Majestic Care Of Kent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel file review, interview and review of the facility policy, the facility failed to ensure staff had tuberculosis (TB) testing prior to working. This affected two staff (Licensed Practical Nurse (LPN) #536 and Certified Nursing Assistant (CNA) #561) of nine staff reviewed during the annual survey with the potential to affect all 55 residents.Findings include:Review of LPN #536's personnel file revealed a hire date of 05/05/25. Further review of the personnel file revealed no evidence TB testing was completed prior to or upon employment.Review of CNA #561's personnel file revealed a hire date of 08/22/24. Further review of the personnel file revealed no evidence TB testing was completed prior to or upon employment.Interview on 09/03/25 at 2:46 P.M. with Regional Human Resources (RHR) #600 and Human Resources (HR) #590 verified they could not locate initial TB testing for LPN #536 or CNA #561. RHR #600 stated a two-step TB test was done upon hire for all new employees.Review of the facility policy,…

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 personnel file review and interview the facility failed to ensure Certified Nursing Assistants (CNAs) had 12 hours of training annually as required. This affected one CNA (#561) of two CNA files reviewed with the potential to affect all 55 residents.Findings include:Review of CNA #561's personnel file revealed a date of hire of 08/22/24. Further review of the file revealed no evidence of training hours.Interview on 09/03/25 at 2:46 P.M. with Regional Human Resources (RHR) #600 and Human Resources (HR) #590 verified they could not locate any evidence of training hours for CNA #561. RHR #600 stated for CNAs, they aimed for at least 12 hours annually for training.

Based on observation, interview and facility policy review, the facility failed to maintain resident rooms and bathrooms in a safe and sanitary condition. This affected four residents (Resident #28, #31, #34, and #44) of 55 residents living in the facility. The facility census was 55.Findings include:Interview and observation on 09/02/2025 at 4:41 P.M. with Certified Nursing Assistant (CNA) #555 of Resident #31 room revealed splatters of food on all four walls and the ceiling of room and outlet by bed was unattached from wall with the wires hanging out.Observation on 09/03/25 between 2:47 P.M. through 3:00 P.M. of multiple resident rooms with Housekeeping Supervisor #513 revealed the following:Resident #31 walls and ceiling were dirty with various food and liquid debris from resident throwing his food. Outlet was being fixed by maintenance at this time. Housekeeping Supervisor #513 revealed Resident #31 throws food at the wall and will put feces on the wall. Staff was supposed to clean daily but confirmed staff had not been wiping walls thoroughly.Resident #34 and Resident #44…

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 authorizations were witnessed for resident funds. This affected one resident (#42) of five residents reviewed for resident funds. Facility census was 55.Findings include:Review of Resident #42's medical record revealed an admission date of 07/19/22 and diagnoses including depression, insomnia, auditory hallucinations, delusional disorders, and psoriasis. Further review of the record revealed Resident #42 had a power of attorney (POA).Review of financial records for Resident #42 revealed an authorization for resident funds signed by the POA on 05/05/25. The authorization lacked any witness signatures on the form.Interview on 09/03/25 at 8:45 A.M. with Business Office Manager (BOM) #523 verified Resident #42 did not have his resident funds authorization witnessed as required. BOM #523 reported the facility did not have a policy regarding resident funds to provide for review at the time of the interview.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure final disbursal of a deceased resident's funds was completed in 30 days as required. This affected one resident (#64) of five residents reviewed for resident funds. Facility census was 55.Findings include:Review of Resident #64's closed medical record revealed an admission date of [DATE] and diagnoses including personality disorder, breast cancer, insomnia and mild cognitive impairment. Further review of the record revealed Resident #64 expired in the facility on [DATE].Review of the financial records for Resident #64 revealed she expired on [DATE]. The resident statement indicated the balance of $75.77 was issued as a check on [DATE].During an interview on [DATE] at 8:45 A.M. Business Office Manager (BOM) #523 was informed that Resident #64's final disbursement exceeded the 30-day limit and she did not disagree. BOM #523 stated the receptionist and not herself did the disbursal for Resident #64. BOM #523 also reported the facility did not have…

