Gardens Of Mayfield Village

Based on record review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were screened for immunization, educated on the risk and benefit of receiving the COVID-19 vaccine, or were offered and received COVID-19 vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations. The facility census was 59. Findings include: 1. Review of Resident #3's medical records revealed an admission date of 05/17/24. Diagnoses included dementia, schizophrenia and muscle weakness. Review of Resident #3's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 stated they were unable to locate the vaccination records, refusals or education for Residents #3, #8, #11, #21, and #60. VPO #172 and RRN #182 further confirmed no documented evidence 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.

Based on record review, observation and interview, the facility failed to ensure the elevators were working in a safe operation condition. This had the potential to affect all 59 residents residing in the facility. Findings include: Review of documentation for elevator concerns including invoices from the elevator service company dated from 11/08/24 to 05/13/25, incident with the fire department with elevator rescue and an employee in-service revealed the facility had been having elevator concerns to both elevators since 11/08/24. Review of the documentation revealed: -11/08/24 invoice-Elevator one was not responding, stuck on unknown floor and the doors closed. It was unoccupied. Elevator technician adjusted the light tray and elevator one was still in service. -12/09/24 invoice-Elevator preventative maintenance. -01/08/25 invoice-Elevator one and two, preventative entrapment, elevators not responding. Both elevators stuck on unknown floors. The doors were closed on both elevators. The elevators were unoccupied. Elevator technician emptied pit buckets on both cars and then checked…

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 maintain a clean, sanitary and safe environment. This had the potential to affect all 59 residents residing in the facility. The facility census was 59. Findings include: Initial observation of the facility on 05/12/25 at 8:15 A.M. of the first floor revealed the bathroom on the first floor toilet paper holder was broken off. The Director of Nursing (DON) was present and verified the finding. On the second floor on the memory care unit there was noted to be strong odors of urine and bowel. The ice machine on the blue hall noted to have water leaking around it with towels and bath blankets laying on the floor to soak up the water that had leaked. Observation on 05/12/25 at 9:04 A.M. of Resident #45's room revealed the resident was not present in room. The bed linens were observed to have been heavily soiled and were odorous. The call light was observed across the room on the floor. On 05/12/25 at 9:18 A.M. returned to Resident #45's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain resident room water temperatures at a comfortable level. This affected five (Residents #7, #19, #27, #32 and #49) out of seven resident rooms tested for water temperatures. The facility census was 59. Findings include: Review of the last audit of water temperatures obtained by the facility was noted to be on 04/02/25 and 04/18/25. Temperatures were noted to be between 113.8 and 116.1. Observation on 05/14/25 at 9:20 A.M. of incontinence care to Resident #19 revealed she stated the water was cold. Certified Nursing Assistant (CNA) #135 stated he had let the water run for five minutes and Resident #19 wanted her water really hot. Observation on 05/14/25 at 9:44 A.M. and 9:45 A.M. of hot water temperatures revealed rooms [ROOM NUMBERS] were of required temperatures between 105 and 120 degrees Fahrenheit. On 05/14/25 at 9:50 A.M. observed water temperatures with CNA #125. room [ROOM NUMBER] (Residents #19 and #49) and room [ROOM NUMBER] (Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehension assessments were accurately completed. This affected five (Residents #34, #39, #51, #59 and #69) out of 40 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 59. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy (seizures), cognitive communication deficit, need for assistance with personal care and history of encephalitis (inflammation of the brain). Review of the census for Resident #51 revealed he was admitted to the hospital from [DATE] through 03/06/25. Review of the nursing readmission assessment dated [DATE] for Resident #51 revealed he had no skin issues noted. Review of the weekly skin assessment on 03/12/25 for Resident #51 revealed his skin was intact. Review of the MDS 3.0 assessment for Resident #51 dated 03/31/25, discharge return anticipated, revealed section M stated he had a Stage III…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure dependent residents were assisted with activities of daily living. This affected four (Residents #21, #24, #39 and #51) of nine reviewed for activities of daily living for dependent residents. The facility census was 59. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy, cognitive communication deficit and need for assistance with personal care. Review of the care plan dated 07/09/24 for Resident #51 revealed he was at increased risk for malnutrition related to medications, seizures, weakness, dysphagia, mechanically altered diet and pocketing food. Interventions included for staff to assist with all meals. Review of the nursing readmission assessment dated [DATE] for Resident #51 revealed he was totally dependent on staff for eating. Observation on 05/19/25 at 12:00 P.M. of Resident #51 revealed his meal tray for lunch was delivered to his…

