Harvard Gardens Rehabilitation & Care Center

Based on observation and staff interview, the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all 107 residents residing in the facility. The facility census was 107.Findings include: Observation of the dumpster area on 02/23/26 at 8:00 A.M., upon entering the facility, revealed two dumpsters were overflowing with trash piled approximately two to three feet high. Further observation revealed three of the four dumpster lids were open.Interview and observation on 02/23/26 at 9:16 A.M. with Dietary Manager (DM) #525 verified the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, business records review, and staff interview, the facility failed to ensure final accounting and conveyance of resident funds was completed within 30 days upon death. This affected three (#126, #127, and #128) of three residents reviewed for final conveyance of trust accounts. The facility census was 107.Findings include:1. Review of the medical record revealed Resident #126 was admitted to the facility on [DATE]. Resident #126 expired at the facility on [DATE].Review of the business records for Resident #126 revealed a check for Resident #126's personal funds balance remaining at the facility in the amount $1,1179.30 was dispensed on [DATE] to the states Medicaid recovery bureau.2. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE]. Resident #127 expired at the facility at the facility on [DATE].Review of the business records for Resident #127 revealed a check for Resident #127's personal funds balance remaining at the facility in the…

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

Based on observation and staff interview, the facility failed to ensure the physical environment was maintained in a clean, sanitary, and homelike manner. This affected 28 (#17, #34, #37, #38, #39, #43, #47, #50, #52, #53, #54, #58, #63, #64, #74, #77, #81, #83, #86, #87, #90, #92, #98, #99, #104, #107, #141, and #162) of 107 residents residing in the facility. The census was 107. Findings Include:1. Observation of Resident #64's room on 02/25/26 at 11:46 A.M. revealed no bathroom door was present.Interview with Licensed Practical Nurse (LPN) #634 on 02/26/25 at 11:50 A.M. verified the lack of a bathroom door in Resident #64's room.2. Observation of the facility environment with Housekeeping Director #700 on 02/26/26 between 1:15 P.M. and 1:45 P.M. revealed the air vent in Resident #50's room was heavily rusted; the privacy curtains in Resident #39, Resident #52, Resident #58, Resident #63, Resident #77, Resident #87, Resident #92, and Resident #107's rooms were visibly stained; the tile flooring in Resident #99 and Resident #162's room contained unidentified substance on the floor…

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 accurately code resident Minimum Data Set (MDS) assessments. This affected nine (#11, #29, #32, #52, #53, #62, #64, #87, and #102) of 24 residents reviewed for MDS assessment accuracy. The facility census was 107.Findings include:1. Review of the medical record for Resident #29 revealed the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and major depressive disorder. Review of the level two Preadmission Screening and Resident Review (PASRR) evaluation dated 03/21/07 revealed Resident #29 had a level two serious mental illness. Review of Resident #29's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility answered, No, to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 2. Review of the medical record revealed Resident #32…

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 residents needs and preferences were met regarding appropriate linens on beds and maintaining bathing equipment for use to accommodate resident preference. This affected two residents (#105 and #22) of 13 residents reviewed for accommodation of needs. The facility census was 107.Findings include:1. Record review for Resident #105 revealed an admission date of 10/24/24. Diagnoses included dislocation of an unspecified knee, morbid severe obesity, and encounter for orthopedic aftercare. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact. Resident #105 had impairment on one side of the lower extremities, used a wheelchair for mobility, required set up or clean up assist with toileting hygiene, supervision or touch assist with personal hygiene, and partial/moderate assist with bed mobility and transfers. 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 medical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after hospice services were discontinued for one resident (#3) of three residents reviewed for hospice services. The facility census was 107.Findings include:Record review for Resident #3 revealed an admission date of 07/19/19. The resident had a diagnosis of benign prostatic hyperplasia. Record review revealed a hospice order dated 10/23/24 to admit Resident #3 to hospice services.Review of the progress note dated 11/14/25 at 12:11 P.M., completed by Licensed Practical Nurse (LPN) #543, revealed Resident #3 was transferred to the hospital via stretcher with two paramedics and hospice was aware.Review of the progress note dated 11/25/25 at 3:16 P.M., completed by LPN #552, revealed Resident #3 returned from the hospital. Resident #3 was admitted for hypernatremia, urinary tract infection, and aspiration pneumonia. Record review revealed a hospice order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, medical record review, and facility policy, the facility failed to develop and effective means of communication for a resident who spoke limited English to ensure the resident was able to effectively communicate requests and needs. This affected one (#89) of 24 residents interviewed for the provision of care. The facility census was 107.Findings include:Review of Resident #89's medical record revealed an admission date of 07/17/25. Diagnoses included age-related osteoporosis with pathological fracture, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure and alcohol abuse. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severely impaired cognition and required maximum assistance and cuing for all activities of daily living.Observation and interview with Resident #89 on 02/23/26 at 9:35 A.M. revealed the resident had difficulties in…