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, review of a self-reported incident (SRI), review of the facility's investigation and review of the facility policy, the facility failed to report allegations of abuse and neglect immediately as required. This affected two residents (#23 and #49) of three residents reviewed for abuse and neglect. Facility census was 55.Findings include:Review of Resident #49's medical record revealed an admission date of 03/01/24 and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Resident #49 had a legal guardian and was receiving hospice services.Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing.Review of Resident #23's medical record…

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, review of a self-reported incident (SRI), review of the facility's investigation and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse and neglect. This affected two residents (#23 and #49) of three residents reviewed for abuse and neglect. Facility census was 55.Findings include: Review of Resident #49's medical record revealed an admission date of 03/01/24 and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Resident #49 had a legal guardian and was receiving hospice services. Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing. Review of Resident #23's medical record…

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, observation, and mechanical lift policy the facility failed to ensure Resident #30 was safely transferred with a Hoyer (mechanical) lift to prevent a fall. This affected one resident (Resident #30) of four residents reviewed for accidents. The facility census was 55.Findings include:Review of the medical record for Resident #30 revealed an admission date of 08/20/25 with diagnosis that include: urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, catatonic disorder, dementia without behavioral disturbance, metabolic encephalopathy, dysphagia and altered mental status.Review of Morse Fall Scale dated 08/20/25 revealed Resident #30 was a high risk for falling.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 cognition was moderately impaired and was dependent on staff for transfers from the chair to the bed.Review of Resident #30 medical chart revealed resident had fallen on 08/21/25, 08/30/25, 08/31/25, 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 and interviews the facility failed to ensure Resident #7, who received hemodialysis (HD) three times a week, was evaluated before and after dialysis treatments. This affected one resident (Resident #7) of one resident received for HD. Facility census was 55.Findings include:Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included diabetes, chronic kidney disease (CKD) - Stage3, major depressive disorder, generalized anxiety disorder, dependence of renal dialysis, heart disease, gastroesophageal reflux disease (GERD), and Vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, for Resident #7, dated 06/20/25 revealed the resident was cognitively intact. Review of the physician orders for Resident #7, dated 04/21/25, revealed that a pre and post assessment needs to be completed on dialysis days.On 09/03/25 at 5:00 P.M., a review of Dialysis PRE/POST Communication Record- - V 2 from 09/01/25, 09/02/25, and 09/03/25…

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

Based on record review and interview, the facility failed to ensure medications to treat diabetes and to improve glucose control were administered as ordered by the physician. This affected one (Resident #61) of six reviewed for medication administration. The facility census was 55.Findings include:Review of the medical record for Resident #61 revealed an admission date of 12/21/24 with diagnoses including diabetes mellitus, hypertension and heart failure. Review of the physician's orders for Resident #61 revealed an order for Insulin Lispro (medication for hyperglycemia) 55 units in the morning and at night dated 12/22/24 and Humalog (medication for hyperglycemia) sliding scale insulin to be given per the blood sugar to be done in the morning, at lunch, at dinner and at bedtime dated 12/22/24.Review of the Medication Administration Record for December 2024 for Resident #61 revealed his Insulin Lispro was not administered on 12/23/24 in the morning and Humalog sliding scale was not administered on 12/23/24 at lunch.Review of Resident #61's care plan dated 12/23/24 revealed he had…

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

Based on record review, observation and interview, the facility failed to ensure medications were properly stored and secured. This affected two (Residents #10 and #55) of two residents reviewed for improperly stored medications. The facility had a census of 55 residents.Findings include:Observation on 08/27/25 at 9:08 A.M. of medication administration with Registered Nurse (RN) #564 to Resident #55 revealed two bottles of Nystatin Powder (antifungal medication used to treat fungal or yeast infections) on her television stand. Once the medication administration was completed and when leaving room, noted Resident #55's roommate, Resident #10, to have a bottle of Nystatin Powder on her tray table. Interview on 08/27/25 at 9:08 A.M. with RN #564 verified medications should not have been in either residents' room as the physician had not ordered medications to be left at bedside for the resident to self-administer.Review of the facility policy titled, Medication Administration, dated 01/02/24, revealed medications were not to be left unattended in the resident's room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain accurate and complete resident records. This affected three residents (#49, #60, #64) of 23 resident records reviewed for documentation. Facility census was 55.Findings include: 1. Review of Resident #49's medical record revealed an admission date of [DATE] and diagnoses including Alzheimer's disease, dysphagia, constipation, generalized anxiety disorder, vascular dementia with behavioral disturbance, psychotic disorder and mood affective disorder. Review of Resident #49's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had cognitive impairment, displayed physical and verbal behaviors one to three days in the look-back period and was dependent for upper body and lower body dressing. Review of Resident #49's physician's orders revealed an order dated [DATE] for Lorazepam oral tablet 0.5 milligrams (mg) give one tablet by mouth every four hours as needed for anxiety. Review of a hospice note dated [DATE] at…