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

Based on record review, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were were offered, screened, educated and received influenza and pnuemociccal vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations with the potential to affect all 59 residents residing in the facility. Findings include: 1. Review of Resident #3's medical records revealed an admission date of 05/17/24. Diagnoses included dementia, schizophrenia and muscle weakness. Review of Resident #3's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #3. VPO #172 and RRN #182 further confirmed no documented evidence was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and interview, the facility did not ensure Resident #26 was assessed to self-administer medications. This affected one resident (Resident #36) of two residents reviewed for self-administering medications. Facility census was 59. Findings include: Record review for Resident #26 revealed an admission date of 04/25/17 with diagnoses of legal blindness, acquired absence of one eye, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and had severe vision impairment. Review of the physician orders revealed Resident #26 self-administered, without supervision, Calcium-Vitamin D tablet 600-400 mg twice a day, Ammonium Lactate 12% Lotion topically to bilateral legs twice a day, and Omega-3 1000 mg soft gel once daily. Physician orders also contained an order Resident #26 was able to have medications at bedside with a start date of 11/30/21. Review of Medication Self-Administration Safety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure a properly functioning elevator to accommodate resident needs. This affected three (Residents #6, #11 and #35) of 20 residents reviewed for environmental accommodation of needs. The facility census was 59. Findings include: Review of the medical record for Resident #6 revealed an admission date of 07/01/24 with diagnoses including morbid obesity, need for assistance with personal care, muscle weakness and difficulty walking. Review of the care plan dated 07/02/24 for Resident #6 revealed he had self care deficit and needed assistance from staff for activities of daily living. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #6, under section F, revealed it was very important to do his favorite activities and somewhat important to do things with a group of people. He was noted to have intact cognition. Review of the medical record for Resident #11 revealed an admission date of 03/02/17 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.

Based on record review and interview, the facility failed to ensure residents received complete and accurate notices of Medicare non-coverage when their skilled services ended. This affected one (Resident #59) of four residents reviewed for liability notices. The facility census was 59. Findings include: Review of the medical record for Resident #59 revealed an admission date of 12/02/24 with diagnoses including heart disease, history of falling and chronic obstructive pulmonary disease. Resident #59 remained in the facility after discontinuation of Medicare A services. Review of the Notice of Medicare Non-Coverage (NOMNC) signed and dated by Resident #59 on 02/21/25 revealed his last covered day for Medicare A services was on 02/24/25. The notice did not provide the type of services that were being discontinued, who he should contact for an appeal or their phone number. Interview on 05/22/25 at 11:26 A.M. with [NAME] President of Operations (VPO) #172 verified Resident #59's NOMNC dated 02/21/25 was not complete and accurate as it did not state the type of services ending, who he…

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 review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to prevent staff-to-resident physical abuse. This affected one resident (#49) out of seven residents reviewed for abuse. Facility census was 59. Findings include: Review of Resident #49's medical record revealed an admission date of 02/20/25 and diagnoses including schizoaffective disorder, anxiety, depression, anemia and post-traumatic stress disorder. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact, had disorganized thinking, had an ostomy and was frequently incontinent of urine. Review of a nurses' note dated 04/02/25 at 9:07 P.M. authored by Licensed Practical Nurse (LPN) #176 revealed the following information: 'This nurse was sitting behind the nursing station charting and preparing medication. The resident tried to go down the elevator with another resident and this nurse stated to resident she could not go…

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 interviews and record review the facility failed to ensure that as needed psychotropic medication orders were limited to 14 days for Resident #4. This affected one resident (Resident #4) out of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of Resident #4's medical records revealed an admission date of 04/30/24. Diagnoses included bipolar, schizoaffective disorder, restlessness and agitation. Review of Resident #4's physician's orders revealed an order dated 04/17/25 for Hydroxyzine (antipsychotic) 25 milligrams (mg) by mouth every 8 (eight) hours as needed for anxiety without a stop date. Review of Resident #4's MDS assessment dated [DATE] revealed cognitive impairment. Review of (Resident #4's) medication administration record (MAR) revealed that Resident #4 received Hydroxyzine on 04/27/25 and 04/29/25. Review of Resident #4's care plan dated 05/01/24 revealed the use of psychotropic medication for behavior management with interventions,…

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, review of self-reported incidents (SRIs), interview and review of the facility policy, the facility failed to timely report allegations of abuse. This affected three residents (#6, #25 and #49) of seven residents reviewed for abuse. Facility census was 59. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 02/20/25 and diagnoses including schizoaffective disorder, anxiety, depression, anemia and post-traumatic stress disorder. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact, had disorganized thinking, had an ostomy and was frequently incontinent of urine. Review of a nurses' note dated 04/02/25 at 9:07 P.M. authored by Licensed Practical Nurse (LPN) #176 revealed the following information: 'This nurse was sitting behind the nursing station charting and preparing medication. The resident tried to go down the elevator with another resident and this nurse stated to resident she…

