Marion Valley Post Acute

Based on medical record review, review of Binding Arbitration Agreements, resident interview, staff interview and policy review, the facility failed to ensure residents were able to understand and comprehend the terms of a Binding Arbitration Agreement before entering into one. This affected five (#27, #31, #60, #64, and #84) of six residents reviewed for arbitration agreements. The facility census was 80. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 05/14/25 with diagnoses including, but not limited to, dementia. Review of the Minimum Data Set (MDS) assessment, dated 05/21/25, revealed Resident #27 was moderately cognitively impaired. Review of the Binding Arbitration Agreement, signed 05/14/25, revealed Resident #27 signed the document herself. Interview on 06/30/25 at 8:01 A.M. with Resident #27 revealed the resident stated that an arbitration agreement was when two people got together and argued a point and come to a solution. Resident #27 stated she did not think she would sign an arbitration agreement with the facility. 2.…

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

Based on medical record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure residents were offered or provided the COVID-19 vaccination. This affected four residents (#28, #33, #47, #50) of five residents reviewed for immunizations. The facility census was 80. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 02/06/19, with diagnoses including chronic heart failure, anxiety disorder, dementia, depression, cardiac arrhythmia, and adult failure to thrive. Review of Resident #47's medical record revealed no evidence she had been offered a COVID-19 booster since 2023. Interview on 07/01/25 at 10:48 A.M. with Licensed Practical Nurse (LPN) #506 verified that there was no evidence the COVID-19 vaccine had been offered to Resident #47 since 2023. 2. Review of Resident #50's medical record revealed an admission date of 03/11/20, with diagnoses including type two diabetes mellitus, chronic respiratory failure, depression, heart failure, and major depressive disorder.…

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

Based on observation, staff interview, medical record review and review of facility policy, the facility failed to maintain resident dignity by ensuring catheter collection bags were covered in common areas. This affected two (#45 and #70) of three residents reviewed for catheter care. The facility census was 80. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 09/04/22 with diagnoses including muscle wasting, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms and retention of urine. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/08/25, revealed Resident #70 was cognitively intact, had an indwelling catheter and was always incontinent of bowel. Review of the care plan, dated 11/07/23, revealed Resident #70 was at risk for infection and/or trauma related to the use of a supra-pubic catheter for obstructive uropathy. Interventions include administer medications per physician order, catheter care every shift, change suprapubic catheter on the 19th of the month, check catheter…

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

Based on medical record review, staff interview, and policy review the facility failed to ensure comprehensive care plans were developed to address resident care needs. This affected one (#53) of six residents reviewed for care plans. The facility census was 80. Findings include: Review of medical record for Resident #53 revealed an admission date of 07/31/24 with diagnoses including, but not limited to, infection and inflammatory reaction to internal right knee prosthesis. Review of the current physician orders revealed Resident #53 was ordered doxycycline (antibiotic) 100 milligrams (mg) twice daily for prophylactic related to total right knee infection per orthopedic surgeon. Review of current care plan revealed no care plan for antibiotic use or infection. Interview on 06/30/25 at 11:04 A.M. with the Director of Nursing (DON) verified Resident #53 did not have a care plan for antibiotic use or infection. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed a comprehensive, person-centered care plan that included measurable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, review of bathing documentation and review of facility policy, the facility failed to ensure dependent residents received timely and adequate staff assistance with personal hygiene. This affected one (#32) of two residents reviewed for activities of daily living (ADLs). The facility census was 80. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] with diagnoses including hemiplegia, muscle weakness, major depressive disorder, abnormalities of gait and mobility, dysphagia, and overactive bladder. Review of the care plan, dated 11/20/23, revealed Resident #32 had an ADL self-care and mobility performance deficit related to generalized weakness, dizziness, post-cerebrovascular accident (stroke), diabetes, and obesity. Interventions included the use of a Hoyer lift, two-person (staff) assistance with toileting and bed mobility, and staff assistance with daily hygiene, grooming, and oral care. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, medical record review, and review of activities documentation, the facility failed to ensure activities were offered to all residents. This affected one (#342) of one resident reviewed for activities. The facility census was 80. Findings include: Review of the medical record revealed Resident #342 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/29/25, revealed Resident #342 had intact cognitive status. The MDS indicated the resident identified that it was somewhat important for her to listen to music that she liked, keeping up with the news, being around pets, going outside when the weather was good and participating in religious practices. Review of Resident #342's activity assessment, dated 06/27/25, revealed that she preferred in-room activities. Interview with Resident #342 on 06/29/25 at 9:45 A.M. revealed that she was not included in activities, but…