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

Based on observation, interview, and record review, the facility failed to ensure education was provided to State Tested Nursing Assistants regarding residents placed on enhanced barrier precautions. This affected six residents (Resident #1, #2, #17, #22, #42, #45) with the potential to affect all 53 residents in the facility. Findings included: Interview with five Stated Tested Nursing Assistants (STNA #547, STNA #565, STNA #567, STNA #574 and STNA #575) on 03/28/23 from 2:06 P.M. to 3:02 P.M. revealed these STNA's when asked, did not know what enhanced barrier precautions meant. These STNAs also did not know what type of Personal Protective Equipment they were required to wear when entering a resident's room who was on enhanced barrier precautions. Review of residents on enhanced barrier infection control precautions revealed Resident #1, #2, #17, #22, #42, #45 were on precautions. Review of the facility policy titled, Enhanced Barrier Precautions, dated 07/22 revealed enhanced barrier precautions were precautions intended for a resident with infections, wounds, and/or with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments for Resident #9, #14, #18, and #51 were complete and accurate. This affected four residents (Resident #9, #14, #18, and #51) of four residents reviewed for the accuracy and completion of their MDS. The facility census was 53. Findings included: 1. Review of medical record for Resident #9 revealed an admission date of 12/01/22 and her diagnoses included cerebral infarction, chronic kidney disease with heart failure, diabetes, and dysphagia. Review of Medicare Five-Day Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed Section C which included Brief Interview for Mental Status (BIMS) score, assessment of short-term memory, assessment of long term assessed memory, assessment of memory/ recall ability assessed, assessment of cognitive skills for daily decision making, and assessment of sign and symptoms of delirium was not assessed. The MDS also revealed Section Q which included resident, family and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were stored in a secure manner and disposed of when they had expired. This affected four residents (Residents #2, #14, #18 and #48) with the potential to affect all residents residing in the facility. The facility census was 53. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of [DATE] with diagnoses including diabetes mellitus, chronic kidney disease and dependence on renal dialysis. Review of Resident #2's physician's orders for [DATE] revealed he had an order for Insulin Glargine (Lantus) (medication used for high blood sugar) 100 units per milliliter (mL) dated [DATE]. The nursing staff were to inject 30 units subcutaneously at bedtime. Review of the Medication Administration Record for [DATE] revealed Resident #2 received his Insulin Glargine as ordered. Observation on [DATE] at 3:05 P.M. with Registered Nurse (RN) #576 of the medication cart on the 200 hall 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 interview and record review, the facility did not ensure Residnet #20 and #23's authorization agreement to manage funds were witnessed by a person not affiliated with the facility. This affected two residents (Resident #20 and #23) out of five residents reviewed for resident funds. Findings included: 1. Review of medical record for Resident #20 revealed an admission date of 04/01/19 and her diagnoses included encephalopathy, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of care plan dated 05/05/19 revealed Resident #20 had impaired cognition, dementia, and/ or impaired thought process due to encephalopathy, frontal lobe dementia, and short term memory loss. Interventions included communicate with family regarding capabilities and needs and provide assistance with decision making. Review of facility form labeled Resident Fund Management Service dated 03/10/20 revealed Resident #20 signed the authorization agreement to allow the facility to handle her funds. The authorization agreement was not witnessed. Interview on 03/28/23 at 4:04 P.M.…

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

Based on observation, interview, and record review, the facility failed to ensure Resident #12 was free from physical abuse involving manual restraint. This affected one resident (#12) out of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/10/23. Resident #12's diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 02/28/23 revealed Resident #12 had a traumatic event identified as physical abuse by a homecare worker in 2019 with injury. Resident #12's triggers were identified as receiving care. Resident #12 would make false allegations of abuse and refuses medications at times. Interventions include but were not limited to allow resident to express feelings when triggers are identified, develop strategies with resident to avoid or decrease trauma triggers, and staff being aware of triggers or potential triggers and understand…