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, medical record review, and staff interview, the facility failed to label, date, or initial supplemental tube feeding containers to notify when the supplement was hung and by which staff as ordered. This affected one (#70) of two residents reviewed for tube feedings. The census was 107.Findings include:Review of the medical record for Resident #70 revealed an admission date of 12/09/25. Diagnoses included dysphagia, severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction.Review of Resident #70's active physician orders for February 2026 identified orders to change the feeding administration set with each new bottle; label the formula container, syringe, and administrative set with the resident's name, date, time, and the nurse's initials.Observation on 02/23/26 at 11:01 A.M. revealed Resident #70's tube-feeding container was hung but not labeled, dated, or initialed.Interview on 02/23/26 at 11:01 A.M. with Registered Nurse (RN) #571 verified Resident #70's tube feeding container was not labeled, dated, or initialed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure a resident had active orders for use of supplemental oxygen. This affected one (#53) of one residents reviewed for respiratory care. The census was 107.Findings include:Review of the medical record for Resident #53 revealed an admission date of 12/30/15 with diagnoses including paranoid schizophrenia, dyskinesia, asthma, respiratory failure, anxiety, dyskinesia, and nicotine dependence.Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact.Observation and interview of Resident #53 on 02/23/26 at 1:12 P.M. revealed an oxygen concentrator was turned on in the room and set to four liters per minute flow rate. When asked about the usage of his oxygen, Resident #53 stated he wore the oxygen intermittently for shortness of breath or after smoking outside. Resident #53…

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 and staff interview, review of medication administration audit reports, and review of a facility policy, the facility failed to ensure pain medications were administered as ordered to effectively manage a resident's pain. This affected one (#11) of seven residents reviewed for medication administration. The facility census was 107.Findings include:Record review for Resident #11 revealed an admission date of 10/30/25. Diagnoses included pain in the left hip; unilateral primary osteoarthritis, left knee; intervertebral disc degeneration; lumbar back pain; and pain in the right foot.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact and had pain frequently.Review of the care plan for Resident #11 dated 11/03/25 revealed Resident #11 was at risk for back pain, fatigue, anxiety, and bone pain. An intervention included to administer medications as prescribed.Review of the physician orders for January and February 2026…

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 and staff interview, and facility policy review, the facility failed to ensure residents were seen by a physician in a timely manner as required. This affected one (#89) of 24 sampled residents reviewed for physician visits. The facility census was 107.Findings include:Review of medical record for Resident #89 revealed an admission date of 07/17/25 with diagnoses including osteoporosis, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse.Review of Resident #89's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. Review of provider notes from 07/17/25 to 02/27/26 revealed only one visit note by the facility physician. The physician admission note for Resident #89 was not conducted until 10/15/25 which was almost three months after initial admission to facility and no follow…

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 facility policy review, the facility failed to ensure timely dental care was provided to address resident needs. This affected one (#89) of 24 sampled residents observed for dental concerns. The facility census was 107.Findings include:Review of the medical record for Resident #89 revealed an admission date of 07/17/25 with diagnoses including osteoporosis with pathological fracture, adult failure to thrive, protein-calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse.Review of Resident #89's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. Review of the care plan dated 12/16/26 revealed goals and interventions for Resident #89's dental problems related to missing teeth. Interventions included daily oral hygiene, notification to the provider with complaints of pain or…

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 facility policy review, the facility failed to ensure complete and accurate documentation was maintained in resident medical records. This affected three (#2, #6, and #14) of four residents reviewed for accuracy of documentation. The facility census was 107.Findings include:1. Record review for Resident #6 revealed an admission date of 03/24/14. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease, contracture of muscle, and muscle weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 had impairment to one side of the upper and lower extremities and was dependent for upper and lower body dressing. Review of the care plan for Resident #6 dated 12/31/25 revealed Resident #6 had the potential for alteration in skin integrity related to impaired mobility and decreased functional ability. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure infection control practices were maintained for residents on enhanced barrier precautions and proper cleaning of bodily fluids was completed. This affected two (#1 and #99) of seven residents reviewed infection control practices. The facility census was 107.Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms, bacteremia, and retention of urine. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was mildly cognitively impaired. Resident #1 had an indwelling catheter and required substantial/maximal assistants with toileting hygiene. Review of the care plan for Resident #1 dated 10/28/25 revealed the had a need for a urinary (Foley) catheter related to urinary retention. An interventions included to document the urinary output. 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 interview, record review, and policy review, the facility failed to ensure Resident #10's responsible party was notified of a change in condition and transfer to hospital. This affected one resident (Resident #10) of three residents reveiwed for change in condition. Findings include: Review of Resident #10's medical record revealed an admission date of 11/03/23 and a re-entry date of 03/21/25. Resident #10's diagnoses included malignant neoplasm of the pancreas, drug-induced polyneuropathy, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the right dominant side. Review of Resident #10's care plan revised 12/11/24 included Resident #10 needed assistance for ADL's related to cancer, bronchitis, asthma and other diagnoses. Resident #10 was able to ambulate on and off the unit, was alert and oriented times three (time, place, person), was able to voice needs and was able to perform ADL's independently and might require assistance during times of fatigue.…

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

Based on medical record review, review of personnel files, review of witness statements, interviews, and review of facility policy, the facility failed to prevent staff to resident verbal abuse. This affected one resident (#28) of three reviewed for respect and dignity. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his behavior was unacceptable, evaluate if behavior was a result of cognitive impairment,…