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 2. Review of medical record for Resident #53 revealed an admission date of 07/31/24 with diagnosis including, but not limited to, obstructive sleep apnea (difficulty breathing when sleeping). Review of current physician orders revealed an order dated 02/19/25 to schedule a sleep study for Resident #53. Further review of Resident #53's medical record revealed no evidence a sleep study was scheduled or completed. Review of a nursing progress note dated 06/09/25 revealed the Certified Nurse Practitioner (CNP) called into the facility to give a new order for a sleep study. Per the resident, they used a continuous positive airway pressure (CPAP) at home and did not bring it to the facility due to it being broken. Interview on 06/29/25 at 10:22 A.M. with Resident #53 revealed that he was supposed to have a sleep study done but it had not happened. Interview on 06/30/25 at 11:04 A.M. with the Director of Nursing (DON) revealed she would look into the status of the sleep study for Resident #53. A follow-up 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, medical record review, staff interview and review of facility policy, the facility failed to ensure oxygen tubing was changed routinely. This affected two (#50 and #78) of three residents reviewed for oxygen. In addition, the failed to monitor and document as needed oxygen use. This affected one (#32) of three residents reviewed for oxygen. The facility census was 80. Findings include: 1. Review of medical record for Resident #50 revealed an admission date of 03/11/20 with diagnoses including, but not limited to, chronic respiratory failure with hypercapnia and hypoxia (trouble breathing), obstructive sleep apnea (difficulty breathing while sleeping), and morbid obesity with alveolar hypoventilation (weight obstructs breathing deeply). Review of the current physician orders revealed Resident #50 received oxygen at two liters per minute (lpm) via nasal cannula (NC) continuously. Observation on 06/29/25 at 10:17 A.M. of Resident #50's oxygen tubing revealed the tubing was dated 03/02/25.…

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 interview, medical record review, and policy review the facility failed to ensure parameters were in place for pain medication administration and ensure non-pharmacological interventions were implemented and descriptions of pain were documented with administration of pain medication. This affected one resident (#48) of two residents reviewed for pain. The facility census was 80. Findings include: Review of Resident #48's medical record revealed an admission date of 03/28/24 with diagnoses including chronic respiratory failure, type two diabetes mellitus, major depressive disorder, generalized anxiety disorder, cognitive communication deficit, unspecified dementia, and metabolic encephalopathy Review of Resident #48's plan of care dated 09/09/24 revealed the resident was at risk for pain related to decreased mobility with neuropathy, restless leg syndrome, and history of migraine headaches. Interventions included acknowledging the presence of pain and discomfort, administering pain medication as ordered, assessing for pain, encouraging non-medicinal interventions, evaluating…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure pre and post dialysis evaluations were completed. This affected one (#15) of one resident identified as receiving dialysis. The facility census was 80. Findings include: Review of medical record for Resident #15 revealed an admission date of 08/11/17 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Review of Resident #15's current physician orders revealed to complete a post-dialysis evaluation, complete a pre-dialysis evaluation and send with the resident, and dialysis every Monday, Wednesday, and Friday. Review of Resident #15's dialysis evaluations for May 2025 and June 2025 revealed no pre or post dialysis evaluations were completed on 05/23/25, 05/30/25, 06/02/25, 06/04/25, 06/13/25, and 06/16/25. Further review of the dialysis communication revealed no post-dialysis evaluations were completed on 06/09/25 and 06/27/25. Interview on 06/30/25 at 11:54 A.M. with the Director of Nursing (DON) verified the facility 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 medical record review, staff interview and review of facility policy, the facility failed to ensure residents were seen by the physician as required. This affected one (#4) of one resident reviewed for physician visits. The facility census was 80. Findings include: Review of the medical record for Resident #4 revealed an admission date of 07/19/24 with diagnoses including, but not limited to, zoster encephalitis, dysphagia, and metabolic encephalopathy. Review of the physician visit notes revealed the resident was seen by the physician on 07/22/24, 01/30/25, and 02/13/25. The resident was seen by the Certified Nurse Practitioner (CNP) on 07/19/24, 07/24/24, 07/31/24, 08/08/24, 08/28/24, 09/19/24, 09/24/24, 10/10/24, 10/28/24, 11/11/24, 11/13/24, 11/26/24, 02/26/25, 03/26/25, and 06/30/25. Interview on 07/01/25 at 7:43 A.M. with the Director of Nursing (DON) verified the physician only completed visits with Resident #4 on 07/22/24, 01/30/25, and 02/13/25. The DON confirmed the physician did not see the resident at least every 30 days for the first 90 days following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure blood pressure medications were administered per physician order. This affected one (#75) of one resident reviewed for medication monitoring. The facility census was 80. Findings include: Review of Resident #75's medical record revealed an admission date of 01/07/25 with diagnoses including type one diabetes mellitus, hypertension, cognitive communication deficit, major depressive disorder, and unspecified dementia, and disorientation. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #75's plan of care dated 01/08/25 revealed the resident was at risk for impaired cardiac function and complications related to diagnoses, history of a pacemaker, and aortic valve replacement in 2020. Interventions included administering medications as ordered, cardiology consultation, diet as ordered, notifying the physician of signs of…

