Cityview Healthcare And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of self-reported incidents and related documents, resident and staff interview, and facility policy review, the facility failed to ensure residents were free from abuse. This affected two (#11 and #64) of six residents reviewed for abuse. The facility census was 91. Findings include: 1. Review of the medical record for Resident #64 revealed an admission date of 08/14/25. Diagnoses include asthma, epilepsy, anemia, bladder dysfunction, psychoactive substance abuse, borderline personality, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact with mild depression and no behaviors. Resident #64 required supervision with ambulating. Review of Resident #64 care plan dated 01/22/26 revealed a plan for mood distress and anxiety related to a history of depressive illness. Interventions include to speaking about feeling and emotions and to attempt alternative therapies such as music. Review of Resident…

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

Based on medical record review, staff interview, review of a self-reported incident, and review of a facility policy, the facility failed to ensure an allegation of abuse was timely reported to the state survey agency. This affected one (Resident #11) of six residents reviewed for abuse. The facility census was 91. Findings include:Record review for Resident #11 revealed an admission date of 10/28/20. Diagnosis included schizoaffective disorder, acquired absence of the left foot, weakness, and anxiety disorder.Record review for Resident #102 revealed an admission date of 03/19/20 and a discharge date of 12/08/25. Diagnoses included schizoaffective disorder and major depressive disorder.Review of the progress note for Resident #11 dated 11/27/25 at 1:30 P.M., completed by Licensed Practical Nurse (LPN) #622 revealed the nurse made aware that the resident alleged he and a peer had an altercation with a skin alteration noted. The residents were separated, the skin alteration was cleansed, and the physician was notified.Record review of a self-reported incident (SRI) for an allegation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, as required. This affected one (#84) three residents reviewed for MDS assessment submissions. The facility census was 91.Findings include: Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, generalized anxiety disorder, and vitamin D deficiency.Review of the Minimum Data Set (MDS) assessment schedule for Resident #84 on 03/31/26 revealed a quarterly MDS assessment was completed on 10/10/25, and a subsequent quarterly MDS assessment was completed on 01/10/26. Further review revealed the 01/10/26 assessment was listed as exported, indicating it had not been successfully transmitted and accepted by the Centers for Medicare and Medicaid Services (CMS) within the required 14-day timeframe following…

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, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure one (#44) of four residents reviewed for activities of daily living (ADLs) was properly assessed and provided services to address a decline in ADLs self-care. The facility census was 91.Findings include:Record review for Resident #44 revealed an admission date of 09/30/22. Diagnoses included paranoid schizophrenia, hemiplegia affecting the left nondominant side, osteonecrosis of the right femur, schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, muscle weakness, extrapyramidal and movement disorder, retention of urine, vertigo, and personal history of a traumatic brain injury. Review of the facility census revealed Resident #44 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 10/29/24. Resident #44 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 07/16/25.Review of the Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of shower schedules, the facility failed to ensure adequate fingernail care was completed for dependent residents. This affected one (#89) of four residents reviewed for bathing/showers. The facility census was 91.Findings include: Record review for Resident #89 revealed an admission date of 06/06/18. Diagnoses included spastic diplegic, cerebral palsy, polyneuropathy, spina bifida, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 was cognitively intact. Resident #89 had impairment on both sides of the upper and lower extremities. Resident #89 used a wheelchair for mobility, was dependent for showers/bathing, personal hygiene, and chair/bed to chair transfers. Review of the care plan dated 12/22/25 revealed Resident #89 had an activity of daily living (ADL) self-care performance deficit related to a decline in functional mobility. Interventions included 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, resident and staff interview, and medical record review, the facility failed to ensure one (#20) resident received assistance with his glasses to ensure consistency with utilizing the prescribed glasses. This affected one (#20) of three residents reviewed for ancillary services. The facility census was 91.Findings include: Record review for Resident #20 revealed an admission date of 07/24/19. Diagnoses included dementia, abnormalities of gait and mobility, and unsteadiness on feet.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Resident #20 used a wheelchair for mobility, required supervision or touch assistance to ambulate 150 wheelchair mobility, had clear speech, was usually understood and understands others, had adequate vision and did not wear corrective lenses for vision.Record review on 03/31/26 at 10:00 A.M. revealed there was no care plan for Resident #20 related to corrective lenses.Review of the eye…

