Kirtland Woods Of Journey

Based on observation, interview, and facility policy review the facility failed to provide a safe, sanitary, and homelike environment. This affected 48 residents (#3, #6, #7, #8, #13, #15, #16, #17, #19, #21, #23, #24, #27, #31, #32, #34, #35, #37, #38, #39, #42, #44, #46, #47, #49, #51, #55, #58, #59, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #88, #89, #92, #93, #95, #97, #100 and #102) and had the potential to affect all 103 residents residing in the facility. Findings include: Observation on 07/17/24 at 10:49 A.M. of the adjoining bathroom shared by Residents #8, #13, #58, and #77 revealed a sticky floor and a toilet paper roll placed on the back of the toilet in lieu of a toilet paper holder, which was not secured tightly to the wall. The toilet water was low inside the commode with a large amount of soiled toilet paper, black/brown in color piled inside, and black/brown soilage dried around the inner commode walls. Residents #13 and #77's shared bedroom closet was missing a handle to functionally open/close the door with only a pointed screw protruding from it, 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 and interview, the facility failed to provide a private closet space separate from roommates' clothing. This affected 46 residents (#1, #2, #4, #6, #7, #8, #11, #13, #16, #20, #22, #23, #27, #31, #34, #35, #41, #42, #44, #47, #50, #51, #58, #59, #61, #64, #69, #73, #77, #78, #79, #80, #81, #82, #83, #84, #86, #88, #92, #93, #94, #97, #98, #100, #102 and #103) out of 103 resident rooms reviewed for closet space. The facility census was 103. Findings include: Observations on 07/23/24 at 10:43 A.M. during a facility tour with Maintenance Director (MD) #474 revealed the following residents were roommates and had one closet shared by both residents that did not separate the roommates' clothing: • Residents #78 and #80 • Residents #100 and #16 • Residents #77 and #13 • Residents #84 and #44 • Residents #58 and #8 • Residents #31 and #47 • Residents #93 and #35 • Residents #98 and #61 • Residents #20 and #64 • Residents #50 and #11 • Residents #4 and #94 • Residents #82 and #59 • Residents #23 and #102 • Residents #73 and #1 • Residents #27 and #79 • Residents #7 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, facility self-reported incident (SRI) review, and interview the facility failed to prevent resident-to-resident abuse for residents #41 and #104. This affected two residents (#41 and #104) of three residents reviewed for abuse. The facility census was 103. Findings include: Review of the closed medical record for the Former Resident #104 revealed an admission date of 06/13/24. The resident was discharged to the hospital on [DATE]. Diagnoses included Alzheimer's disease, diabetes, and dementia with agitation. The resident was at the facility for a respite stay. Review of the admission Minimum Data Set (MDS) assessment, dated 06/20/24, revealed Resident #104 had severely impaired cognition. The resident's hearing and vision were adequate without devices. Behaviors included physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, and rejection of care. Review of physician orders for June 2024 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately document fall interventions for Resident #62 and make vaccination documentation readily accessible in the medical record for Residents #97 and #102. This affected three residents (#62, #97 and #102) of 23 medical records reviewed. The facility census was 103. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 04/18/23. Diagnoses included muscle weakness and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment completed 06/19/24 indicated Resident #62 had moderately impaired cognition and received hospice services. Review of the physician's orders revealed an order initiated 12/01/23 and effective July 2024 indicated Resident #62 was to have a floor mat to the left bedside while in bed. Observation on 07/17/24 at 11:50 A.M. revealed Resident #62 was in bed with no fall mat to the left bedside as ordered. Interview at the time of the observation with State Tested…

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 provide an adequate bathroom door for privacy for Resident #25. This affected one resident (#25) of 103 residents whose rooms were observed for privacy. The facility census was 103. Findings include: Observations on 07/23/24 at 10:43 A.M. during a facility tour with Maintenance Director (MD) #474 revealed Resident #25's room had a bathroom entrance with a full-length curtain installed to cover the doorway in lieu of a door. The curtain was placed on a rod which extended approximately two to three inches away from the wall/door opening so when the curtain was drawn completely closed, it left a wide gap on both sides leaving ample opening to see inside the bathroom. With Resident #25's bedroom door opened and the bathroom curtain closed, the inside bathroom remained visible through the left bathroom curtain gap from the facility hallway outside of the bedroom. Interview at the time of the observation with MD #474 verified the findings. This deficiency represents non-compliance investigated under Master Complaint Number…