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 review of the facility policy, the facility failed to thoroughly investigate allegations of abuse. This affected one resident (#49) of seven residents reviewed for abuse. Facility census was 59. Findings include: Review of Resident #49's medical record revealed an admission date of 02/20/25 and diagnoses including schizoaffective disorder, anxiety, depression, anemia and post-traumatic stress disorder. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact, had disorganized thinking, had an ostomy and was frequently incontinent of urine. Review of a nurses' note dated 04/02/25 at 9:07 P.M. authored by Licensed Practical Nurse (LPN) #176 revealed the following information: 'This nurse was sitting behind the nursing station charting and preparing medication. The resident tried to go down the elevator with another resident and this nurse stated to resident she could not go down by herself and smoke, she had to wait…

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 Resident #49's medical record revealed an admission date of 02/20/25 and diagnoses including schizoaffective disorder, anxiety, depression, anemia and post-traumatic stress disorder. Review of an admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively intact, had disorganized thinking, had an ostomy and was frequently incontinent of urine. Review of a plan of care dated 02/25/25 revealed Resident #49 had an alteration in gastrointestinal status related to ostomy. Interventions were listed including: Avoid lying down for at least one hour after eating; Keep head of bed elevated; Encourage to stand/sit upright after meals; Discuss with the resident/family/caregivers any concerns/fears/issues related to gastro-intestinal distress; Empty ostomy every shift and as needed (PRN); Encourage the resident to avoid alcohol, smoking, coffee (even decaffeinated), fatty foods, chocolate, citrus juices, [NAME], tomato products, garlic and onions; Encourage a bland diet;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure showers were completed as scheduled and per resident preference. This affected two (Residents #27 and #59) out of two residents reviewed for showers who required less than or equal to limited assistance. The facility census was 59. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 12/02/24 with diagnoses including heart disease, history of falling and chronic obstructive pulmonary disease. Review of the nursing admission assessment dated [DATE] revealed Resident #59 was independent for eating, toileting, and bed mobility. He needed supervision for transferring and dressing. He needed limited staff assistance for personal hygiene and physical help only with the transfer for bathing. Review of the facility shower schedule, undated, revealed Resident #59 was to receive showers on Mondays and Thursdays on night shift. Interview on 05/12/25 at 10:11 A.M. with Resident #59 revealed he did not receive…

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 Resident #48's medical records revealed an admission date of 01/30/25. Diagnoses included cognitive deficits, schizoaffective and bipolar. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Review of progress note dated 05/02/25 timed 10:30 P.M. authored by Registered Nurse (RN) #156 revealed Resident #48 had returned from the hospital with diagnoses of aggressive behaviors. No progress note had been authored prior to Resident #48's hospital discharge and no change in condition assessments had been documented. Interview on 05/20/25 at 12:35 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 revealed if a resident had a change in condition a change in condition assessment should be documented as well as a progress note. Review of Resident #48's medical records with VPO #172 and RRN #182 at time of interview confirmed no documentation regarding Resident #48's hospitalization. 3. Review of Resident #65's medical…

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 ancillary appointments and interviews, the facility failed to coordinate a follow up vision appointment for Resident #27 as required. This had the potential to affect one resident (Resident #27) of two residents reviewed for vision. Findings include: Review of the medical record for Resident #27 revealed an admission date of 05/01/24. Review of the diagnoses included but were not limited to adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia and depression. Review of the 05/09/25 annual Minimum Data Set (MDS) 3.0 for Resident #27 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Resident #27 was noted to require moderate assistance from staff for bathing, dressing, and personal hygiene. Resident #27 was noted to have adequate vision and wear corrective lenses. Review of the facility ancillary appointment list revealed Resident #27 had a vision appointment at the facility on 03/03/25 and 04/24/25. Review of the eye doctor visit note dated 03/03/25 for Resident #27 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure adequate catheter care and positioning of a urinary catheter bag. This affected one resident (#9) of one observed for catheter care. The facility census was 59. Findings include: Review of Resident #9's medical records revealed an admission date of 04/09/25. Diagnoses included neuromuscular bladder, infection related to indwelling urethral catheter and need for personal care assistance. Review of care plan dated 04/14/25 revealed Resident #9 had an indwelling urinary catheter. Interventions included monitor for signs and symptoms urinary tract infection that included cloudiness, foul smelling urine and deepening of urine color. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition. Resident #9 had a indwelling urinary catheter and required maximum assistance with toileting. Review of physician orders for May 2025 for Resident #9 revealed to provide catheter care every shift and as…

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, observation and record reviews, the facility failed to implement nutritional intervention to address a significant weight change for Resident #62. This affected one resident (Resident #62) of one reviewed for nutrition. Facility census was 59. Findings include: Review of Resident #62's hospital admission record dated 02/11/25 revealed a weight of 178 pounds (lbs.). Review of the medical record for Resident #62 revealed an admission date of 02/26/25 with diagnosis of Alzheimer's disease, diabetes mellitus type two, bipolar disorder. Review of Resident #62's care plan dated 03/04/25 revealed that resident was at risk for malnutrition. Interventions included monitor weights and notify of any significant changes. Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 03/05/25 revealed the resident had impaired cognition. Resident #62 required set-up assistance for eating. Review of Resident #62 weights obtained at the facility revealed the following: 02/26/25 at 178.0 lbs., 03/07/25 at 178.1 lbs., 03/27/25 at 145.2 lbs. (18.43 percent weight loss in…