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, medical record review, and policy review, the facility failed to ensure orders for urostomy care were obtained and completed. This affected one (#25) of one resident reviewed for urostomy care. The census was 91.Findings include:Record review for Resident #25 revealed an admission date of 03/19/26. Diagnoses included chronic kidney disease, borderline personality, post-traumatic stress disorder, heart failure, and suicidal ideation. Review of the baseline admission assessment and baseline care plan dated 03/19/26 revealed Resident #25 was cognitively intact and used a device for ambulation. Resident #25 had a urostomy (an artificial opening which allows urine to urine to leave the body through a stoma (opening) in the abdomen) was in normal limits. The assessment did not identify a care plan and or interventions for the urostomy. Review of Resident #25's physician orders revealed an order dated 03/19/26 with a start date of 04/01/26 to change the urostomy bag every three days and as needed. There was an order dated 04/01/26 with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of a dialysis agreement, the facility failed to ensure ongoing assessments of a resident's condition and monitoring for complications before and after dialysis treatments were consistently completed. This affected one (#6) of one resident reviewed for dialysis. The facility census was 91. Findings include:Review of the medical record for Resident #6 revealed an admission date of 02/18/26. Diagnoses included end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, morbid (severe) obesity due to excess calories, schizoaffective disorder, bipolar type, anxiety disorder, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition, required supervision or touch assistance with eating, and was dependent on staff for bed mobility and transfers. The assessment also indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, medical record review, and review of the facility policy, the facility failed to ensure staff maintained proper infection control practice when providing care for residents in enhanced barrier precautions (EBP). This affected two (#5 and #33) of eight residents observed for EBP. The facility census was 91.Findings include: 1. Record review for Resident #5 revealed an admission date of 10/31/24. Diagnoses included obstructive and reflux uropathy, retention of urine, and chronic viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact. Resident #5 had an indwelling catheter and was dependent for personal hygiene.Review of the care plan dated 09/08/25 revealed Resident #5 required enhanced barrier precautions (EBP) related to the suprapubic catheter. Interventions included the use of appropriate EBP when performing resident care tasks including dressing, bathing, showering, transferring, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure a clean sanitary environment for Resident's #12, #13, #32, #33, #37, #44, #53, #56, #70, #74, #84, #89 and #92 who resided on the third floor nursing unit and failed to ensure phone calls to the facility were answered timely. This had the potential to affect all residents residing in the facility. The facility census was 93. Findings include: 1. Review of Resident #44's medical record revealed an admission date of 07/19/23 and diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, schizophrenia and unspecified dementia with other behavioral disturbance. Review of Resident #44's care plan dated 04/18/25 included Resident #44 had an ADL self-care performance deficit related to diagnoses. Resident #44 would maintain current level of function through the review date of 10/27/25. Interventions included Resident #44 was independent for toileting and 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, interview, record review, review of the facility Activity Calendar and review of facility policy the facility failed to ensure residents were provided activities as scheduled and failed to ensure Resident's #11, #33, #47 #67, and #82's care planned interventions were implemented for activities and activities were offered per their preferences. This had the potential to affect all the residents in the facility. The facility census was 93. Findings include: Review of Resident #67's medical record revealed an admission date of 04/05/25 and a readmission date of 06/19/25. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left dominant side, type two diabetes mellitus and schizoaffective disorder. Resident #67 resided on the second floor nursing unit. Review of Resident #67's electronic record from 06/01/25 through 06/26/25 did not reveal evidence Resident #67 had one-to-one activity participation or self-directed activity participation.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #19 and #43 received appropriate incontinence care timely. This affected two residents (Resident's #19 and #43) out of three residents reviewed for incontinence. The facility census was 93. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 04/17/12 and a readmission date of 01/06/15. Diagnoses included senile degeneration of the brain, Parkinson's Disease and paranoid schizophrenia. Review of Resident #43's care plan revised 10/07/24 revealed Resident #43 had bladder and bowel incontinence and was at risk for skin breakdown and urinary tract infections. Resident #43 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included staff would provide assistance with toileting and incontinence care as needed. Review of Resident #43's Quarterly 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, interview, record review and review of facility policy the facility failed to ensure Resident #19's physician orders and care planned interventions for enhanced barrier precautions were followed. This affected one resident (Resident #19) of two residents observed for enhanced barrier precautions. The facility census was 93. Findings include: Review of Resident #19's medical record revealed an admission date of 07/20/09 and diagnoses included unspecified dementia, anxiety disorder and adult failure to thrive. Review of Resident #19's physician orders revealed Enhanced Barrier Precautions related to feeding tube, every shift. Review of Resident #19's care plan revised 10/15/24 revealed Resident #19 required Enhanced Barrier Precautions related to feeding tube. To reduce the potential of spreading multi-drug resistant organisms daily. Interventions included use of appropriate Enhanced Barrier Precautions when performing the following including personal hygiene, toileting and peri care. 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 closed record review, facility policy review, and interview, the facility failed to report an incident of potential neglect involving Resident #93 to the State Agency as required. This affected one resident (#93) of nine residents reviewed for abuse and neglect. The facility census was 91. Findings include: Review of Resident #93's closed medical record revealed an original admission date of [DATE] with diagnoses of schizoaffective disorder, bipolar, dementia, anxiety, antisocial personality disorder, hallucinations and body dysmorphic order, and right leg above the knee amputation. Resident #93 had elected to be a full code (requiring full resuscitation efforts including cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). Resident #93 was transported to a local hospital where he was pronounced deceased on [DATE]. Review of Resident #93's care plan dated [DATE] revealed the resident had a self-care performance deficit for activities of daily living related to diagnoses 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of facility self-reported incidents (SRIs), policy review, and review of facility corrective action, the facility failed to ensure residents were free from resident-to-resident physical abuse. This affected five (#2, #20, #21, #22, and #23) of five residents reviewed for abuse. The facility census as 98. Findings Include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, dementia, and dysphagia. Review of the most recent comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and required extensive assistant for completing his activities of daily living (ADLs). 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses that…