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

Based on medical record review, review of pharmacy recommendations, and staff interview, the facility failed to ensure the physician addressed pharmacy recommendations timely. This affected one (#76) of five residents reviewed for unnecessary medications. The facility census was 80. Findings include: Review of Resident #76's medical record revealed an admission date of 04/20/24 with diagnoses including metabolic encephalopathy, dementia without psychosis, chronic kidney disease stage four, peripheral vascular disease, anxiety, depression, and dysphagia. Review of Resident #76's pharmacy recommendation form dated 10/23/24 revealed a gradual dose reduction of buspirone (anti-anxiety medication) was recommended. Further review revealed no evidence the physician addressed the recommendation. Review of Resident #76's pharmacy recommendation form dated 11/26/24 revealed it was recommended the physician review the resident's order for loratadine (allergy medication) as there were two orders for the medication, one for 10 milligrams (mg) every other day and one as needed. Further review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of urine culture results, staff interview and review of the facility policy, the facility failed to ensure urinary tract infections (UTIs) were treated appropriately. This affected one (#70) of two residents reviewed for UTIs. The facility census was 80. Findings include: Review of the medical record for Resident #70 revealed an admission date of 09/04/2022, with diagnoses including muscle wasting, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms, and urinary retention. Review of the care plan dated 11/07/23 revealed Resident #70 was at risk for infection and/or trauma related to the use of a suprapubic catheter. Interventions included administering medications as ordered, performing catheter care every shift, changing the suprapubic catheter on the 19th of each month, checking catheter patency and tubing every shift, and providing catheter care per facility policy. Review of the Minimum Data Set (MDS) 3.0 assessment dated…

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

Based on observation, interview, record review, and facility policy review the facility failed to ensure the crash carts were inspected routinely. This had the potential to affect all 47 residents the facility identified to have a Full Code status. The facility census was 87. Findings include: Review of the crash cart sign off sheet revealed staff to check every shift to verify the lock code is the same as the shift prior. If the code needs to be changed because the cart was accessed, use the provided inventory sheet to confirm all items have been replaced. Apply a new lock and document the code on the sheet. The subsequent shift should then verify the lock number is the same as the shift prior (new lock applied, if indicated). Observation on 05/12/25 at 2:17 P.M. of crash cart in the nurse's station on 400/500/600 hall revealed the Automated External Defibrillator (AED) was in the bottom drawer. Review of the Crash cart sign off for the 400/500/600 hall revealed the lock was verified by one nurse 03/01/25 through 03/11/25 and the lock was changed on 03/11/25. The sign off was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure fall interventions were in place. This affected one (#71) of three residents reviewed for falls. The facility census was 87. Findings include: Review of medical record for Resident #71 revealed an admission date of 02/26/24 with diagnoses including but not limited to senile degeneration of brain, Alzheimer's disease, major depressive disorder, unsteadiness on feet, and disorientation. Review of minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of care plan for falls revealed the following interventions non-skid material under cushion and on top of wheelchair cushion and non-skid strips to the closet side of the bed. Observation on 05/12/25 at 2:05 P.M. of Resident #71 revealed no non-skid strips to the closet side of the bed or any non-skid material in Broda chair. Interview on 05/12/25 with Certified Nursing Assistant (CNA #368) verified no non-skid strips to the closet side…