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

Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to effectively implement their policy on abuse in regard to the timely reporting of an allegation of abuse and conducting a thorough investigation of an allegation of abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care.…

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

Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to report an allegation of staff to resident verbal abuse to the proper authorities. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his…

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

Based on medical record review, review of personnel files, review of witness statements, interviews, review of the facility's self-reported incidents (SRIs), and review of facility policy, the facility failed to conduct a thorough investigation of an allegation of staff to resident verbal abuse. This affected one resident (#28) of one reviewed for abuse. The facility census was 87. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/20/23 with diagnoses including hypertension, alcohol induced persisting dementia, dementia with agitation, violent behavior, anxiety disorder, anterograde amnesia, insomnia, and heartburn. Review of the behavior care plan, revised 08/29/24, indicated Resident #28 did not conform to the boundaries of socially acceptable behaviors because he would take bowel movements and place them in drawers and cabinets, go in and out of rooms and turn the water on and off, and have episodes of refusing personal and incontinence care. Interventions included discuss with resident in a straight-forward yet kind manner that his…

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 #31's incontinence care was provided timely. This affected one resident (Resident #31) out of three residents reviewed for incontinence care. The facility census was 87. Findings include: Review of Resident #31's medical record revealed an admission date of 08/01/14 and diagnoses included Alzheimer's Disease, anxiety disorder and type two diabetes mellitus. Review of Resident #31's care plan revised 02/11/25 included Resident #31 was incontinent of bowel and, or bladder. Resident #31 refused care at times and was not a candidate for a toileting program. Resident #31 would be free of skin breakdown related to incontinence. Interventions included to change Resident #31 every two hours and as needed; provide incontinence care and apply barrier cream after each incontinent episode. Review of Resident #31's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 did not have a…

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

Based on observation, interview and review of the facility policy, the facility failed to assure expired medications were removed from the medications used for resident consumption. This had the potential to affect all 96 residents residing at the facility. Findings include: Observation on 02/10/25 at 6:30 P.M. with Licensed Practical Nurse (LPN) #416 of the South Medication Storage Room revealed a container of promethazone hydrochloride tablets 50 milligrams (mg) with an expiration date of 10/24/24, bisocodyl suppositories (six of 12 remaining) with an expiration date of January 2025, an additional box of bisocodyl suppositories (eight of 12 remaining) with an expiration date of January 2025, a Trulicity pen with the expiration date of 01/17/25, a humulog insulin pen with an expiration date of 12/20/24, deep sea nasal spray with an expiration date of January 2025, and two bottles of omeprazole 20 mg with an expiration date of January 2025. LPN #416 verified the expired medications and confirmed they were stored with medications used for residents. Observation on 02/13/25 at 12:23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the manufacturer instructions, and review of the facility policy, the facility failed to maintain appropriate infection control practices when obtaining blood glucose levels via a glucometer. This affected three (Residents #83, #156 and #52) of three residents observed for blood sugar assessments via glucometer and had the potential to affect an additional 19 residents, Resident #2, #4, #7, #8, #11, #19, #24, #27, #28, #34, #36, #41, #61, #66, #72, #73, #105, #153, and #154 who were identified by the facility as receiving blood sugar checks via glucometer. In addition the facility failed to have a complete water management plan in place. This had the potential to affect all residents. The facility census was 96. Findings include: 1. Medical record review for Resident #83 revealed an admission date of 01/06/25. Diagnosis included diabetes mellitus due to underlying condition with diabetic amyotrophy. Review of the care plan dated 01/07/25 revealed 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 interview and record review, the facility failed to ensure resident concerns documented in the Resident Council Meeting Minutes for November and December 2024 were not altered or removed and failed to ensure concerns from the group meetings were acted upon. This affected Resident #2, #7, #16, #17, #19, #24, #30, #34, #42, #47, #51, #58, #61, #71, #72, #74, #76, #78, #95, #152, #155 and #160 who attended resident council meetings and/or expressed concerns related to call light response. This affected 21 of 96 facility residents and had the potential to affect all residents. Findings include: 1. Review of Resident Council minutes provided by the Administrator from 01/05/24 through 12/20/24 revealed Resident Council meetings were held monthly. Resident #7 was the Resident Council President from 01/05/24 through 12/20/24. Review of the Resident Council minutes provided by Former Activity Director (FAD) #650 revealed three copies dated 11/29/24. The first copy under new concerns for nursing revealed the concerns were call light and under call light was an additional concern:…