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 Resident Council meeting minutes, the facility failed to ensure meals were served at an appropriate temperature and were palatable. This had the potential to affect all residents, except Resident #50 was what identified by the facility as receiving no food from the kitchen. The facility census was 101. Findings include: Observation on 11/12/24 at 12:35 P.M. of the lunch meal service with Licensed Practical Nurse (LPN) #241 revealed a lunch tray that contained of a plate of a red watery substance, a mixture of meat and beans and a bag of chips. LPN #241 stated she was unsure what the meal was and stated this is the slop they are often served. Further observation revealed a container of ice cream on the tray. LPN #241 removed the lid from the ice cream and revealed the ice cream was melted. LPN #241 verified the ice cream was melted and stated the residents often complained about the food and the small portions they received. Concurrent interview with Resident #71 and Resident #73 revealed the food was awful 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 and staff interview, the facility failed to ensure resident call lights were in working order and able to be reached by residents. This affected 14 residents (#41, #42, #43, #44, #63, #64, #80, #81, #83, #84, #89, #90, #91 and #92) of 14 residents observed for call lights. The facility census was 101. Findings include: Interview on 11/12/24 at 11:46 A.M. with Activities Aide (AA) #236 revealed she had observed short call light cords in some resident rooms. AA #236 stated she was unsure why the call light cords were shorter than others. Observation with AA #236 revealed call light cords, approximately two to three inches in length, were in Resident #89, Resident #90, Resident #91 and Resident #92's rooms. AA #236 verified the call light cords were not long enough to reach the residents if they were in bed. Continued observations with AA #236 revealed call lights were not functioning in Resident #80, Resident #81, Resident #83, Resident #84, Resident #89, Resident #90, Resident #91 and Resident #92's rooms and there was no evidence an alternative call light system…