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

Based on observation, record review, interview, and facility policy, the facility failed to ensure Resident #165's respiratory status was properly monitored and oxygen was administered per physician orders. This affected one resident (Resident #165) of two residents reviewed for respiratory services. Findings include: Review of Resident #165's medical record revealed and admission date of 04/03/25 with diagnoses including unspecified injury to cervical spine, quadriplegia C1-C4, tracheostomy, major depressive disorder. Review of Resident #165's physician admission orders revealed oxygen at two liters humidified air via trach mask to maintain oxygen level equal or greater than 92%., suction every shift and as needed, change trach inner canula monthly and as needed. Review of Resident #165 medical record dated 04/03/25 to 05/13/25 revealed the oxygen order and suction order were not transcribed on the medical record to document when completed and monitored. Review of Resident #165's vitals record revealed there was limited oxygen readings documented in the medical record. 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.

Based on the medical record review, physician visit records and interviews, the facility failed to ensure physician visits were provided as required for Resident #34. This had the potential to affect one resident (Resident #34) of 40 residents reviewed for physician services. Findings include: Review of the medical record for Resident #34 revealed and admission date of 07/29/22 with diagnoses included but were not limited to osteonecrosis, gastrostomy, history of malignant neoplasm of other sites of lip, oral cavity and pharynx and nicotine dependence. Review of the 05/09/24 quarterly Minimum Data Set (MDS) 3.0 for Resident #34 revealed he had severe cognitive impairment and was independent for activities of daily living. Resident #34 was not noted to have significant weight changes and was using a feeding tube for over 51 percent (%) of his nutrition needs. Review of the medical record for Resident #34 revealed an admission physician visit completed on 08/03/22 and a physician order fax dated 08/19/22 for enteral tube feeding orders for Resident #34. No other physician visits were…

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

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and administered as ordered. This affected one (Resident #51) of five residents reviewed for medications received from the pharmacy. The facility census was 59. Findings include: Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy (seizures), cognitive communication deficit, need for assistance with personal care and history of encephalitis (inflammation of the brain). Review of the nursing progress notes reviewed from 03/31/25 to 05/12/25 revealed Resident #51 did not receive medications as ordered at times due to the facility not having them from the pharmacy and the physician not being notified. These included: -Clobazam (seizure medication) 15 milligrams (mg) on 04/03/25 at 4:34 A.M., medication on order. -Clobazam 5 mg on 04/06/25 at 3:16 A.M., medication on order. -Enoxaparin Sodium Injection Prefilled Syringe 40 mg/0.4 milliliters (mL) (blood thinner medication) on 04/16/25 at 6:02 P.M.,…

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

Based on interview, record review and review of the facility policy, the facility failed to timely address pharmacy recommendations. This affected two residents (#11 and #51) of five residents reviewed for unnecessary medications. Facility census was 59. Findings include: 1. Review of medical record for Resident #11 revealed an admission date of 03/02/17 and diagnoses including asthma, type two diabetes, morbid obesity, generalized anxiety disorder, gout, insomnia, depression, vitamin D deficiency and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #11's historical physician's orders revealed an order dated 11/24/22 for Xanax tablet 0.25 milligram (mg) give one tablet by mouth one time a day for anxiety. The order was discontinued on 12/30/24. Review of a medication review dated 06/13/24 identified Resident #11 was receiving Xanax 0.25 mg daily for anxiety, Buspirone Hydrochloride 10 mg daily for anxiety and Bupropion Hydrochloride extended release 12-hour 150 mg twice a day for depression. The pharmacist's recommendation stated 'if warranted and not…

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

Based on record review, observation and interview, the facility failed to ensure medication error rate was less than five percent. There were a total of 26 medication opportunities observed with two medication errors resulting in a 7.69% medication error rate. This affected one (Resident #55) out of two residents observed for medication administration. The facility census was 59. Findings include: Review of the medical record for Resident #55 revealed an admission date of 11/14/23 with diagnoses including diabetes, hypertension and depression. Review of the physician's orders dated 05/12/25 for Resident #55 revealed she was to receive the following medications upon rising: Blood sugar check; blood pressure check; Amlodipine 5 milligrams (mg) for hypertension; Cholecalciferol 1,000 units, give 2, for supplement; Claritin 10 mg for allergies; Flomax 0.4 mg for overactive bladder; Januvia 50 mg for diabetes; Lisinopril 20 mg for hypertension; Pantoprazole 40 mg for gastroesophageal reflux disease; Potassium Chloride 20 milliequivalents (meq) for low potassium; Sertraline 100 mg, give…