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

Based on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected two residents (62 and #107) of three residents (#62, #106, and #107) reviewed for appropriate beneficiary notices. The facility census was 96. Findings include: 1. Review of the beneficiary notice worksheet provided by the facility during the annual survey revealed Resident #62 was discharged from skilled therapy services while using his Medicare Part A benefit on 09/03/24 and remained in the facility. Review of the notices provided to Resident #62 upon discontinuation of skilled services revealed a Notice of Medicare Non-coverage (NOMNC) signed by the resident representative on 09/10/24. There was no Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) provided as required. 2. Review of the beneficiary notice worksheet provided by the facility during the annual survey revealed Resident #107 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 interview, record review, and review of the facility policy, the facility failed to conduct a quarterly care plan meeting for one resident, Resident #2, of three residents reviewed for care plan meetings. The facility census was 96. Findings include: Medical record review for Resident #2 revealed an admission date of 10/18/17. Diagnoses included hemiplegia affecting left nondominant side, type two diabetes mellitus, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had no impairment of the upper extremities, impairment on both sides of the lower extremities, and used a wheelchair for mobility. Review of Resident #2's medical record from 01/01/24 through 02/10/25 revealed no documentation of care plan meetings scheduled or held. Interview on 02/11/25 at 9:33 A.M. with Resident #2 revealed she was only invited to care plan meetings once a year. Interview on 02/12/25 at 1:22 P.M. with Licensed Social Worker…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident #2 received range of motion and a palm guard or carrot after receiving therapy services for a left hand contracture. This affected one resident (Resident #2) of one resident reviewed for contractures. The facility census was 96. Findings include: Medical record review for Resident #2 revealed an admission date of 10/18/17. Diagnosis included hemiplegia affecting left nondominant side. Review of the care plan revised 07/25/24 revealed Resident #2 needed assistance for activities of daily living related to left hand contracture, and impaired mobility. Interventions included left hand carrot orthosis six to eight hours per day as tolerated. An additional care plan for Resident #2 updated 11/07/24 revealed Resident #2 had a contracture post cerebrovascular accident (CVA) to her left hand. Interventions included range of motion as tolerated to the site. Review of the quarterly 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.

Based on observation, interview, and record review, the facility failed to ensure the hydration needs of Resident #156 were met when water flushes were not administered via a percutaneous endoscopic gastrostomy (PEG) tube per the physician orders. This affected one of one resident reviewed for tube feedings, Resident #156. The facility census was 96. Findings include: Medical record review for Resident #156 revealed an admission date of 02/03/25. Diagnosis included malignant neoplasm of oropharynx. Review of the progress notes dated 02/03/25 timed 10:25 P.M. authored by Licensed Practical Nurse (LPN) #640 revealed Resident #156 was alert and oriented to person, place, and month. Resident #156 received tube feeding via PEG tube. Resident #156 received nothing by mouth (NPO). Review of Resident #156's physician orders revealed an order dated 02/04/25 for enteral feed every four hours flush with 120 milliliters (ml) water every four hours. An order dated 02/05/25 indicated enteral feed every shift of Isosource HN 60 ml continuously. Observation of Resident #156's tube feeding pump on…

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

Based on record review and interview the facility failed to ensure pharmacy recommendations were addressed. This affected one resident (#86) of five residents (#53, #69, #84, #86, and #156) reviewed for unnecessary medications. The facility census was 96. Findings include: Review of the medical record for Resident #86 revealed and admission dated of 03/16/24. Diagnoses included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and major depressive disorder, recurrent and moderate. Review of the physician orders for February 2025 revealed active orders for quetiapine fumarate (antipsychotic) oral tablet 25 milligrams (mg). Give two tablets by mouth two times a day related to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Pharmacist's Recommendation to Prescriber forms dated 04/04/24 and 01/15/25 revealed a request to clarify/document the approved diagnosis to justify use of quetiapine and update order in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure call lights were easily accessible and consistently in good working order. This affected five residents (#6, #7, #154, #155, and #156) of five residents reviewed for call lights. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/03/24. Diagnoses included osteoarthritis, paranoid schizophrenia, anxiety disorder, and presence of cardiac pacemaker. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition and required supervision or touching assistance with chair/bed to chair transfer, partial or moderate assistance with toilet transfer, and used a wheelchair. Interview on 02/11/25 at 11:37 A.M. with Resident #6 revealed he pressed his call light and was waiting for staff to assist him to bed. Resident #6 stated he had been waiting for 15 minutes and no one had responded. Resident #6 stated this happened a lot. Observation at the time…

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

Based on observation, interview, and policy review, the facility failed to serve food in a manner to protect it from contamination. This had the potential to affect all residents residing in the facility. The census was 96. Findings include: Observations of tray line on 01/06/25 at 4:33 P.M. revealed two fans running on high speed, one fan was facing the dishwasher, the other was facing the tray line. A layer of brownish/black dust was covering both fans. Interview during the observation with Dietary Manager #210 verified the build of dirt/dust on the fans. Further interview revealed all facility residents consumed food prepared in the kitchen. Review of the undated facility policy titled Nursing Home Kitchen Cleanliness revealed daily tasks included cleaning and sanitizing countertops, stovetops, and food preparation surfaces, washing dishes, utensils, and kitchen equipment, and sweeping and mopping kitchen floors. Weekly tasks involved deep cleaning refrigerators and freezers, cleaning and sanitizing kitchen storage areas, and checking and cleaning vents and exhaust systems.…

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

Based on record review, observation and interviews, the facility failed to ensure a well maintained and comfortable environment. This affected seven (Residents #4, #6, #31, #38, #40, #58, and #86) of 29 residents residing on the second floor. Findings include: Review of the medical record for Resident #4 revealed an admission date of 05/30/24. Diagnoses included vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/15/24, revealed Resident #4 had intact cognition and was independent with activities of daily living (ADL). Review of the medical record for Resident #6 revealed an admission date of 06/16/23. Diagnoses included bipolar disorder, psychotic disorder with delusions, and schizophrenia. Review of the quarterly MDS assessment, dated 11/03/24, revealed Resident #6 had intact cognition and required maximum assistance with ADLs. Review of the medical record for Resident #31 revealed an admission date of 11/15/24. Diagnoses included schizophrenia, unspecified and obesity. Review of the quarterly MDS assessment, dated…