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 resident interview, observation and staff interview, the facility failed to ensure a clean and sanitary environment. This affected two residents (#39 and #46) of three residents reviewed for environment. The facility census was 101. Findings include: 1. Interview on 11/12/24 at 8:59 A.M. with Resident #39 revealed there was water coming into his room from the ceiling and wall. The resident stated the leak had been going on for a few weeks. Resident #39 stated he he informed the Administrator and maintenance of the situation; however, it had not been fixed. Resident #39 stated staff placed towels and sheets down to soak up the water. Concurrent observation revealed a large puddle of water, with multiple sheets placed on the floor near the baseboard, in Resident #39's room. Additionally, Resident #39's sheets were odorous and had several brown and black stains. Resident #39 stated he could not recall the last time the sheets were changed. During the observation of Resident #39's room, Housekeeper (HSK) #321 entered and stated she had seen the water in the room for several…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure Resident #8 was free from resident-to-resident physical abuse by Resident #59. This affected one resident (#8) of three residents reviewed for abuse. The facility census was 104. Findings include: Review of the medical record for Resident #8 revealed an admission date is 10/06/23. Diagnoses included diabetes, dementia, muscle weakness, liver cancer, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. He required supervision for showering and personal hygiene and setup help for eating, oral hygiene, and toileting. He displayed no behaviors. Review of the progress note dated 02/18/24 at 3:21 P.M. revealed Resident #8 obtained several scratches on his face as the result of an altercation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #103 received an orderly discharge from the facility. This affected one resident (Resident #103) out of three residents reviewed for discharge. Findings include: Review of Resident #103's medical record revealed an admission date of 09/23/21 and diagnoses included quadriplegia, C5 through C7 incomplete, neuromuscular dysfunction of bladder, and neurogenic bowel. Review of Resident #103's care plan revised 11/02/22 included Resident #103 had an ADL (Activity of Daily Living) self-care performance deficit related to limited mobility due to quadriplegia, scoliosis and other diagnoses. Interventions included Resident #103 was dependent on staff for dressing, Resident #103 preferred to wear shoes and to make sure shoes were comfortable and not slippery. Review of Resident #103's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #103 was cognitively intact. Resident #103 was dependent…

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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, and record review the facility failed to fix a broken basement door lock to maintain safe environment. This had the potential to affect all 104 residents living in the facility. Findings include: Observation of the double basement doors on 01/24/24 at 10:30 A.M. revealed the doors were situated at ground level near the loading dock and provided access to the dumpsters. Both doors were unlocked. The open doors had potential to grant outsiders access into the facility with access to an elevator that led to residential floors specifically the second and fourth floors without a necessary security code. Interview on 01/24/24 at 10:46 A.M. with the Administrator who verified the basement door was not locked, and a code was not needed to use the basement elevator to reach residential floors. The Administrator stated the door had been open with outside access since March 2023. The Administrator further revealed that in the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review the facility failed to ensure falls were thoroughly investigated and failed to ensure safe smoking practices. This affected five residents (#43, #48, #58, #60, and #80) of seven residents reviewed for accidents. The facility census was 104. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 11/03/16. Diagnoses included schizoaffective disorder, vascular dementia, unspecified convulsions, and cataracts. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was rarely or never understood. He required substantial or maximum assistance for toileting, hygiene, and lower body dressing, partial assistance for upper body dressing, and supervision for eating. Review of the fall risk assessment dated [DATE] revealed Resident #43 was at high risk for falls. Review of the care plan dated 06/24/21 revealed Resident #43 was at risk for falls due to dementia, medication…

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, self-reported incident (SRI) review, and facility policy review the facility failed to follow their abuse policy regarding reporting allegations of abuse timely and thoroughly investigate all allegations of abuse. This affected three residents (#20, #48 and #50) of four residents reviewed for abuse. The facility census was 104. Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI…