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 facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 110 residents residing in the facility. Findings include: Observations on 06/17/24 between 11:03 A.M. and 11:14 A.M. of the East wing revealed the window at the east end of the East wing was open, hot air was blowing in, grayish-black spots were noted on the seals of the window and along the top and bottom edges of the top and bottom windowpanes, there were multiple tears in the screen, and at least 25 dead insects on the windowsill. The light fixtures in the East halls contained multiple dark spots, some shaped like insects, under the fixture covers. Further observation of the common sitting area on the East wing revealed windows were on the north and south side of the room, each side had a window open, blowing hot air into the facility. Closer observation of the sitting area on the East wing revealed one window with no screen,…

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 call lights were within reach at all times. This affected one (Resident #86) of five sampled residents. The facility census was 110. Findings include: Review of the medical record for Resident #86 revealed an admission date of 08/12/21 with diagnoses including visual hallucinations, hemiplegia and hemiparesis affecting right dominant side, type two diabetes mellitus with diabetic retinopathy and macular edema, asthma, neuromuscular dysfunction of the bladder, unspecified psychosis, anxiety disorder, essential (primary) hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment completed on 03/20/24 revealed Resident #86 had intact cognition. Further review of the MDS revealed Resident #86 had an impairment on one side, was dependent for toileting and bathing, was always incontinent of bowel and bladder, and required maximal assistance for transfers. Review of the care plan dated 06/13/24 revealed Resident #86 required assistance with incontinence…

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

Based on observation, interview and review of facility policy, the facility failed to ensure choices were honored for one (Resident #86) of five residents reviewed for choices. The facility census was 110. Findings include: Review of the medical record for Resident #86 revealed an admission date of 08/12/21with diagnoses including visual hallucinations, hemiplegia and hemiparesis affecting right dominant side, type two diabetes mellitus with diabetic retinopathy and macular edema, asthma, neuromuscular dysfunction of the bladder, unspecified psychosis, anxiety disorder, essential (primary) hypertension, muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment completed on 03/20/24 revealed Resident #86 had intact cognition. Further review of the MDS revealed Resident #86 had an impairment on one side, was dependent for toileting and bathing, was always incontinent of bowel and bladder, and required maximal assistance for transfers. Review of the care plan dated 06/13/24 revealed Resident #86 had an alteration in 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 observation, interview, and review of the National Weather Service website (forcast.weather.gov) the facility failed to ensure a comfortable and safe ambient temperature for all residents. This affected one of five sampled residents, Resident #73. Findings include: Observations on 06/17/24 between 11:03 A.M. and 11:14 A.M. of the East wing revealed the window at the east end of the East wing was open, hot air was blowing into the building. Further observation of the common sitting area on the East wing revealed windows were on the north and south side of the room, each side had a window open, blowing hot air into the facility. Interview on 06/17/24 at 11:08 A.M. with Housekeeper #398 confirmed hot air was blowing into the facility from the open window on the east end of East wing. A follow-up interview with Housekeeper #398 on 06/17/24 at 11:25 A.M. confirmed there were screens coming loose and with tears and there was hot air coming into the facility from the open windows., Observation on 06/17/24…

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, record review and facility policy review, the facility failed to complete annual nurse aide performance evaluations as required. This had the potential to affect all 120 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #536 revealed a hire date of 03/07/23. There was no evidence in the personnel file of an annual performance evaluation as required. Review of the personnel file for STNA #537 revealed a hire date of 03/14/23. There was no evidence in the personnel file of an annual performance evaluation as required. Review of the personnel file for STNA #507 revealed a hire date of 04/25/23. There was no evidence in the personnel file of an annual performance evaluation as required. Interview on 05/01/24 at 12:17 P.M. with Human Resource Business Partner #560 verified the above findings were accurate. Review of the facility policy titled Staff Competency, dated 12/31/23, revealed the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents'…