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

Based on record review, observations, policy review and interview, the facility failed to serve palatable meals at an appropriate temperature. This affected 11 (Resident #7, #20, #47, #53, #62, #64, #67, #69, #72, #76 and #82) of 96 residents residing in the facility. Findings include: Interviews on 01/02/25 at 8:30 A.M. with Residents #62, #64, #72, and #82 revealed the food was always cold. Resident #72 stated the food was horrible and cold. Observations of tray line on 10/02/24 at 4:20 P.M. noted staff preparing to plate the dinner meals which consisted of ravioli, mixed vegetables, hamburgers, mashed potatoes and bread sticks. Temperatures of the food obtained before plating revealed the regular ravioli was 138 degrees Fahrenheit (F), the mixed vegetables were 158 degrees F, hamburgers were 152 degrees F, puree ravioli was 123 degrees F, and the renal ravioli was 111 degrees F. A test tray was requested and left the kitchen at 4:40 P.M. The test tray arrived on the North one unit at 4:41 P.M. Certified Nursing Assistant (CNA) #202 and Unit Manager #212 immediately began passing…

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, interview, and facility policy review, the facility failed to ensure Resident #51was seen my a physician least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. This affected one resident (#51) of the three residents reviewed for physician visits. The facility census was 92. Findings include: Review of the medical record for Resident #51 revealed an admission date of 02/05/24 with diagnosis including vascular dementia, depression, epilepsy, atrial fibrillation, anxiety, hypertension, heart failure, and hemiplegia. Review of the practitioner's progress notes dated 02/07/24 revealed a New admission History and Physical was conducted by a virtual visit by Physician #348 for Resident #51. Review of medical record progress notes revealed no visits were made by a general practitioner after 02/07/24 until 05/08/24. Review of practitioner's progress note revealed the last general practitioner note was written on 05/08/24. The was no evidence of a general practitioner visit for Resident #51 after 05/08/24. Review of the…

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

Based on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary manner. In addition, the facility did not ensure that food was plated to be served in a sanitary manner. This had the potential to affect all 94 residents receiving food from the kitchen. There were no residents residing in the facility not receiving food from the kitchen. Findings Include: Observation on 02/21/24 at 10:05 A.M. a tour of the kitchen was conducted with the Director of Nursing (DON). The floor had dirt and food buildup. There was also a buildup of dirt under the steam table where food was served from. The dirty floor was verified with the DON at the time of the tour. The inside of the drawer holding the serving and cooking utensils had dirt and grease buildup. The surface of the drawer had a greasy texture. The DON verified the dirty utensil drawer at the time of the kitchen tour. Dietary Manager (DM) #118 was observed packing brown bag lunches for dialysis residents. DM #118 did not have a hairnet on. The DON verified the absence of the…

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

Based on observation, interview and review of cleaning schedules, the facility did not ensure residents were sitting in clean wheelchairs. This affected four residents (#14, #15, #29 and #47) out of 66 residents utilizing wheelchairs. The facility census was 94. Findings include: On 02/21/24 between 10:00 A.M. and 12:00 P.M. during the tour of the facility, Residents #14, #15, #29 and #47 were observed to be sitting in wheelchairs. Each chair had a buildup of dirt on the frame. Interview with the Director of Nursing (DON) verified the dirt buildup on each wheelchair at the time of the tour. Interview on 02/21/24 during the tour, the DON stated that wheelchairs were to be cleaned two times weekly. A review of the cleaning schedule revealed wheelchairs were to be cleaned two times weekly on Monday and Wednesday on night shift. This deficiency represents noncompliance investigated under Complaint Number OH00151189.

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 interview, schedule review, and policy review the facility did not ensure sufficient nursing staff to provide nursing and related services to assure resident safety when two of four nurses left the building for lunch at 12:00 A.M. on 02/05/24 and did not return until 4:30 A.M. (4.5 hours). This had the potential to affect 37 residents (#2, #3, #4, #7, #10, #12, #13, #11, #18, #19, #28, #30, #34, #38, #44, #47, #49, #50, #52, #54, #53, #56, #57, #60, #62, #66, #70, #71, #76, #80, #81, #86, #88, #89, #93, #91, and #97) residing on the units assigned to the two nurses. The facility census was 94. Findings Include: A review of the facility assessment dated [DATE] revealed the facility will be staffed with three to four nurses per shift. A review of staffing sheets dated 02/04/24 revealed Licensed Practical Nurse (LPN) #234 was scheduled from 7:00 P.M. until 7:00 A.M. the following day…