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 an allegation of abuse towards Resident #12 was reported immediately and failed to ensure the resident was protected from further abuse after the allegation was made. This affected one resident (#12) out of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/10/23. Resident #12's diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed Resident #12 had verbal and other behaviors that occurred one to three days during the look back period. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 02/28/23 revealed Resident #12 had a traumatic event identified as physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure proper incontinence care was provided to Resident #16. This affected one resident (Resident #16) out of two residents who were reviewed incontinence care. Findings included: Resident #16 was admitted to the facility on [DATE]. Her admitting diagnoses included anemia, hypertension, type II diabetes, Alzheimer's Disease, a central venous attack (CVA), and dementia. Review of Resident #16's Minimum Data assessment dated [DATE] revealed this resident had moderate cognitive impairment. Functionally, she needed extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of her bowel and bladder assessment of this MDS revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Observation of Resident #16 on 03/28/23 at 3:00 P.M. revealed two State Tested Nursing Assistants (STNA) provided incontinence care to this resident. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure Resident #38 received his nutritional supplement as ordered. This affected one resident (Resident #38) out of two residents reviewed for nutritional needs. Findings included: Review of medical record for Resident #38 revealed an admission date of 02/20/23 and his diagnoses included catatonic schizophrenia, dementia, dysphagia, and depression. Review of weight record for Resident #38 revealed on 02/20/23 his admission weight was 163 pounds. The weight record revealed Resident #38 had weight loss as his weight on 03/20/23 was 155.2 pounds which was a three percent change over the last 30 days. His weight remained on 03/28/23 at 155 pounds. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was rarely and/ or never understood. He required extensive assistance of one person with eating. His weight was recorded as 165 pounds with no weight loss. He was on a mechanically altered diet. Review of care plan 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 observation, interview and record review, the facility failed to ensure oxygen orders were in place for Residents #14 and #18. This affected two residents (Resident #14 and Resident #18) of two residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 12/04/20 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic respiratory failure with hypoxia. Review of the physician's orders for March 2023 revealed there were no orders for Resident #14 to have oxygen. Observation on 03/27/23 at 9:56 A.M. of Resident #14 revealed she had oxygen on via a nasal cannula and the oxygen concentrator was set at three liters. Interview with Resident #14 revealed she always had oxygen on. Interview on 03/27/23 at 10:28 A.M. with Registered Nurse (RN) #576 verified Resident #14 had oxygen on at 3 liters and she did not have a physician's order. Review of the facility policy titled, Oxygen Handling, revised January 2021, revealed 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 and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. This affected one (Resident #2) of one resident receiving dialysis. The facility census was 53. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including chronic kidney disease and dependence on renal dialysis. Review of the physician's order dated 11/29/22 for Resident #2 revealed he had dialysis on Mondays, Wednesday and Fridays. Staff were to obtain vital signs before and after dialysis. Review of Resident #2's assessments for March 2023 revealed dialysis assessments were not completed prior to dialysis. Dialysis assessments for Resident #2 were only completed after dialysis on 03/01/23, 03/13/23, 03/15/23 and 03/20/23. Interview on 03/29/23 at 9:09 A.M. with the Director of Nursing (DON) verified Resident #2's dialysis assessments were not completed as stated above. He stated it was the facility's policy 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 record review, interview, and facility policy review, the facility failed to ensure care planned interventions were implemented to provide Resident #12 comfort and opportunities for choice during care and to maintain the highest practicable mental and psycho-social well being. This affected one resident (Resident #12) out of one resident reviewed for behavioral health services. Findings include: Review of the medical record for the Resident #12 revealed an admission date of 02/10/23. Diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the physician orders dated 02/10/23 revealed an order for psychology consult as needed. Review of the physician orders dated 02/14/23 revealed Resident #12 required a room on the secured unit to promote psychosocial well-being and interactions with peers. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed…

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

Based on observation, interview and record review, the facility failed to honor food preferences. This affected two residents (#12 and #47) out of two residents for food preferences. The facility census was 53. Findings include: 1. Review of the medical record for the Resident #12 revealed an admission date of 02/10/23. Diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. The resident required supervision with eating and received a therapeutic diet. Review of physician's orders for March 2023 revealed Resident #12 received a consistent carbohydrate diet (CCD), regular texture with thin consistency liquids. Review of the Resident #12's diet tray ticket revealed Resident #12 received a renal CCD diet with no dislikes or preferences mentioned. It indicated a house nutritional shake to be…