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

Based on observation, interview, record review and facility policy review, the facility failed to properly store injectable pharmaceuticals by dating opened containers and failed to maintain clean medication storage refrigerators. This was identified in two of four medication rooms and one of six medication carts which affected one resident (#61) and had the potential to affect all 120 residents residing in the facility. Finding include: During medication storage observation on 04/25/24 at 1:48 P.M. with Director of Nursing (DON) the [NAME] medication cart contained one opened and undated insulin pen (Humalog KwikPen) for Resident #61. Both the [NAME] and Central medication room refrigerators had gross overgrowth of ice from lack of defrosting. The Central medication room refrigerator contained one opened and undated vial of Tuberculin purified protein derivative (Tubersol) solution for intradermal tuberculin testing. Interview at the time of the observation with DON verified the above findings and indicated Tubersol was used for tuberculin testing on residents and employees. Review…

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

Based on observation and interview, the facility failed to ensure meals were served at palatable temperatures. This affected four residents (#37, #59, #63, and #107) and had the potential to affect all residents receiving food from the kitchen. The facility census was 120. Findings include: Interview on 04/22/24 at 12:09 P.M. with Resident #59 revealed the food was terrible, and the hot food was not served hot. Interview on 04/22/24 at 3:14 P.M. with Resident #37 revealed the meals were served cold. Observation on 04/24/24 at 4:17 P.M. revealed Dietary Assistant (DA) #552 obtained food temperatures for dinner from the steam table in the kitchen. The barbeque beef riblet were 188 degrees Fahrenheit, and the baked beans were 160 degrees Fahrenheit. At 5:37 P.M. a test tray was placed on the last meal cart delivered to the 100-hall. The staff immediately began passing the hall trays. At 6:07 P.M. the last meal tray was served, and the test tray was performed with Dietary Manager (DM) #613. DM #613 obtained the temperature of the barbeque beef riblet which was 97 degrees Fahrenheit, and…

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

Based on observation, interview and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents. The facility census was 120. Findings include: Observations on 04/22/24 from 8:54 A.M. to 9:24 A.M. during the initial tour of the kitchen with Dietary Manager (DM) #613 revealed: • An opened, bulk bag of panko sitting on the floor in the dry storage area. • The table where the coffee maker was located revealed the back wall was dirty with various dried food splatter. The three drawers of this table that contained the serving utensils including scoops, spoons, and spatulas, the inside of the drawers was dirty with dark brownish food stains/debris. • The prep sink where the toaster was located revealed the back wall and the silver portion of the table that extended up on the wall had various dried food splatter. The shelf underneath where the cutting boards were located had dried white stains or water spots and various dried food splatter. • The dish room had 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, staff interview, Centers for Disease Control and Prevention review and facility policy review, the facility failed to complete admission testing for tuberculosis (TB) for Resident #419. This affected one resident (#419) of seventeen residents reviewed for new admissions. In addition, the facility failed to accurately complete the new hire testing for TB on five new employee (Maintenance Director #594, Licensed Practical Nurse (LPN) #591, LPN #571, Human Resource Business Partner (HRBP) #560, and Assistant Director of Nursing (ADON) #504) of 11 new hire personnel files reviewed. This had the potential to affect all 120 residents residing in the facility. Findings include: 1. Resident #419 was admitted to the facility on [DATE] with diagnoses including stroke, atrial fibrillation, congestive heart failure, chronic kidney disease dependent on dialysis, heart disease, dementia without behavioral disturbance, multiple myeloma, and diabetes. Review of the admission Minimum Data Set (MDS) 3.0…