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

Based on record review and interview, the facility failed to ensure Resident #51's laboratory testing was completed as ordered. This affected one (Resident #51) of four residents reviewed for laboratory orders. The facility census was 59. Findings include: Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy (seizures), cognitive communication deficit, need for assistance with personal care and history of encephalitis (inflammation of the brain). Review of the physician's orders for Resident #51 for active laboratory orders revealed he was to have an Albumin level every Wednesday for pressure ulcer dated 04/30/25 for four weeks; Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) was ordered every two weeks dated 03/30/25; CBC with differential and BMP weekly dated 02/12/25; Depakote levels monthly while taking the medication dated 10/08/24; and CBC, BMP, Ammonia level, Iron and Liver Function every six months and Valproic Acid, Iron, and Phenobarbital level every three months dated 10/01/24. Review of the…

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

Based on medical record review, dietary tray ticket review and interview, the facility failed to ensure resident preferences were honored and updated as required for Resident #27. This affected one resident (Resident #27) of five residents reviewed for food. The facility census was 59. Findings include: Review of the medical record for Resident #27 revealed an admission date of 05/01/24. Review of the diagnoses included but were not limited to adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia and depression. Review of the 05/09/25 annual Minimum Data Set (MDS) 3.0 for Resident #27 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Resident #27 was noted to require set up for meals. Review of the physician ordered diet for Resident #27 dated 05/06/25 revealed regular diet with regular texture with thin liquids. No oatmeal, prefers cold cereal, request chef's salad for upgraded diet. Review of the care plan last updated 02/21/25 for Resident #27 revealed a nutritional problem related to obesity. Interventions were 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 2. Review of the medical record for Resident #27 revealed an admission date of 05/01/24. Review of the diagnoses included but were not limited to adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia and depression. Review of the 05/09/25 annual Minimum Data Set (MDS) 3.0 for Resident #27 revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Resident #27 was noted to require moderate assistance from staff for bathing, dressing, and personal hygiene. Review of the nursing progress note dated 04/05/25 revealed Resident #27 was given two tablets of 500 milligram (mg) of Tylenol for pain in her right knee. Review of the nursing progress note dated 04/09/25 timed at 12:10 A.M. revealed Resident #27 was given two 500 mg of Tylenol for leg pain that was not relieved by repositioning. Review of the physician order dated 04/16/25 for Resident #27 revealed an order for an ultrasound of the right knee for painful lump. Review of the 04/16/25 ultrasound result for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8. Review of Resident #53's medical record revealed an admission date of 01/24/24 and diagnoses including type two diabetes, morbid obesity, non-pressure chronic ulcer of left heel and midfoot, arthritis and atrial fibrillation. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact, required staff set-up for activities of daily living and did not reject care. Review of Resident #53's physician's orders relative to wound care as of 05/14/25 revealed an order dated 01/14/25 for wound type and site sub fifth MTH left lower extremity cleanse with normal saline, apply alginate, maintain affixed padding with pad edges against the wound edges and cover with ABD pad then wrap with kerlex daily and as needed (PRN) every day shift every Tuesday, Thursday Saturday for treatment; an order dated 01/22/25 for horseshoe adhesive padding for the foot-place on the foot daily with changes around the wound to keep the pressure off; an order dated 03/14/25 for left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to coordinate Resident #39's care and services with hospice to ensure continuity of care. This affected one resident (Resident #39) of one resident reviewed for hospice. Findings include: Review of the medical record for Resident #39 revealed an admission date of 05/22/22 with diagnoses of unspecified dementia with severe anxiety, moderate protein calorie malnutrition, history of falls, palliative care, hyperlipidemia. Review of Resident #39's medical record indicated that the resident had been admitted to Palliative Care on 1/30/23 for adult failure to thrive. Review of Resident #39's medical record of the hospice care plan dated 05/07/24 indicated that the resident required assistance of one for feeding. There were no other focus or interventions in place for the care plan. Review of Resident #39's care plan dated 04/23/25 revealed the resident was at risk for skin breakdown with an intervention for nursing as well as Hospice to visit and provide care,…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to complete care conferences in a timely manner for Resident #25, #35, #40, and #63. This affected four residents (#25, #35, #40, and #63) of four residents reviewed for care conferences. The facility census was 71. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 01/24/24 with diagnoses including type two diabetes mellitus, morbid obesity, hypertension, and non-pressure chronic ulcer of the left foot. Review of the care conference assessment, dated 01/25/24, revealed a care conference was held with the former social worker, a representative from the activities department, a representative from therapy services, and Resident #25. The assessment form had the social services and resident/family sections completed and the nursing summary, dietary summary, recreation summary, pharmacy summary, therapy and restorative summary, and physician summary sections were either blank or marked not applicable (N/A). The assessment was signed and locked on…