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 Resident #54 received meals according to documented food preferences. This affected one resident (#54) of three residents investigated for food preferences. The facility census was 94. Findings Include: Record review for Resident #54 revealed an admission date of 02/05/24 with diagnoses including vascular dementia, depression, epilepsy, anxiety, diabetes mellitus type II, and hemiplegia following a cerebral vascular accident (CVA). Resident #54's diet orders included a regular diet with low concentrated sweets. Review of a dietary admission note dated 02/15/24 included Resident #54 disliked pork and ground meat. Review of the nurse practitioner notes dated 02/19/24 revealed Resident #54 does not eat pork or beef. The nurse practitioner instructed nursing to inform the kitchen. Interview with the Director of Nursing (DON) on 02/22/24 at 9:00 A.M. revealed resident food preferences were honored. On 02/22/24 at 9:30 A.M. an interview with Director of Dietary Services #118 revealed resident food preferences were honored,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #100) of one resident reviewed for elopement. The facility census was 99. Findings include: Review of the medical record for Resident #100 revealed an admission date of 11/30/23 with diagnosis including diabetes mellitus, depression and COVID-19. His medical record contained a photograph so that he was identifiable to staff. He was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #100 had impaired cognition. Review of Resident #100's Skilled Nursing Summary dated 12/27/23 revealed the resident's gait was unsteady, had a balance problem, and required ambulatory assistance of one. Review of Resident #100's plan of care revealed the resident had impaired cognitive process for daily decision making and was at risk for further decline in cognitive status. Interventions included but were…

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, interviews, facility policy review, and facility invoices, the facility failed to serve hot and palatable foods. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98. Findings include: Interview with Resident #14 on 09/18/23 at 10:29 A.M. revealed the facility's food was horrible. Interview with Resident #44 on 09/18/23 at 10:41 A.M. revealed the facility's food was nasty and cold. Interview with Resident #343 on 09/18/23 at 10:49 A.M. revealed the facility's food was poor and not much to it with taste. During tray line service on 09/18/23 beginning at 11:45 A.M., the kitchen was noted to be without an insulated base and covers for plates while plating the second-floor unit. Observation revealed State Tested Nurse (STNA) #1146 was measuring out cling wrap and placing it over each lunch meal plate. Interview on 09/18/23 at the time of the observation of the plating of the lunch meal, Food Service…

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 foods were stored in a matter to prevent contamination. This had the potential to affect all residents. The facility identified 97 of 98 residents that received food from the kitchen. Resident #5 was identified as receiving no food by mouth. The facility census was 98. Findings include: During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. the following was observed: • On 09/18/23 at 8:30 A.M. the ice machine was observed to be open with ice exposed to air and the door was broken and placed on top of the ice machine. • During the tour of the kitchen there were piles of oatmeal spilled at the entryway to the kitchen with other food, dirt, and various spills throughout the kitchen. The trashcan located near the handwashing station adjacent to the kitchen office space, was full and overflowing, the garbage dumpster was open and full of trash spilling out, and multiple small flying bugs were observed throughout the kitchen. • During the tour Dietary Aide (DA) #1137 was observed to be without…

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, personnel file review, job description review, interview, review of a facility Legionella water management plan documentation, review of Centers for Disease Control and Prevention (CDC) guidance, review of facility self-reported incidents (SRI), and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Tthe facility failed to prevent an in-house acquired pressure ulcer for Resident #14. Actual Harm occurred on 05/23/23 when Resident #14, who was dependent on staff for bed mobility, was observed to have an unstageable/suspected deep tissue injury (SDTI) (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. Following the development of the ulcer, 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 interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 98 residents in the facility. Findings include: Review of the PBJ report for Fiscal Year (FY) Quarter 2 (January 1, 2023 through March 31, 2023) revealed the facility triggered failing to submit data for the quarter and one-star staffing rating as identified areas of concerns. Interview on 09/20/23 at 12:04 P.M. with the Administrator and Facility Owner (FO) #5500 revealed FO #5500 was responsible for the submission of data to CMS regarding the PBJ. Interview revealed PBJ staffing information for FY Quarter 2 was never reported. Interview revealed FO #5500 submitted staffing information for the PBJ to CMS on 08/14/23 for FY Quarter 3. Review of the facility document titled CMS Submission Report PBJ Final File Validation Report dated 08/14/23 revealed the facility submitted PBJ staffing information for FY Quarter 3 and was unable to produce any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. In addition, the facility failed to maintain standard infection control protocols regarding isolation precautions. This had the potential to affect all 98 residents residing in the facility. Findings include: 1. Interview on 09/25/23 at 9:29 A.M. with the Administrator confirmed she did not have documented evidence of facility Legionella testing for 2022. Review of the facility policy titled Legionella Surveillance and Detection, revised July 2017, revealed Legionnaire's disease will be included as part of our infection surveillance activities. Review of the facility policy titled Infection Control/Water Systems, revised 03/23, revealed the facility will conduct routine water…

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 floor plan review the facility failed to ensure its environment was maintained in a clean and sanitary manner. This affected 9 residents (#4, #14, #18, #23, #33, #46, #68, #76, and #77) with the potential to affect all residents. The facility census was 98. Findings include: Observation during the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. with Dietary Aide (DA) #1137 of the designated outside area for the garbage dumpsters (loading dock) revealed two signs attached to the building reading No Smoking. Observation revealed a black square rug, adjacent to the on and off ramp, with approximately 13 cigarette ends and multiple new and old crumbled leaves on top of the rug. Interview during tour with DA #1137 revealed the area was not a designated smoking area; however, staff used the area to smoke often. DA #1137 verified the above findings at the time of the tour. Observation and verification on 09/18/23 at 1:13 P.M. with Maintenance Director (MD) #1159 of Residents #4, #23, and #46 room revealed a ceiling vent…