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, self-reported incident review, and facility policy review the facility failed to report allegations of abuse to the state agency in a timely manner. This affected two residents (#20 and #50) of four residents reviewed for abuse. The facility census was 104. Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI tracking number 242461 dated 12/26/23 and timed 2:00 P.M. revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, self-reported incident review, and facility policy review the facility failed to ensure allegations of abuse were thoroughly investigated. This affected three residents (#20, #48, and #50) of four residents reviewed for abuse. The facility census was 104. Findings include: 1. Review of the medical record for Resident #20 revealed admission date of 01/07/22. Diagnoses Included quadriplegia, dysfunctional bladder, depression, history of falling, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact. She displayed no behaviors, hallucinations, or delusions. She used her walker to ambulate and required setup help for eating and oral hygiene. She required substantial or maximum assistance for upper body dressing and was dependent for toileting, showering or bathing, lower body dressing, and hygiene. Review of the facility SRI tracking number 242461 dated 12/26/23 and timed 2:00 P.M. revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure care plans were updated annually and as needed. This affected one resident (#43) of ten residents reviewed for accurate care plans. The facility census was 104. Findings include: Review of the medical record for Resident #43 revealed an admission date of 11/03/16. Diagnoses included schizoaffective disorder, vascular dementia, unspecified convulsions, and cataracts. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was rarely or never understood. He required substantial or maximum assistance for toileting, hygiene, and lower body dressing, partial assistance for upper body dressing, and supervision for eating. Review of the physician's orders for January 2023 revealed orders for Depakote sprinkles 125 milligrams (mg) by mouth (PO) two times per day (BID) for seizures beginning on 08/12/21, Melatonin tablet 6 mg PO at bedtime (HS) beginning 12/05/21, Medroxyprogesterone 10 mg PO…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to notify the physician of a radiology report for Resident #48 in a timely manner. This affected one resident (#48) of three residents reviewed for notification. The facility census was 104. Findings include: Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusions and used a walker and wheelchair to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent for showering and bathing, and required maximum assistance for hygiene. She had one fall with no injury and one with a major injury since the prior assessment. Review of the fall risk assessment dated [DATE] revealed Resident #48 was at a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure medical records were accurate and complete. This affected two residents (#48 and #63) of ten residents reviewed for assessments. The facility census was 104. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 08/05/23. Diagnoses included epilepsy, asthma, repeated falls, anemia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was rarely or never understood. She had no behaviors, hallucinations, or delusion and used a walker and wheelchair to ambulate. She required setup help for eating, oral hygiene, toileting, upper and lower body dressing, was dependent for showering and bathing, and required maximum assistance for hygiene. Review of the care plan dated 11/27/23 revealed Resident #48 was at risk for falls due to history of falling, seizures, and medication noncompliance. Interventions included a head-to-toe…

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

Based on observation, record review, policy review, review of job descriptions and interview the facility failed to ensure only qualified and competent licensed nursing staff completed resident skin assessments and failed to ensure all licensed nursing staff demonstrated the competency necessary to provide adequate and necessary skin and wound care. This affected seven residents (#9, #25, #31, #65, #37, #90 and #107) and had the potential to affect all 105 residents residing in the facility. Findings include: Review of the personnel file for Assistant Director of Nursing (ADON) Wound Care Nurse Licensed Practical Nurse (LPN) #201 revealed a hire date of 03/31/22. The LPN had also been noted to be responsible for wound care in the facility since hire (03/31/22). Review of the LPN's personnel file revealed no evidence of any type of additional training specific to wound care/wound management. Interview on 08/08/23 at 3:00 P.M. with the DON confirmed ADON Wound Care Nurse LPN #201 was hired in the position of ADON Wound Care Nurse. The DON verified the facility had no evidence of…