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

Based on interview and record review, the facility failed to accurately document medication administration for Resident #18, enteral feedings for Resident #69, and make available for review controlled medication disposition records for Residents #18, #22 and #43. This affected four residents (#18, #22, #43 and #69) out of 19 medical records reviewed and had the potential to affect all 71 residents residing in the facility. There were 16 residents who received controlled medications (#1, #7, #12, #18, #22, #28, #38, #40, #41, #43, #44, #51, #56, #58, #60 and #61) and four residents who received enteral feedings (#13, #22, #41 and #69). Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/26/22. Diagnoses included dementia, insomnia, anxiety disorder and adult failure to thrive. The Quarterly MDS (Minimum Data Set) assessment completed 05/11/24 indicated Resident #18 was rarely or never understood. Review of Resident #18's physician orders effective July 2024 revealed the following controlled medication orders: tramadol 50 mg (milligrams)…

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 review, the facility failed to initiate and provide adequate individualized wound care and administer medications as ordered by the physician. This affected two residents (#36 and #40) of two residents reviewed for wound care and four residents (#18, #25, #30 and #63) of seven residents reviewed for medication administration. The facility census was 71. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/16/24. Diagnoses included diabetes mellitus (DM) type II with diabetic neuropathy, peripheral angiopathy and chronic kidney disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acquired absence of left foot, non-pressure chronic ulcer of other part of left foot, and peripheral vascular disease. The quarterly Minimum Data Set (MDS) assessment completed 06/08/24 indicated moderate cognitive impairment. Interview on 07/31/24 at 9:41 A.M. with Resident #36…

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 the facility's fall investigations and incident reports, staff interview, and review of the facility's fall policy, the facility failed to conduct a thorough investigation after falls occurred and failed to implement appropriate interventions after a fall. This affected three residents (#31, #40, and #66) of three residents reviewed for falls. The facility census was 71. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 06/13/23 with diagnoses including hemiplegia and hemiparesis affecting the right side, morbid obesity, muscle weakness, hypertension, and a history of falling. Review of the fall risk care plan, revised 09/22/23, revealed no new interventions were added since 09/22/23. Review of the fall risk assessment dated [DATE] revealed Resident #31 was high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/13/24, revealed Resident #31 was dependent on staff for activities of daily…

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

Based on record review, resident interview, and staff interview, the facility failed to ensure residents were seen by a general physician or nurse practitioner at least once every 60 days. This affected two residents (#16 and #51) of three residents reviewed for physician visits. The facility census was 71. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 04/25/17 with diagnoses including legal blindness, anxiety disorder, and hypertension. Review of the practitioner's progress notes revealed the last general practitioner note was written on 02/29/24. There was no evidence of a general practitioner visit for Resident #16 after 02/29/24. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/29/24, revealed Resident #16 was cognitively intact. On 07/31/24 at 11:58 A.M., an interview with Resident #16 stated he had not seen the general practice physician or nurse practitioner in a very long time. 2. Review of the medical record for Resident #51 revealed an admission date of 08/28/13 and readmission date of 03/02/17.…

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, facility policy review, review of manufacturer instructions, and review of the Food and Drug Administration (FDA) database of licensed biological products, the facility failed to be free of a five percent or greater medication error rate. This affected one resident (#2) of five residents (#1, #2, #22, #32 and #46) observed for medication administration. This had the potential to affect 15 residents (#1, #2, #9, #15, #21, #27, #29, #30, #31, #34, #35, #36, #38, #54 and #57) who received insulin, and all 60 residents (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #19, #21, #22, #24, #25, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #59, #60, #62, #63, #64, #66, #67, #68, #69, #70 and #71) who resided on the facility's second floor. The facility census was 71. Findings include: Review of the medical record for Resident #2 revealed an admission date of 08/10/23. Diagnoses included dementia, diabetes mellitus (DM) type 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 observation, interview, record review, facility policy review, review of manufacturer instructions, and review of the Food and Drug Administration (FDA) database of licensed biological products, the facility failed to prevent a significant medication error for Resident #2 when insulin was inappropriately administered, and a medication was administered using the wrong dose and route. This affected one resident (#2) of five residents observed for medication administration. This had the potential to affect 15 residents (#1, #2, #9, #15, #21, #27, #29, #30, #31, #34, #35, #36, #38, #54 and #57) who received insulin, and all 60 residents (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #19, #21, #22, #24, #25, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #42, #43, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #59, #60, #62, #63, #64, #66, #67, #68, #69, #70 and #71) who resided on the facility's second floor. The facility census was 71. Findings include: Review of the medical record for Resident #2 revealed an…