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

Based on observation, interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all residents who receive food and beverages from the kitchen in the facility. The facility census was 103. Findings include: Interview on 11/21/2024 at 2:17 P.M. with Resident #38's family member revealed his other family member was allowed to go into the kitchen to get ice and they stated the kitchen was very unsanitary. Observation on 11/26/2024 at 11:16 A.M. revealed a ceiling tile behind the tray line was water damaged, cracked, and bowing outwardly toward the floor. Interview on 11/26/2024 at 11:16 A.M. with Dietary Aide #72 confirmed the ceiling tile was water damaged, cracked and bowing. Dietary Aide #72 revealed the ceiling tile did leak sometimes when it rained. Interview on 11/26/2024 at 11:18 A.M. with Dietary Director #1 revealed that the ceiling did leak, but he had not seen it actively leak. Review of the policy titled Environment dated September 2017 revealed the Dining Services Director would ensure that the…

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

Based on observations, staff interview, and review of facility policy, the facility failed to ensure proper hand hygiene during lunch meal service. This had the potential to affect 113 residents who ate food served from the kitchen. The facility identified two (#21 and #107) residents who received no food from the kitchen. The facility census was 115. Findings include: Observations on 05/30/24 from 11:40 A.M. to 12:20 P.M. revealed [NAME] #309 donned clean gloves at 11:42 A.M., without completing any hand hygiene prior to donning the gloves. [NAME] #309 started the lunch meal service. At approximately 11:45 A.M., [NAME] #309 used his gloved hands to touch the spaghetti noodles that were hanging down off the plate to put them on the plate properly. At 11:48 A.M. and 11:50 A.M., [NAME] #309 adjusted his pants and pulled up his sweater sleeves with the same gloves on. At 11:50 A.M., [NAME] #309 was observed touching the inside of the plate prior to placing food items on it with the same gloved hands. [NAME] #310 was also observed opening the steamer by grabbing the handle with gloved…

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

Based on resident personal needs accounts (PNA) reviews and staff interviews, the facility failed to ensure Medicaid residents were provided notification to spend down when their account was reaching the Medicaid Resource Limit. This affected one (#65) out of five residents accounts reviewed. The facility census was 97. Findings include: Review of Resident #65's PNA account revealed the resident was a Medicaid recipient. Further review of Resident #65's PNA account identified on 09/19/22 the balance is $4,011.68. The records identified Resident #65's balance has exceeded the $2,000 Medicaid Resource Limit since at least April 8, 2021. There was no evidence Resident #65 or the residents representative were provided with a notice to spend down. Interview with Business Office Manager (BOM) #756 on 09/22/22 at 8:34 A.M. revealed the facility could no locate any policy or procedure that identified when notifications to spend down should occur and what to do if there is a lack of response. BOM #756 confirmed she is fairly new to the position and was instructed to send the letters out 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 medical record review, observations and resident and staff interview, the facility failed to ensure residents were provided with timely incontinent care. This affected two (#24 and #25) of four residents reviewed for activities of daily living. The facility census was 97. Findings include: 1. Review of Resident #24's medical record revealed the resident was admitted on [DATE] with diagnoses of atherosclerotic heart disease, weakness, heart failure, transient cerebral ischemic attack, and type two diabetes. Review of Resident 24's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident is cognitively intact, had no behaviors and required extensive assist for toileting and personal hygiene. Resident was coded as frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident #24's at risk related to urinary incontinence care plan revealed intervention to provide incontinent care as needed. Interview with Resident #24 on 09/19/22 at 2:24 P.M. revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to implement as needed laxatives when a resident was experiencing constipation. This affected one (#73) out of six residents reviewed during the annual survey. The facility census was 97. Findings include: Review of Resident #73 medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, other symptoms and signs involving the musculoskeletal system, heart failure, cognitive communication deficit, dementia, repeated falls, hypertension, need for attention for personal care. Review of the Minimal Data Set (MDS) dated [DATE] revealed Resident #73 had cognitive impairment. Her functional status is listed as extensive two person assist for all activities of daily living. The MDS also revealed Resident #73 is frequently incontinent of urine and always incontinent of bowel. The MDS also revealed the Resident has no skin issues. Review of the care plan dated 08/24/22 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 medical record review, observation and staff interview the facility failed to provide the correct enteral feeding to a resident. This affected one (#90) out of one resident reviewed for enteral feeding. The total facility census was 97. Findings include: Review of Resident #90's medical record revealed the resident was admitted on [DATE] with diagnoses that include but are not limited to sepsis, hyperlipidemia, vitamin D deficiency, hemiplegia, acute pyelonephritis and acute kidney infection. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment, no behaviors, required extensive assist with eating, had enteral feeding and was on a nutritional program for pressure ulcer care. Review of Resident #90's care plan dated 08/24/22 revealed altered nutritional nutritional status as related to diagnosis cerebrovascular accident, nothing by mouth and dependent upon enteral feed to meet nutrient needs. Care plan included enteral feeding related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff interview the facility failed to provide therapeutic diets as ordered. This affected three (#53, #67, and #13) out of three residents reviewed for therapeutic diets. The facility census was 97. Findings include: 1. Review of Resident #53's medical record revealed the resident was admitted on [DATE] with diagnosis that include Alzheimer's disease, weakness, and depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident is cognitively impaired had no behaviors required a mechanically altered diet and had no mouth pain, no broken or loosely fitting full or partial denture. Review of Resident #53's orders revealed the resident was ordered a regular diet with mechanical soft texture on 08/31/22. Observation of the lunch meal in the main dining room on 09/19/22 at 12:09 A.M. revealed Resident #53 received her meal in the main dining room. Observation of meal tray pass on 09/19/22 at 12:50 P.M. revealed Resident #53…