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

Based on observation, interview, facility policy review, and review of the Occupational Safety and Health Standards (OSHA) standards for safe oxygen storage the facility failed to ensure oxygen tanks were stored and secured in a safe manner. This had the potential to affect all 98 residents in the facility. Findings include: Observation of the oxygen storage area on 09/19/23 at 9:40 A.M. revealed the facilities oxygen storage was located inside a fenced area on the back dock with a no smoking sign on the wall behind it. The area revealed large amounts of combustible leaves mixed with cigarette butts underneath and around the 22 oxygen tanks stored in the fenced area. Interview on 09/19/23 at 9:40 A.M. with Director of Maintenance #1150 confirmed the observation and revealed staff were not to smoke near the area. Review of the facility policy titled Resident Smoking Policy, dated June 2018, revealed oxygen tanks were prohibited in smoking areas. Review of the OSHA standards for safe oxygen storage, amended 03/07/1996, revealed the bulk oxygen storage location shall be permanently…

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 care plans were updated and accurate for Residents #7, #14, #35, #73, #80, #244 and #294. This affected seven residents (#7, #14, #35, #73, #80, #244 and #294) of 23 residents reviewed for assessments. The facility census was 98. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 05/21/22. Diagnoses included schizophrenia, diabetes, chronic obstructive pulmonary disease (COPD), and gastro esophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. She required supervision for transfers and was independent with no set up help for bed mobility, dressing, toileting, eating, and hygiene. She occasionally rejected care. Review of the elopement assessment dated [DATE] revealed Resident #7 resided on a secured unit. Review of a nurse's note dated 08/28/23 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.

Based on record review, interview, and facility policy review the facility failed to obtain signed consents or declinations and evidence of education for influenza vaccinations for Residents #40 and #62. This affected two residents (#40 and #62) of six residents reviewed for immunizations. Findings include: 1.Review of the medical record or Resident #40 revealed an admission dated 12/04/18 with diagnoses including dementia, diabetes mellitus, morbid obesity, and schizophrenia. Review of Resident #40's medical record under the immunization tab revealed influenza consent was refused but no date was listed. Review from 09/01/22 to 03/31/22 of nursing progress notes or under the miscellaneous tab did not reveal any documented evidence of influenza immunization being offered or education being provided for the influenza vaccine. 2. Review of the medical record for Resident #62 revealed an admission date of 01/24/20 with diagnoses including unspecified protein-calorie malnutrition, atrial fibrillation, peripheral vascular disease, and acquired absence of right leg above knee. Review of…

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

Based on record review, interview, and facility policy review the facility failed to timely notify the physician and dietitian of Resident #294's continued refusal of daily weights. This affected one resident (#294) of four residents reviewed for weights. The facility census was 98. Findings include: Review of Resident #294's medical record revealed an admission date of 08/31/23 with diagnoses including chronic systolic congestive heart failure, stage IV chronic kidney disease, and depression. Review of the physician's orders revealed Resident #294 had an order dated 09/05/23 for daily weights related to a diagnosis of congestive heart failure. Further review of the medical record and medication administration record (MAR) for September 2023 revealed Resident #294's weights were marked as refused on 09/05/23, 09/06/23, 09/08/23, 09/10/23, 09/11/23, 09/12/23, 09/13/23, 09/15/23, 09/17/23, 09/18/23, and 09/20/23. No response was indicated on 09/07/23, 09/14/23, and 09/19/23. Review of the electronic medical record under the weight monitoring tab for Resident #294 revealed a weight 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 record review, staff interview, self-reported incident (SRI) review, and facility policy review, the facility failed to prevent resident-to-resident abuse. This affected one resident (Resident #81) of four residents reviewed for abuse. The facility census was 98. Findings Include: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS) assessment dated [DATE] revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents. Review of the nursing progress note dated 08/12/23 at 3:00 A.M. revealed Resident #81…

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 implement their abuse policy regarding an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen 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 record review, interview, and facility policy review the facility failed to report an allegation of resident-to-resident abuse to the state agency within the required time frames. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to investigate an allegation of resident-to-resident abuse. This affected two residents (#68 and #55) of four residents reviewed for abuse. The facility census was 98. Findings include: 1.Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the nursing progress note dated 09/02/23 for Resident #55 revealed Licensed Practical Nurse (LPN) #1134 heard a loud commotion in the hallway. LPN #1134 observed Resident #55 arguing with another resident. Resident #55 said another resident had slapped and choked her. Resident #55's face was slightly red and swollen and there was a small skin…

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 facility policy review the facility failed to develop care plans regarding behaviors and medications usage. This affected three residents (#55, #73, and #68) of four residents reviewed for behaviors and psychotropic medications. The facility census was 98. Findings include: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic pancreatitis, anxiety, depression, Covid-19, psychoactive substance abuse, a right above the knee amputation, and schizophrenia. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact, exhibited no behaviors during the assessment period. Review of the physician's orders for Resident #55 revealed an order for: • Acyclovir (an antiviral medication) 400 milligrams (mg) by mouth twice a day for Herpes Viral Infection dated 03/28/23. • Amitriptyline (a psychotropic medication) 75 mg by mouth twice a day for Anxiety, Depression, and Schizophrenia,…