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 staff followed enhanced barrier precautions during wound care, and failed to ensure staff followed infection control standards to prevent cross contamination in regards to use of a glucometer. This affected one (Resident #22) of one resident reviewed for wound care and two (Residents #2 and #20) of two residents reviewed for blood sugar checks with a glucometer. Findings include: 1. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including dementia and a pressure ulcer to the sacral region. Review of the physician's orders for Resident #22 revealed an order for enhanced barrier precautions related to catheter and wound care dated 01/09/23. Observation on 03/28/23 at 1:00 P.M. of wound care with Licensed Practical Nurse (LPN) #561 to Resident #22 revealed she was on Enhanced Barrier Precautions. There was signage on the door stating Enhanced barrier precautions, everyone must clean 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.

Based on observation, record review and interview the facility failed to maintain sanitary conditions in the kitchen to prevent contamination and/or food borne illness. This had the potential to affect 71 of 71 residents residing in the facility who received meal trays. The facility identified two residents, Resident #9 and #64 who received nothing by mouth. The facility census was 73. Findings include: A tour of the kitchen on 08/12/19 from 8:30 A.M. to 8:50 A.M. with Dietary Manager (DM) #503, revealed the following observations: On the bottom shelf of the prep sink there were various dried food crumbs scattered throughout. Stored on this shelf were two blenders and attachments, and a silver rack that held cutting boards. The top of the dish machine had a moderate amount of a tannish, wet residue. The prep table next to the steam table, the outer surface appeared worn and rusted. The side of this prep table that faced the steam table had a moderate layer of blackish grease and various dried food splatters. The bottom shelve of the steam table had various dried food crumbs and…

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

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during meal delivery, blood glucose monitoring and during housekeeping services to prevent the spread of infection. This affected two residents (#4 and #19) observed receiving meal trays, two residents (#16 and #8) observed during blood glucose monitoring, one resident (#219) observed in contact precautions and had the potential to affect all 73 residents residing in the facility. Findings include: 1. Observation on 08/12/19 at 12:15 P.M. revealed State Tested Nurse Assistant (STNA) #500 was observed passing a meal tray to Resident #19. STNA #500 entered the resident's room, placed the tray down and moved the bed tray closer to the resident who was laying in bed. The STNA then exited the room, obtained a meal tray for Resident #4 without first washing hands or using hand sanitizer and proceeded to obtain a meal tray for Resident #4. STNA #500 opened the door to Resident #4's room using the left hand and placed the tray down on the resident's bed tray. STNA #500…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #39, who required staff assistance with toileting received timely and adequate care related to the use of a bedside commode. This affected one resident (#39) of one resident reviewed for activities of daily living (ADLs). Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with a diagnosis including closed fractures of the lower end femur and left tibia. The admission Minimum Data Set (MDS) 3.0 assessment, dated 07/12/19 revealed Resident #39 had intact cognition and required extensive assistance of two staff for transfers and toilet use. Interview on 08/12/19 at 11:06 A.M. with Resident #39 revealed she used the bedside commode and often it took staff a long time to empty it. Resident #39 stated she needed assistance on and off the bedside commode, so staff were aware it needed to be emptied. Resident #39 stated one day six hours went by before it was emptied. Observation on 08/14/19…

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 resident medical record documentation was accurate and complete related to antibiotic use. This affected three residents (#48, #62 and #63) of three residents reviewed for antibiotic use. Findings include: A review of Resident #48's physician's orders revealed an order for Azithromycin Tablet 500 milligrams (mg), one tablet by mouth at bedtime for upper respiratory infection (URI), to start 08/05/19 for seven days. A review of Resident #48's progress notes revealed only one entry regarding a reaction to the antibiotic. A review of Resident #62's physician's orders revealed an order for Cephalexin 500 mg, one tablet by mouth twice daily for urinary tract infection (UTI), to start on 08/07/19 for seven days. A review of Resident #62's progress notes revealed no entries regarding the start of treatment nor follow up of antibiotic treatment to show progress, resident condition, or any adverse reactions. A review of Resident #63's physician's orders revealed an order for Cephalexin 500 mg, two tablets by mouth once daily…

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