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

Based on record review, staff interview, and policy review, the facility failed to develop and implement action plans to improve performance and/or address concerns as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 105 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had no documentation regarding any performance improvement plans initiated to addressed identified concerns. Interview on 08/07/23 at 11:20 A.M. with the Administrator confirmed the facility had no information related to the performance improvement activity following concerns with skin assessments/wound care identified in March 2023 involving Resident #107 as part of their QAPI program. The facility provided information of counseling to two staff, LPN #208 and Assistant Director of Nursing (ADON) Wound Care Nurse Licensed Practical Nurse (LPN) #201 from March 2023 but no evidence of any other actions or skin/wound care improvement plan at that time. Interview on 08/08/23 at 8:20 A.M. with 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 and interview, the facility failed to develop and implement comprehensive care plans for skin integrity/wound care. This affected four residents (#107, #25, #9, and #37) of 10 residents reviewed for care planning. Findings include: 1. Review of Resident #107's closed medical record revealed an admission date of 11/02/22 and a discharge date of 03/10/23 with diagnoses including type two diabetes mellitus with diabetic neuropathy, hypertensive heart with chronic kidney disease with heart failure, muscle weakness, localized edema, age related cataract bilateral, and detachment of retina left eye. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/18/23 revealed Resident #107 was at risk for pressure ulcers but did not have any skin wounds. Review of the care plan for Resident #107 revealed no care plan was found in the medical record addressing Resident #107's risk for skin breakdown related to diabetes mellitus with diabetic neuropathy. Review of the progress notes dated…

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

Based on interview and record review the facility did not ensure Resident #48 received an annual dental exam. This affected one of three residents reviewed for dental. The facility census was 96. Finding Include: Review of the medical record for Resident #48 revealed an admission date of 07/27/21. Diagnoses included dementia and partial traumatic amputation of right forearm. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/16/22, revealed the resident had severely impaired cognition. Review of the physician's orders revealed an order for dental consult as needed on 07/28/21. Review of the medical record revealed Resident #48 had not had a dental exam. Interview on 10/31/22 at 12:30 P.M. with Resident #48's sister revealed the resident had not seen the dentist in quite a while and his teeth were a mess. Interview on 11/02/22 at 3:02 P.M. with the Director of Nursing confirmed Resident #48 did not receive any dental services and there had not been any refusals to see the dentist.

Based on observation, resident interview and staff interview the facility failed to ensure Resident #9's bathroom ceiling was in good repair. This affected one (Resident #9) of five residents reviewed for environment. The facility census was 96. Findings Include: Interview on 10/31/22 at 10:09 A.M. with Resident # 9 revealed the ceiling in Resident #9's bathroom had been leaking for a couple of weeks. The staff put a sign on her bathroom door to alert others of the leaking ceiling and to not use the bathroom. Observation on 10/31/22 at 10:12 A.M. of Resident #9's bathroom revealed water leaking from small holes in the ceiling tiles. The holes looked uniform in shape, as if made with a drill. Interview and observation on 10/31/22 at 1:05 P.M. with Maintenance Director (MD) #529 stated he was not aware Resident #9's bathroom ceiling had water leaking and he had been working at the facility for three months. MD #529 verified the sign on the bathroom door to not use the bathroom and verified the water leaking from the bathroom ceiling. MD #529 stated the leak was due to a leaky toilet…

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, resident interview and staff interview the facility failed to ensure resident rooms were free from infestation of gnats. This affected two (Resident #9 and #50) of five Residents reviewed for environment. The facility census was 96. Findings Include: 1. Interview on 10/31/22 at 10:09 A.M. with Resident #9 revealed her room had an infestation of gnats Resident #9 attributed to the leaking ceiling in her bathroom. Resident #9 stated staff knew about the bathroom ceiling and the gnats in her room. Observation on 10/31/22 at 10:10 A.M. of Resident #9's room revealed gnats flying in her room and in bathroom. 2. Interview on 10/31/22 at 10:32 A.M. with Resident #50 stated he had been having problems with gnats in his room for months and the gnats were coming out of the sink in his room. Resident #50 stated he told staff he had gnats in his room. Observation on 10/31/22 at 10:33 A.M. of Resident #50's room revealed gnats flying in his room, gnats on the mirror, walls and in sink there was a collection of several gnats around the sink drain. There were also some gnats…