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

Based on record review, observation, interview and facility policy review, the facility failed to provide clean shower rooms for resident use. This had the potential to affect all residents. The facility also failed to provide a clean privacy curtain for two residents (#11 and #12) of 74 residents reviewed for environment. The facility census was 74. Findings include: On 06/24/24 at 9:30 A.M. during the facility tour, an observation of the resident shower room on the 100 hall was noted to have a sink with buildup of dirt. The floor had a buildup dirt and debris on it. The tiles were cracked and broken in the corner of the shower. There was what appeared to be smeared bowel movement on the toilet seat. Maintenance Director (MD)#259 verified the findings at the time of the tour. On 06/24/24 at 9:50 A.M. an observation of the shower room on the second-floor blue hall was noted to have a dirty sink. The sink was dry and appeared to not have been used recently. The shower was noted to have a black substance on the tiles. The floor had a buildup dirt and debris. The shower chair in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to provide incontinence care in a dignified manner to Residents #33 and #48. This affected two residents (#33 and #48) of 48 residents who were identified as needing assistance with incontinence care. The facility census was 74. Findings include: 1. A review of medical records for Resident #48 revealed an admission date of 02/16/24. Significant diagnoses included diabetes mellitus type II, need for personal assistance, and a chronic ulcer of other part of the left foot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact. Review of the care plan dated 06/11/22 revealed Resident #48 had a self-care deficit and needed toileting assistance. On 06/24/24 at 3:10 P.M. an observation revealed Resident #48 activated the call system. On 06/24/24 at 3:16 P.M. an observation of Resident #48 revealed the call light being answered by State Tested Nurse Aide (STNA)…

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 respond to Resident #48's needs in a timely manner. This affected one resident (#48) of 74 residents observed for call light response. The facility census was 74. Findings include: A review of medical records for Resident #48 revealed an admission date of 02/16/24. Significant diagnoses included diabetes mellitus type II, need for personal assistance, and a chronic ulcer of other part of the left foot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #48 was cognitively intact. Review of the care plan dated 06/11/22 revealed Resident #48 had a self-care deficit and needed toileting assistance. On 06/24/24 at 3:10 P.M. an observation revealed Resident #48 activated the call system. On 06/24/24 at 3:16 P.M. an observation of Resident #48 revealed the call light being answered by State Tested Nurse Aide (STNA) #269. Resident #48 told STNA #269 that they needed changed. STNA #269 left 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 record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH (Nursing Home), staff interview, and facility policy review, the facility failed to ensure staff followed enhanced barrier precautions (EBP) protocols. This affected two residents (#44 and #48) of 14 residents reviewed and identified as being on EBP. The facility census was 74. Findings include: 1. A review of medical records for Resident #44 revealed an admission date of 12/16/23. Significant orders included management of a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach for feeding) and EBP. On 06/24/24 at 3:00 P.M. an observation of medication administration with Licensed Practical Nurse (LPN) #266 revealed LPN #266 administering carbamazepine 400 milligrams (mg) (anticonvulsant) via Resident #44's PEG tube. LPN #266 did not don a gown. LPN #266 verified the EBP sign on Resident #44's door. An interview at the time of the observation with LPN #266 revealed she did not know what EBP was. LPN #266 also verified…

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, record review and review of the facility policy, the facility failed to ensure Residents #142 and #154 were free of significant medication errors. This affected two residents (#142 and #154) out of five residents observed for medication administration. The facility census was 68. Findings included: 1. Review of the medical record for Resident #154 revealed an admission date of 03/27/20 with diagnoses including paraplegia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cardiomyopathy, and epilepsy. Review of the care plan dated 01/11/24 revealed Resident #154 had hypertension. Interventions included administering anti-hypertensive medications as ordered, monitoring for side effects such as orthostatic hypotension and increased heart rate. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #154 had impaired cognition. Review of the June 2024 Medication Administration Recird (MAR) revealed Resident…

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

Based on observation, medical record review, resident and staff interviews, review of an ambulance run report and interview with the local assistant fire chief, the facility failed to ensure bariatric mechanical lifts were available to assist residents with transfers. This affected three (#9, #19 and #58) of three residents reviewed for mechanical lifts. Additionally, the facility failed to ensure residents had appropriately fitting beds and mobility assistance equipment. This affected one (#9) of three residents reviewed for bed equipment and mobility needs. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/25/24. Diagnoses included type II diabetes, paraplegia, obesity and fusion of the spine. Further review revealed Resident #9 was six feet three inches tall and weighed 300 pounds. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/25/24, revealed Resident #9 had intact cognition and was dependent on staff for rolling left to right, toileting, and transferring. Review of the Care…

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

Based on medical record review, observation, staff interview, review of mechanical lift manufacturer's instruction and review of facility policy, the facility failed to ensure staff were properly trained to safely transfer residents utilizing mechanical lifts. This affected one (#58) of three residents reviewed for transfers. The facility identified 13 residents requiring a mechanical lift for transfer. The facility census was 64. Finding include: Review of the medical record for Resident #58 revealed an admission date of 08/30/18. Diagnoses included morbid obesity, multiple sclerosis (MS) and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/16/24, revealed Resident #58 had intact cognition and was dependent on staff for rolling left to right, toileting, and transferring. Review of the Care Plan, dated 04/22/24, revealed Resident #58 had a self-care deficit related to MS and chronic pain. Interventions included a mechanical lift with two staff assistance with all transfers. Observation on 05/08/24 at 5:00 P.M. of the second-floor nurses' station…