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 contracted quotes, the facility failed to ensure the washers and dryers were in good repair. This had the potential to affect all residents. The facility census was 120. Findings include: Observations on 05/01/24 from 8:48 A.M. to 9:03 A.M. of the laundry area with Housekeeping Manager (HM) #611 revealed in the room with the washing machines revealed a large bin filled to the top with soiled personal clothes and another bin with linens both waiting to be washed. Two of three washing machines were in use, both with linens. The third washing machine was not being used. In the next room over, two of four dryers were being used to dry linens. Interview on 05/01/24 between 8:48 A.M. and 9:03 A.M. with HM #611 verified there was one washing machine and one dryer that did not work. HM #611 stated the washing machine had been down for about seven months, and it was to be fixed but parts could not be found due to the fact that it was an old machine. HM #611 stated he was then told it was to be replaced, but he had not heard anything else…

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 facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 120 residents residing in the facility. Findings include: Interview on 04/22/24 at 12:09 P.M. with Resident #59 stated there was a breeze from the window, and maintenance had taped a plastic covering around the window but did not securely tape it in place. Resident #59 stated at night while in bed she feels the breeze and has to bundle up at night. Observation at this time of a clear, plastic covering taped over the window except in the lower left side corner, closer to the resident's bed. Observation on 04/22/24 at 12:29 P.M. of an odor of urine on the 100-hall near the nursing station. Interview at this time with Stated Tested Nurse Aide (STNA) #528 verified the odor of urine and stated it was new as of today. STNA #528 stated housekeeping had been through the rooms and everyone was checked and changed. STNA #528…

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 handrails were in good repair. This had the potential to affect all residents. The facility census was 120. Findings include: Observation on 04/25/24 at 11:13 A.M. with Maintenance Assistant (MA) #593 of the missing portion of the handrail across from the 300-hall dining/activity area and right next to the area where the puzzles were kept. Interview at this time with MA #593 verified the observation and stated he did not how long it had been that way but would get it fixed. This deficiency represents non-compliance investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001.

Based on record review, interview and facility policy review, the facility failed to complete the required 12 hours of annual training for nurse aides. This had the potential to affect all 120 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #537 revealed a hire date of 03/14/23. There was no evidence any training was completed toward the required minimum of 12 hours annually. Review of the personnel file for STNA #507 revealed a hire date of 04/25/23. There was no evidence any training was completed toward the required minimum of 12 hours annually. Interview on 05/01/24 at 12:17 P.M. with Human Resource Business Partner #560 verified the above findings were accurate. Review of the facility policy titled Staff Competency, dated 12/31/23, revealed the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents' needs. This deficiency represents non-compliance investigated under Complaint Number OH00153001.

Based on record review and interview the facility did not ensure Resident Fund Authorizations were witnessed. This affected six of six residents (#41, #63, #76, #83, and #220) whose fund accounts were reviewed. The facility census was 120. Findings include: Review of the authorization forms for Resident Fund Accounts for six residents (#41, #63, #76, #83, and #220) revealed none had been witnessed as required. Interview on 04/30/24 at 3:38 P.M. Business Office Manager #506 verified the facility had not had the Resident Fund Account authorization forms witnessed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument User's Manual, the facility failed to ensure assessments were completed accurately for Residents #3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070. This affected 41 residents (#3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070) of 42 residents reviewed for resident assessments. The facility census was 102. Findings include: 1. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke. Review of the physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission. This affected four residents (#105, #114, #418, and #419) of 32 residents reviewed for care plans. The facility census was 120. Findings include: 1. Resident #105 was admitted to the facility on [DATE] with diagnoses including dementia with severe agitation, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, diabetes, traumatic brain injury, and an abdominal aortic aneurysm. Review of the medical record for Resident #105 revealed no information regarding the resident or his responsible party being provided information regarding his care plan within 48 hours of admission. Review of the admission assessment for Resident #105 dated 10/10/23 revealed no information regarding formulation of a care plan for the resident. Interview with Minimum Data Set (MDS) Director #596 on 04/29/24 at 10:44 A.M. 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 immunization reviews, staff interview, and education review, the facility failed to offer COVID-19 education and vaccination opportunities for five staff members (State Tested Nursing Assistant [STNA] #509, [NAME] #548, Licensed Practical Nurse [LPN] #588, LPN #590, and Registered Nurse [RN] #599) of five staff members reviewed for COVID-19 immunizations. The facility census was 120. Findings Include: 1. STNA #509's date of hire was 08/25/21. COVID-19 immunization dates were 11/18/21 and 12/22/21. No evidence was provided regarding education being provided or if the vaccine was offered when booster doses became available. The status of the immunization was listed as past due. 2. [NAME] #548's date of hire was 03/21/23. No information was provided regarding if the employee had been educated and offered the COVID-19 vaccination. The status of the immunization was listed as past due. 3. LPN #588's date of hire was 11/01/19. COVID-19 immunization date provided was 03/23/22. No evidence was provided regarding education being provided or if the vaccine was offered when booster…