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

Based on observation, interview of facility staff, and review of facility policy, the facility failed to store and label food in an appropriate manner. This had the potential to affect all 115 residents residing in the facility. Findings include 1. Observation on 09/23/19 at 8:30 A.M. revealed boxes sitting on the floor of the pantry. The boxes showed wet marks and the floor around the boxes was wet. The boxes were not labeled with the date received by the facility. Interview on 09/23/19 at 8:30 A.M. with Dietary Aide (DA) #331 revealed the boxes had been received on 09/21/19 as frozen juices. The boxes were kept in the pantry so the juices would start to thaw. The boxes would then be placed into the refrigerator after thawing for several days. Observation on 09/23/19 at 8:40 A.M. revealed the juice boxes were labeled with the date received of 09/21/19 and placed into refrigerator. Interview on 09/23/19 at 10:20 A.M. with Food Service Director (FSD) #332 verified the boxes were stored on the pantry floor and were not labeled with the date received by the facility. Review of the…

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

Based on the medical record review, observation, staff interview, review of manufacturer recommendations and review of the facility policy, the facility failed to ensure staff administered the proper dose of insulin, which results in a significant medication error. This affected one (Resident #57) of five residents observed for medication pass. This had the potential to affect 20 residents who received insulin via the Kwik Pen. The facility census was 115. Findings include: Review of the medical record for Resident #57 revealed an admission date of 07/24/19. Diagnoses included diabetes mellitus. Review of the physician's order for Resident #57 revealed an order for Insulin Lispro 100 unit per milliliter to inject subcutaneous as per sliding scale to be given before meals and at bedtime. Observation of medication pass with Licensed Practical Nurse (LPN) #300 on 09/24/19 at 11:33 A.M. revealed she was giving insulin to Resident #57. She pulled out the Insulin Lispro Kwik Pen units 100 cleaned the end with alcohol pad, then placed the new insulin needle on the end. She dialed up two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and review of facility policy, the facility failed to ensure staff were properly securing medication carts when left unattended. This had the potential to affect five cognitively impaired residents who reside on the 300-hall. The facility census was 115. Findings include: Observation of the medication cart on 300-hall on 09/24/19 at 7:40 A.M. revealed Registered Nurse (RN) #310 walked away from the unlocked medication cart at this time. At 7: 43 A.M., the RN walked back to the cart and immediately walked away to behind the nurse's desk to the medication room. RN #310 walked back to the medication cart at 7:48 A.M. and verified the medication cart was left unlocked and stated she had a rough night. Observation of Licensed Practical Nurse (LPN) #320 on 09/24/19 at 8:24 A.M. revealed the LPN went to the medication cart and unlocked it. He left the unlocked medication cart and went into room [ROOM NUMBER]. Interview with LPN #310 on 09/24/19 at 8:26 A.M. verified he had walked…

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 interviews, review of facility's admission packet and record review, the facility failed to issue a bed hold notification letter to a resident. This affected one (Resident #115) of one resident reviewed for hospitalization. The facility census was 115. Findings include: Record review for Resident #115 revealed the resident was admitted to the facility on [DATE] for rehabilitation services. Review of the nursing progress note, dated 07/22/19, revealed the resident was crying in room because of hip pain and requested to be sent to the emergency room. The resident was transferred to the hospital at 4:25 P.M. on 07/22/19 and admitted to the hospital for hip pain and hypokalemia. On 09/25/19 at 2:04 P.M., an interview with the Administrator and the Director of Nursing revealed the resident did not receive a bed hold notification letter because Medicaid was not her payor source. On 09/26/19 at 12:28 P.M., interview with the Business Office Manager #330 revealed they did not give Resident #115 a bed hold…

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.