include: 1. Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] and discharged on 07/01/18. Diagnosis included chronic obstructive pulmonary disease, cerebral vascular disease, congestive heart failure, and schizophrenia. Review of admission minimum data set (MDS) dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, limited assistance was required with eating, personal hygiene, a cane and walker were utilized for mobility. 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 and interview the facility failed to have an operational call light system. This affected 10 rooms (#300, #314, #410, #412, #414, #416, #422, #423, #424,and #425) out 21 rooms reviewed for operational call lights. This had the potential to affect 16 Residents (#1, #6, #21, #22, #24, #25, #28, #31, #33, #37, #51, #52, #58, #63, #75, and #184) identified by the facility as residing in the affected rooms. The facility census was 85. Findings include: Observation on 11/13/18 at 11:28 A.M. revealed there was no call light button to push to activate the call light in room [ROOM NUMBER]. Interview on 11/13/18 at 11:31 A.M. with Maintenance Director (MD) #36 verified there was no push button to activate the call light in room [ROOM NUMBER]. A tour conducted on 11/13/18 from 12:10 P.M. to 12:28 P.M with State Tested Nursing Aide (STNA) #34 revealed the following: rooms [ROOM NUMBERS] the call light did not activate when pushed, rooms [ROOM NUMBER] the bathroom call light did not activate when the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide required beneficiary notices in writing to residents when skilled Medicare Part A services were discontinued. This affected two (#31 and #285) of three residents reviewed for beneficiary protection notification. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #31 was admitted on [DATE]. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review provided by the facility revealed the resident received skilled Part A services, and the last covered day of services was 10/26/18. Further review of the medical record revealed the resident remained in the facility after skilled services were discontinued. Review of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) revealed the facility contacted the resident's representative on 10/18/18 by telephone to inform of skilled services ending and the content of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Facility Reported Incidents (FRI) and written statement reviews, interviews, and review of facility policy, the facility failed to prevent resident to resident abuse. This affected three Residents (#22, #33, & #69) of five reviewed for abuse. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, hypertension, dysphagia, constipation, magnesium deficiency, impulse disorder, depression, psychosis, mood disorder, and cerebrovascular disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 had moderate cognitive deficits. Review of the closed medical record revealed Resident #50 was admitted on [DATE] with diagnosis including cerebrovascular disease, schizoaffective disorder, diabetes, abuse of non-psychoactive substances, traumatic brain injury, muscle weakness, bipolar disorder, hypertension, and dementia with behavioral disturbance. Resident #50 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 closed medical record review, interviews, and review of facility Abuse Prevention Program and Abuse Investigation and Reporting Policies the facility failed to report to the state agency a resident to resident altercation and an injury of unknown origin. This affected one (#83) of five residents reviewed for abuse. The facility census was 85. Findings include: Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] and discharged on 07/01/18. Diagnosis included chronic obstructive pulmonary disease, cerebral vascular disease, congestive heart failure, and schizophrenia. Review of admission minimum data set (MDS) dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, limited assistance was required with eating, personal hygiene, a cane and walker were utilized for mobility. Review of nursing progress note dated 06/13/18 at 7:47 P.M. revealed Resident #7 self…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, interviews, and review of facility Abuse Prevention Program and Abuse Investigation and Reporting Policies the facility failed to thoroughly investigate and resident to resident altercation and an injury of unknown origin. This affected one(#83) of five Residents reviewed for abuse. The facility census was 85. Findings include: Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] and discharged on 07/01/18. Diagnosis included chronic obstructive pulmonary disease, cerebral vascular disease, congestive heart failure, and schizophrenia. Review of admission minimum data set (MDS) dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, limited assistance was required with eating, personal hygiene, a cane and walker were utilized for mobility. Review of nursing progress note dated 06/13/18 at 7:47 P.M. revealed Resident #7 self propelled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interviews the facility failed to provide a written discharge notice or notify the ombudsman office of a facility initiated discharge. This affected one (#85) of one resident