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 formulate comprehensive care plans to include all necessary goals of care for Residents #21, #37 and #104. This affected three residents (#21, #37 and #104) of 29 residents reviewed for comprehensive care plans. The facility census was 120. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 03/28/24. Diagnoses included anxiety disorder, depression, type II diabetes mellitus, borderline personality disorder, bipolar disorder, schizoaffective disorder, and post-traumatic stress disorder (PTSD). Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had an intact cognition and PTSD listed as a diagnosis. There was no care plan in the medical record related to diagnoses of PTSD. Interviews on 04/29/24 at 9:24 A.M. and at 10:43 A.M. with MDS Director #596 stated they obtained their information from staff and interview with the residents. MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review the facility failed to revise Resident #62's care plan in a timely manner. This affected one resident (#62) of 32 residents reviewed for care plans. The facility census was 120. Findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses of dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke. Review of the physician's orders for Resident #62 revealed she was admitted to hospice services on 09/18/22 for vascular dementia with cerebral vascular disease. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 was severely cognitively impaired and was rarely understood. She demonstrated physical behaviors towards others, verbal behaviors directed at others, and rejected care one to three days of the assessment reference period. The resident was dependent on staff for all care. Review of the progress notes revealed on 03/12/24 her…

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, review of the activity log, activity evaluation, and review of the facility policy and procedure, the facility failed to ensure activities were provided consistently according to the care plan and resident preferences for Resident #70. This affected one resident (#70) of three residents reviewed for activities. The facility census was 120. Findings include: Review of the medical record for Resident #70 revealed an admission date of 04/28/23. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, and schizophrenia. Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. The assessment also indicated under activities it was very important to listen to music he likes, be around animals, to do things with groups of people, to do favorite activities, go outside for fresh air when the weather is good, and participate in religious services. The primary…

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 review of the menu, the facility failed to ensure Resident #70 was served finger food items per physician's orders. This affected one resident (#70) of three residents reviewed for nutrition. The facility census was 120. Findings include: Review of the medical record for Resident #70 revealed an admission date of 04/28/23. Diagnoses included dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, alcohol dependence with alcohol induced persisting dementia, and schizophrenia. Review of the Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. The assessment indicated the resident required set up or clean up assistance with eating, weighed 140 pounds, had unplanned weight loss, and did not receive a therapeutic or mechanically altered diet. Review of the care plan dated 03/08/24 revealed monitor Resident #70 for potential nutritional problem related to diagnoses of dementia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and facility policy review, the facility failed to assess residents for influenza or pneumonia immunization status upon admission to the facility. This affected two residents (#104 and #105) of 17 residents reviewed for new admission to the facility. The facility census was 120. Findings include: 1. Resident #104 was admitted to the facility on [DATE] with diagnoses including high blood pressure, a stroke, dementia, anxiety, depression, bipolar disease, psychotic disorder, and chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #104 was severely cognitively impaired and required staff assistance for personal care. Review of the immunization status for Resident #104 revealed the resident had tuberculosis testing upon admission but there was no information on the status of influenza or pneumonia immunization status. On 05/01/24 at 12:14 P.M. the Director of Nursing (DON) confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a facility self-reported incident (SRI), facility policy review and interview, the facility failed to ensure Resident #17 was free from an incident of staff to resident abuse. This affected one resident (#17) of three residents reviewed for abuse prohibition. The total census was 125. Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including dementia, delusional disorders, generalized anxiety disorder, and major depressive disorder. Record review revealed a 09/14/23 progress note indicating staff identified bruising to the resident's hands and notified the unit manager and physician. A 09/14/23 skin assessment revealed the resident had bruising to her bilateral hands with no measurement. Progress notes on 09/21/23 and 09/30/23 revealed the bruising faded substantially over this…