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 reviews, interviews, and facility policy review the facility failed to adequately monitor Resident #90 after a significant change in condition and failed to follow physician orders for daily weights for Resident #294. This affected one resident (#90) out of three residents reviewed for death and one resident (#294) of four residents reviewed for weights. The facility census was 98. Findings include: 1.Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene. She had no issues with swallowing and had one fall since the previous assessment, with no injury. Review of the fall risk 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 interview, record review, and facility policy review the facility failed eliminate risk hazards when a staff member pushing a dietary cart ran into Resident #90 causing the resident to fall out of her wheelchair. This affected one resident (#90) of three residents reviewed for falls. The facility census was 98. Findings include: Review of the closed medical record for Resident #90 revealed an admission date of 02/28/19 with diagnoses including diabetes, hypertension, altered mental status, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 was severely cognitively impaired. She required total assistance of two people for bed mobility and transfers and extensive assistance of one person for dressing, toilet use, and hygiene. Review of the care plan dated 08/17/23 revealed Resident #90 was at risk for falls due to unsteadiness on her feet and impaired cognition. Interventions included using assistive devices for ambulation and non-skin footwear when out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, and facility policy review the facility failed to ensure timely colostomy care was provided. This affected one resident (#14) of one resident observed for colostomy. The facility identified two residents (#10 and #14) with colostomies. The facility census was 98. Findings include: Review of Resident #14's medical record revealed an admission date of 11/05/22 with diagnoses including peripheral vascular disease, type two diabetes, and paraplegia. Review of the annual, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated he was alert and oriented with intact cognition. Review of the MDS assessment revealed Resident #14 had a colostomy for bowel elimination and required one-person physical total dependence for managing the colostomy. Review of the care plan dated 09/07/23 revealed Resident #14 had potential for bowel and/or bladder elimination complications…

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 facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #50. This affected one resident (#50) of one resident reviewed for dialysis. The facility census was 98. Findings include: Review of the medical record for Resident #50 revealed an admission date of 10/19/22 with diagnoses including diabetes mellitus with kidney complication, adult failure to thrive, paranoid schizophrenia, dependence on renal dialysis, and end stage renal disease. Review of the physician's orders dated 08/08/23 revealed an order for dialysis communication tool under the assessment tab in the electronic medical record to be completed and printed to send to dialysis with Resident #50 every Tuesday, Thursday, and Saturday for dialysis assessment. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #50 revealed she was on dialysis treatments. Review of Resident #50's care plan dated 10/19/22 revealed she is…

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, self-reported incident (SRI) review, and facility policy review the facility failed to implement interventions to attain or maintain a resident's highest practicable psychosocial well-being. This affected one resident (#73) of four residents reviewed for behaviors. The facility census was 98. Findings include: 1. Resident #81 was admitted to the facility on [DATE] with diagnoses including depression, bipolar disorder, psychotic disorder with delusions, and schizophrenia. The resident resides on the facility's secured unit. Review of the comprehensive admission minimum data set (MDS), dated [DATE], revealed Resident #81 was moderately cognitively impaired, exhibited no behaviors during the assessment period, and was non-ambulatory. Review of Resident #81's care plans revealed he was at risk for altered cognitive function related to schizophrenia and would have alterations in behavior leading to abusive attacks on staff and residents. Review of the nursing progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of pain medication for Resident #80. This affected one resident (#80) of five residents reviewed for unnecessary medication use. The facility census was 98. Findings include: Review of the medical record for Resident #80 revealed and admission date of 05/31/23. Diagnoses included diabetes, hypertension, depression, anxiety, and heart failure. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #80 was moderately cognitively impaired. She required supervision and set up help for bed mobility, transfers, dressing, eating, toilet use, and hygiene. She had trouble falling and staying asleep, she felt down and depressed, had little interest in doing things, had trouble concentrating and displayed no behavior. Review of the physician's orders for September 2023 revealed Resident #80 was ordered Percocet (opioid pain 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.

Based on observation, staff interview, record review, and facility invoices, the facility failed to ensure the facility, including the kitchen and resident rooms, was free from pests (ants, flies, and gnats/fruit flies). This affected the kitchen and three residents' rooms (#4, #23, and #46). The facility census was 98. Findings include: During the initial kitchen tour on 09/18/23 between 8:30 A.M. and 9:00 A.M. approximately two to three flies and seven to eight gnats/fruit flies were noted swirling around the trashcan, food serving and preparation areas. During the second tour of the kitchen between 9:15 A.M. and 9:45 A.M., Food Service Supervisor (FSS) #1145 confirmed and verified the existence of the flies and gnats/fruit flies. FSS #1145 revealed that the facility utilized extermination services but could not confirm the date of the last visit and treatment. Observation on 09/18/23 at 10:20 A.M. of Residents #4, #23, and #46 room, revealed approximately 23 small ants crawling on the floor near the entrance to the room. Interview on 09/18/23 at 10:23 A.M. with State Tested Nurse…

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.