reviewed for discharge. The facility census was 85. Findings include: Closed medical record review revealed Resident #85 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis included schizophrenia, cognitive communication deficit, difficulty walking, diabetes, and asthma. Review of the quarterly minimum data set (MDS) dated [DATE] revealed intact cognitive skills for daily decision making, Resident #85 was independent with transfers, mobility, supervision was required with eating, limited assistance was required with toileting and personal hygiene. A cane or crutch was utilized for mobility. Review of the care plan dated [DATE] revealed a self care deficit with decline expected related to cognitive deficit. Alterations in mood and behavior related to anxiety, cognitive decline/deficit,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interviews the facility failed to ensure a resident was properly prepared for a safe and orderly discharge. This affected one (#85) of one resident reviewed for discharge. The facility census was 85. Findings include: Closed medical record review revealed Resident #85 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis included schizophrenia, cognitive communication deficit, difficulty walking, diabetes, and asthma. Review of the quarterly minimum data set (MDS) dated [DATE] revealed intact cognitive skills for daily decision making, Resident #85 was independent with transfers, mobility, supervision was required with eating, limited assistance was required with toileting and personal hygiene. A cane or crutch was utilized for mobility. Review of the care plan dated [DATE] revealed a self care deficit with decline expected related to cognitive deficit. Alterations in mood and behavior related to anxiety, cognitive decline/deficit, and signs/symptoms of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review and interview the facility failed to ensure a minimum data set (MDS) assessment was completed and submitted upon discharge from the facility. This affected one (#83) of one resident reviewed for resident assessment. The facility census was 85. Findings include: Closed medical record review revealed Resident #83 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis included chronic obstructive pulmonary disease, cerebral vascular disease, congestive heart failure, and schizophrenia. Review of admission MDS assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, limited assistance was required with eating, personal hygiene, a cane and walker were utilized for mobility. The medical record did not contain any completed MDS assessments after [DATE]. Review of nursing progress note dated [DATE] at 3:15 P.M., revealed nine-one-one (911) was called 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 closed record review and interviews the facility failed to ensure a Pre-admission Screen and Resident Review (PASRR) extension was requested timely. This affected one (#85) of one Resident reviewed for discharge. The facility census was 85. Findings include: Closed medical record review revealed Resident #85 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis included schizophrenia, cognitive communication deficit, difficulty walking, diabetes, and asthma. Review of the quarterly minimum data set (MDS) dated [DATE] revealed intact cognitive skills for daily decision making, Resident #85 was independent with transfers, mobility, supervision was required with eating, limited assistance was required with toileting and personal hygiene. A cane or crutch was utilized for mobility. Review of the care plan dated [DATE] revealed a self care deficit with decline expected related to cognitive deficit. Alterations in mood and behavior related to anxiety, cognitive decline/deficit, 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 medical record review, resident interview, and staff interview, the facility failed to ensure care was planned with the input of the resident. This affected one resident (#4) of one reviewed for care planning. The facility census was 85. Findings include: Review of medical record revealed Resident #4 was admitted on [DATE] with diagnoses including muscle weakness, adult failure to thrive, anorexia, pancreatic steatorrhea, dysphagia, hypertension, and depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact for making decisions, independent with bed mobility, but extensive assist with one person for transfers and toilet use. Further review of the medical record revealed the resident was his own responsible party/representative. Review plan of care dated 02/13/17 revealed advanced care planning wishes will be respected and coordinated with resident upon his choices. Review of care conference meetings revealed none were offered 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, observation, and interview the facility failed to ensure a splint was applied per physician's order. This affected one Resident (#28) of three reviewed for range of motion. The facility census was 85. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnosis including acute respiratory failure, dementia, voice and resonance disorder, intellectual disabilities, anemia, dysphagia, muscle weakness, hemiplegia, obstructive sleep apnea, schizoaffective disorder, and depression. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #28 had moderate to severe cognitive impairment, required extensive assist with activities of daily living, impairment on right upper side extremity, and was always incontinent of bowel and bladder. Review of physician order dated 09/28/18 revealed that Resident #28 was to wear right hand splint eight hours daily as tolerated. Further review of the record revealed no evidence the resident was unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and policy review the facility failed to store oxygen safely and appropriately. This affected one Resident (#62) of two reviewed for respiratory care. The facility census was 85. Findings include: Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnosis including early onset Alzheimer's, dysphagia, restlessness, agitation, gastro-esophageal reflux disease, and hypertension. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #62 had moderate impaired cognitive deficits and required extensive assistance with all activities of daily living. Observations on 11/13/18 at 12:09 P.M. and 11/14/18 at 9:00 A.M. revealed there were two canisters of oxygen in Resident #62's room. The observations also revealed no signage indicated that oxygen was in use in the room. Interview on 11/14/18 at 9:14 A.M. with Licensed Practical Nurse (LPN) #62 verified there was no sign to indicate the use of oxygen in the residents room. LPN…

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 oxygen tubing was changed on a weekly basis according to physician orders. This affected one Resident (#28) of two reviewed for respiratory care. The facility census was 85. Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnosis including acute respiratory failure, dementia, voice and resonance disorder, intellectual disabilities, anemia, dysphagia, muscle weakness, hemiplegia, obstructive sleep apnea, schizoaffective disorder, and depression. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #28 had moderate to severe cognitive impairment, required extensive assist with activities of daily living, had impairment on right upper side extremity, and was always incontinent of bowel and bladder. Review of physician order dated 01/21/17 revealed an order to change oxygen tubing/mask every week on Sunday on night shift. Further review of the medical record 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 and interview the facility failed to have a stop date for an as needed antipsychotic medications. This affected one Resident (#21) out of five reviewed for unnecessary medications. The facility census was 85. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE] with diagnosis including altered mental status, psychosis, ataxia, mood disorder, diabetes, dementia with behavioral disturbance, and idiopathic peripheral neuropathy. Review of the Quarterly Minimum Data Set, dated [DATE] revealed Resident #21 had severe cognitive deficits, required extensive assistance with personal hygiene, toileting, dressing, supervision with the remaining activities of daily living, and was occasionally incontinent of bowel and bladder. Review of physician order dated 10/30/18 revealed to give Haldol (antipsychotic) one milligram (mg) tablet by mouth every eight hours as needed for agitation with no end date. Interview on 11/14/18 at 3:42 P.M. with the Director of Nursing…

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 have ordered laboratory tests completed and drawn as ordered. This affected one Resident (#33) out of five reviewed for unnecessary medications. The facility census was 85. Findings include: Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, hypertension, dysphagia, constipation, magnesium deficiency, impulse disorder, depression, psychosis, mood disorder, and cerebrovascular disease. Review of Quarterly Minimum Data Set, dated [DATE] revealed Resident #33 had moderate cognitive deficits, required extensive assistance with toileting, supervision with remaining activities of daily living, was occasionally incontinent of bladder, and always continent of bowel. Review of physician order revealed an order dated 01/28/17 for serum magnesium, complete metabolic panel, valproic acid serum, complete blood count, liver function test every six months on the fourth Monday in January/July. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interviews, test tray trial, and review of resident council meetings, the facility failed to follow the prepared menus and failed to provide meal preferences for the residents. This affected two Residents (#4 and #19) of three reviewed for food preferences. The facility census was 85. Findings include: 1. Review of the medial record revealed Resident #4 was admitted [DATE] with diagnoses including muscle weakness, adult failure to thrive, anorexia, pancreatic steatorrhea, dysphagia, hypertension, and depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition for decisions. Further review revealed Resident #4 took supplements for every meal. Interview on 11/13/18 at 10:58 A.M., Resident #4 indicated he had reported concerns to the dietary manager that the food did not taste well and he was tired of eating sandwiches for lunch and dinner. Resident #4 reported the facility served bologna…

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.