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

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to effectively implement their abuse policy to prevent and timely report an incident of abuse involving Resident #17. This affected one resident (#17) of three residents reviewed for abuse prohibition. The total census was 125. Findings include: Record review revealed Resident #17 was admitted to the facility 06/23/23 with diagnoses including dementia, delusional disorders, generalized anxiety disorder, and major depressive disorder. Review of a facility self-reported incident (SRI), dated 09/14/23 revealed the facility reported an allegation of physical abuse to the State agency involving Resident #17 on 09/14/23 at 4:30 P.M. Staff were made aware of the event at 8:00 P.M. on 09/13/23, and the administrator was informed on 09/14/23 at 4:30 P.M. A witness statement by State Tested Nursing Assistant (STNA) #203 revealed on 09/13/23 at…

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

Based on observation and interview, the facility did not ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 117 residents receiving meals from the kitchen excluding . Zero residents in the facility were identified as not eating any foods by mouth. The facility census was 117. Findings include: Observation of the facility kitchen on 08/21/23 at 10:20 A. M. with Dietary Manager (DM) #399 revealed the entire perimeter of the kitchen floor where the walls met the floor contained heavy collections of food crumbs, particles of food, black and brown stains and grime with highest build up behind large equipment and food preparation tables. In the dish room there were two large trash cans full of food and the trash cans and lids were heavily soiled with dried on food splatter. There were small black insects flying around these cans. Underneath the dish machine was evidence of the floor not being properly swept and mopped, as there was a large build up of yellow and brown staining with multiple pieces of food and food particle build up…

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

Based on observation, interview, record review and policy review, the facility failed to keep the facility reasonably free from insects and pests with the potential to affect all 117 residents. The facility census was 117 . Findings include: Review of a service report from the pest control company, dated 03/22/23, contained special instructions at the bottom of the report that stated Employee sanitation practices need improvement. Please ensure employees are following the proper sanitation guidelines mandated by your facility. Mop sink and buckets should be emptied after use to help prevent pests. Observation on 08/21/23 from 8:41 A.M. to 9:28 A.M. of the resident common areas, hallways, dining areas and laundry rooms revealed evidence of living and dead pests in the facility. The floors in the main dining and activity room had food residue, dead flies and spider webs with eggs by the baseboards and behind the piano. The laundry room had moist walls with black staining. There was dirty trash piled high and used dirty gloves scattered on the floor. Laundry aid #405 verified about…

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 notify the physician for Resident #61 when Resident #61 did not receive the ordered treatment of permethrin cream (treatment used for scabies caused by the itch mite Sarcoptes scabiei which produces a highly contagious skin rash) on the date of 07/26/23 when it should have been administered to Resident #61. This affected one resident (Resident #61) out of seven residents (Resident #26, #36, #54, #61, #62, #96, and #103) reviewed for notification of changes. The facility census was 117. Findings included: Review of the medical record for Resident #61 revealed an admission date of 01/13/23 and diagnoses included psychosis, dementia, and chronic obstructive pulmonary disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] and revealed Resident #61 was cognitively impaired as his brief interview for mental status (BIMS) score was a nine. He required supervision only with bed mobility, transfers, and ambulation. Review of a nursing…