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

Based on observation, record review and interview the facility failed to ensure food items were properly stored in the kitchen and in the nursing unit refrigerators to prevent contamination and/or food borne illness. The facility also failed to maintain the nursing unit refrigeration in a sanitary condition to prevent contamination. This had the potential to affect all residents residing in the facility who received meal trays with the exception of Resident #13 and #123 who received nothing by mouth. The facility census was 126. Findings include: 1. On 12/15/19 from 8:41 A.M. to 8:59 A.M. a tour of the kitchen with Dietary Staff (DS) #370 revealed in the walk-in cooler on the middle shelf was a medium sized steam table pan of chicken without a label or date. Next to it was a small steam table container of what appeared to be gravy without a label and date, and on the bottom shelf of same rack a large white tub of what appeared to be soup, whitish in color also without a label or date. Observation of bread rack revealed an opened bag of hotdog buns that had a hole created in the top…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review the facility failed to implement a surveillance plan to identify, track, monitor and/or report infections, failed to initiate contact isolation procedures timely for Resident #105, failed to ensure Registered Nurse (RN) #404 applied gloves prior to a treatment to Resident #132's peripherally inserted central catheter (PICC) line and failed to implement linen/laundry precautions to prevent the spread of infection. This affected two residents (#105 and #132) and had the potential to affect all 126 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE] with diagnoses including severe chronic kidney disease, spastic hemiplegia affecting left non-dominant side. He was admitted to Hospice services on 06/24/19. Review of the nurse's progress note dated 12/07/19 at 11:17 P.M. indicated Resident #105 had a scab with a puss filled bump on his nose and swelling 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, interview and policy review the facility failed to ensure each resident received adequate supervision to prevent accidents related to smoking safety. This affected five residents (#40, #69, #71, #110 and #122) of six residents reviewed for accidents of 43 residents identified as smokers who resided on the two of four unsecured floors of the facility. Findings include: 1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including diabetes with neuropathy, chronic obstructive pulmonary disease, nicotine dependence, schizoaffective disorder bipolar type, major depressive disorder recurrent and acquired absence of left leg below knee. Review of the plan of care dated 05/15/19 for Resident #40 included the potential for injury due to smoking habit. The goal included to provide Resident #40 and family information/education regarding the facility smoking policy. Interventions included Resident #40 will have supervision while…

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

Based on observation, staff interview and facility insulin storage instructions revealed the facility failed to ensure insulin storage guidelines were followed. This affected five residents (#40, #82, #89, #102 and #112) of 17 residents receiving insulin on 100 and 400 halls. The facility census was 126. Findings include: Observation on 12/16/19 at 9:50 A.M. with Licensed Practical Nurse (LPN) # 413 of insulin stored in the fourth floor medication cart and in refrigerator revealed Resident #82 had a Humulin (Intermediate acting insulin) vial with an open date of 10/22/19, Resident #89 had a Lantus (long acting insulin) vial with an open date of 11/07/19, Resident #112 had Humalog (rapid acting insulin) vial with an open date of 11/07/19 and a Basaglar (long acting insulin) KwikPen with an open date of 10/22/19. Interview on 12/16/19 at 10:10 A.M. with LPN #413 verified the Basaglar, Lantus and Humalog had an expiration date of 28 days after being opened and the Humulin had an expiration date of 42 days after being opened. LPN #413 verified the above insulin vials/pen were past their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide Resident #49 double entrée as ordered. The facility failed to use the correct scoop sizes for the pureed diet during observation of the tray line for residents. The facility also failed to serve the appropriate meal for the residents who had orders for renal diets also during observation of the tray line. This affected one resident (#49) of four residents (#44, #49, #69, and #110) reviewed for double portions, three residents (#106, #129, and #133) of three residents who received a pureed diet and five residents (#41, #43, #85, #100, and #112) of five who received a renal diet. Findings include: 1. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dysphagia, and history of cachexia (weakness and wasting of the body due to severe chronic illness). The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/14/19 revealed Resident #49 had intact cognition…

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

Based on observation, record review and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for all residents. This affected five residents (#62, #86, #90, #99 and #126) of 126 residents residing in the facility. Finding include: Observation on 12/15/19 at 10:53 A.M. of Resident #90's floor mat next to bed revealed it was dirty and covered with multiple stains. Interview on 12/15/19 at 10:56 A.M. with Licensed Practical Nurse (LPN) #345 verified the stain on the mat and stated it was housekeeping staff responsibility to clean. Interview on 12/15/19 at 11:10 A.M. with Housekeeper #371 revealed she will sweep the room but was not sure who was responsible for scrubbing the mats on the floor. Review of the facility undated policy titled Housekeeping revealed resident room furnishings were to be clean and free of odors and stains. An environmental tour conducted on 12/18/19 at 1:48 P.M. with Maintenance Director #336 revealed the following concerns which were verified at the time of the observation: a. Observation of Resident #62's room…

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 promote a dignified dining experience for Resident #129 as State Tested Nursing Assistant (STNA) #409 was observed standing to provide feeding assistance to the resident. This affected one resident (#129) of six residents the facility identified as requiring feeding assistance on the fourth floor. Findings include: Record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia and muscle weakness. Record review revealed Resident #129 had a care plan initiated on 08/14/18 for Activities of Daily Living (ADLs) self-care performance deficit related to hemiplegia. Interventions included Resident #129 required extensive to total staff participation to eat. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #129 had impaired cognition and required extensive assistance of one staff for eating. On 12/15/19 at 12:21 P.M. observation of the lunch…

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 timely notify Resident #82 and Resident #120's physician of significant weight loss. This affected two residents (#82 and #120) of seven residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including disease of the pancreas, malignant neoplasm of the pancreatic duct and dysphagia. Review of Resident #82's care plan initiated on 08/07/19 revealed Resident #82 was on a therapeutic diet with risk for weight loss and nutritional risk related to altered nutritional needs, body composition and nutritionally relevant diagnoses of edema, cancer, diabetes type II, and pancreas disease. Interventions included the dietitian to evaluate and make diet change recommendations as needed. The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/06/19 revealed Resident #82 had intact cognition, required supervision of one staff for eating and received a therapeutic diet.…

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

Based on observation, record review and interview the facility failed to revise Resident #13's plan of care related to nutrition/hydration following orders for the resident to receive nothing by mouth. This affected one resident (#13) of one resident reviewed for tube feeding. Findings include: Review of the medical record for Resident #13 revealed an admission date of 07/03/19 with diagnoses including malignant neoplasm of oropharynx and larynx and dementia. Review of the current plan of care, dated 10/22/19 revealed the resident had altered nutritional status due to malignant neoplasm of oropharynx/larynx. Interventions included flushes via enteral feeding only, monitor by mouth intake, provide extra gravy on meats/entrée to aid in safe swallowing, prescribed diet is regular with extra gravy, provide dietary supplements as ordered (boost). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/02/19 revealed the resident had impaired cognition. The resident required supervision for eating. The assessment indicated the resident had a percutaneous endoscopic…

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 timely initiate nutritional interventions following Resident #82 and #120's significant weight loss and Resident #90's nutrition recommendations from dialysis. This affected three residents (#82, #90, and #120) of seven residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including disease of the pancreas, malignant neoplasm of the pancreatic duct and dysphagia. Review of Resident #82's care plan initiated on 08/07/19 revealed Resident #82 was on a therapeutic diet with risk for weight loss and nutritional risk related to altered nutritional needs, body composition and nutritionally relevant diagnoses of edema, cancer, diabetes type II, and pancreas disease. Interventions included the dietitian to evaluate and make diet change recommendations as needed. The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/06/19 revealed Resident #82 had intact cognition,…

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

Based on observation, record review, interview and policy review the facility failed to assess, educate and monitor Resident #13 while independently administering enteral (tube) feed and other fluids. This affected one resident (#13) of three residents who received enteral feeding. Findings include: Review of the medical record for Resident #13 revealed an admission date of 07/03/19 with diagnoses including malignant neoplasm of oropharynx and larynx and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/02/19 revealed the resident had impaired cognition. The resident required supervision for eating. The assessment indicated the resident had a percutaneous endoscopic gastrostomy (peg tube or feeding tube). Review of the nutrition note dated 11/08/19 revealed the resident had new orders for nothing by mouth (NPO). The enteral feeding order recommendations were Isosource (nutritional supplement) 1.5 calories (kcal) continuous feed via peg tube at 45 milliliter per hour (ml/hr.), which provided 1620 kcal a day. Current weight 150.5 pounds (lbs.). 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.