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

Based on observation, interview, and facility policy review the facility failed to serve meals at a palatable temperature. This had the potential to affect all residents in the facility. The facility census was 117. Findings include: Interview on 07/17/23 at 10:19 A.M. with Resident #100 revealed food was not very warm at times. Interview on 07/17/23 at 11:00 A.M. with Resident #61 revealed food was not always warm enough. Observation on 07/18/23 at 7:03 A.M. revealed the breakfast tray line started. The last cart of resident trays left the kitchen at 8:03 A.M. and arrived on the 100 unit at 8:05 A.M. The last resident food tray was passed at 8:21 A.M. A test tray conducted on 07/18/23 at 8:22 A.M. with Food Service Director (FD) #228 revealed the scrambled eggs were 107 degrees Fahrenheit. FD # 228 confirmed she wished the scrambled eggs were hotter. Review of facility food council meeting minutes from 04/17/23 to 07/17/23. Some initial concerns related to taste and temperature were expressed on 04/17/23. Review of the revised facility policy dated October 2017 titled Food 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 interview and record review, the facility failed to have a building-specific legionella assessment in place. This had the potential to affect all 117 residents in the facility. Findings include: Review of the facility legionella prevention documentation revealed the facility did not have a building-specific assessment identifying where legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. These findings were verified with the Administrator on 07/20/23 at 2:09 P.M.

Based on observation, record review, and interview the facility failed to ensure resident rooms were maintained in a sanitary condition and in good repair and failed to ensure the common bathroom on the secured memory care unit (SMCU) was maintained in a sanitary condition. This finding affected one resident (#88) and had the potential to affect an additional 42 residents who reside on the SMCU including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163. Findings include: 1. Interviews on 07/17/23 at 12:29 P.M. with Resident #88's daughter and son-in-law indicated the bathroom toilet had a toilet seat riser in place, and stool was observed on the rim and outer bowl of the toilet, the closet door was not on the track and had been broken for approximately one year, and the nightstand's second drawer that was broken. Observation on 07/17/23 at 12:45 P.M. with Maintenance Assistant #209 confirmed Resident #88's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure Resident #162 was transferred according to the physician's order and failed to ensure Resident #107's fall investigations were completed to ensure fall prevention interventions were in place as well as new interventions implemented. This finding affected two residents (#107 and #162) of three residents reviewed for transfers and falls. The facility census was 117. Findings include: 1. Review of Resident #162's medical record revealed she was admitted on [DATE] with diagnoses including other Alzheimer's disease, chronic obstructive pulmonary disease, and overactive bladder. Review of Resident #162's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for transfers and toileting. Review of Resident #162's physician orders revealed an order dated 06/30/23 for two staff member assist during transfers every shift. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review the facility failed to ensure adequate staffing to meet the needs of the residents. This finding affected Residents #99 and #162 and had the potential to affect all 43 residents residing on the secured memory care unit (SMCU) including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #88, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163. Findings include: 1. Review of Resident #99's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, malignant neoplasm of the prostate, anxiety disorder and major depressive disorder. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem and required extensive one person assist for bed mobility, dressing, and personal hygiene as well as extensive two person assist for transfers and toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide appropriate oral care for Resident #71 and failed to document refusals. This affected one resident (#71) of three residents reviewed for activities of daily living. The census was 117. Findings include: Observation of Resident #71 on 07/17/23 at 11:35 A.M. revealed Resident #71 sitting in a common room. She had brown teeth with a noticeable moist film on them and a crusty orange substance on her teeth and lips. She was not interviewable. Record review of Resident #71 revealed she was admitted [DATE] with diagnoses including dementia, macular degeneration, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment on 06/14/23 revealed Resident #71 was rarely or never understood, required extensive assistance for personal hygiene, and received hospice services. She was care planned for refusing oral care; however, review of the progress notes and hygiene care documentation revealed no documented evidence of refusals 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, interview, and facility policy review the facility failed to ensure Resident #99 was provided timely care. This finding affected one resident (#99) of three residents reviewed for incontinence care. Findings include: Review of Resident #99's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, malignant neoplasm of the prostate, anxiety disorder, and major depressive disorder. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem and required extensive one person assist for bed mobility, dressing, and personal hygiene as well as extensive two person assist for transfers and toilet use. Observation on 07/17/23 at 10:09 A.M. revealed Resident #99 was in the common television lounge on the secured memory care unit (SMCU). He was observed in a reclined Broda chair sleeping with music on the television. Observation on 07/17/23 at 12:12 P.M. revealed Resident #99 was moved from…

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