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 work orders, the facility failed to ensure the environment was adequately maintained. This affected three (#49, #55 and #58) of five residents reviewed for environmental concerns. The facility census was 64. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 05/26/22. Diagnoses included dementia, malnutrition, anxiety and adult failure to thrive. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/09/24, revealed the resident was severely cognitively impaired. She was totally dependent upon staff for eating, oral hygiene, personal hygiene, showering and dressing. Observation on 05/08/24 at 9:08 A.M. revealed the window ledge in Resident #49's room had wallpaper located directly underneath it, which was peeling from the wall. There was an unknown black substance on the back of the wallpaper. The wall behind the wallpaper was cracked and falling off in pieces to the floor beneath. Concurrent interview with Maintenance Director (MD) #143 confirmed…

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 clean and sanitary environment. This affected four (#15, #46, #48 and #58) of six residents whose rooms were observed. The facility census was 58. Findings include: 1. Observation of Resident #46's room on 04/01/24 at 8:52 A.M. revealed two pieces of bread with jelly on the fall mat next to Resident #46's bed with numerous ants on the bread and surrounding the area. The observation was confirmed by the Director of Nursing (DON) on 04/01/24 at 9:15 A.M. 2. Observation of Resident #55's room on 04/01/24 at 8:54 A.M. revealed a large brown dried stain on Resident #55's bed sheets and various food debris on the floor and underneath Resident #55's bed. This was confirmed with State Tested Nurse Aide (STNA) #340 at the time of the observation. 3. Observation of Resident #48's room on 04/01/24 at 11:04 A.M. revealed various debris and dirt on the floor and underneath Resident #48's bed. This was confirmed with STNA #340 at the time of the observation. 4. Observation of Resident #15's room on 04/01/24 at 2:17 P.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to ensure residents/resident representative participated in care planning. This affected three residents (#39, #48 and #49) of three reviewed for care conferences. Findings include: Review of Resident #39's medical records revealed an admission date of 10/22/23. Diagnoses included paraplegia and stroke. Review of Resident #39's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had impaired cognition. Review of Resident #39's care plan dated 03/14/24 revealed Resident #39 had impaired cognition. Interventions included communicate with family and caregivers regarding needs. Review of Resident #48's medical records revealed an admission date of 03/24/23. Diagnoses included cognitive deficits and stroke. Review of Resident #48's MDS assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of the care plan dated 03/14/24 revealed Resident #48 had impaired cognition. Interventions included…

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

Based on observation, and interview the facility failed to ensure call lights were within reach and accessible for residents. This affected one (Resident #46) of six residents observed for call light placement. The facility census was 58. Findings include: Observation on 04/01/24 at 8:52 A.M. revealed Resident #46 was yelling out. Upon entering Resident #46's room a strong odor of urine was detected. Resident #46's call light was observed on the floor behind the bed. This observation was confirmed at 9:15 A.M. by the Director of Nursing (DON). The DON stated call lights should be within reach of residents. Review of Resident #46's care plan dated 02/28/24 revealed staff were to encourage Resident #46 to use call light.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility policy review the facility failed to ensure timely incontinence care was provided and failed to ensure adequate care of a suprapubic urinary catheter. This affected one resident (#46) of three residents observed for incontinence care and one resident (#15) of two residents observed for suprapubic catheter care. The facility census was 58. Findings include: 1. Review of Resident #15's medical records revealed an admission date of 10/24/23. Diagnoses included bladder dysfunction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 had a suprapubic urinary catheter (tube inserted through the abdominal wall for urinary elimination). Review of the care plan dated 02/28/24 revealed Resident #15 was at risk for complications related to the suprapubic catheter. Interventions included monitor for signs and symptoms of infection. Review of Resident #15's physician orders for April 2024 revealed cleanse suprapubic…

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 insulin vials were dated after opening. This affected one resident (#2) of two residents reviewed who received insulin. The facility census was 58. Findings include: Review of Resident #2's medical records revealed an admission date of 01/02/24. Diagnoses included diabetes. Review of Resident #2's physician orders for April 2024 revealed Resident #2 was ordered Lantus (long acting insulin) six units in the morning and Humalog (fast acting insulin) before meals according to a sliding scale. Observation of medication administration on 04/01/24 at 8:30 A.M. with Licensed Practical Nurse (LPN) #335 revealed LPN #335 obtained Resident #2 blood sugar and the glucometer read high (no numeric value was registered). LPN #335 informed Resident #2 she would need to contact the physician for orders. LPN #335 received an order to administer 16 units of Humalog. Resident #2 was informed of the physician orders and stated to LPN #335 that's too much, I'll take six units. LPN #335 contacted the physician 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 interview and record review the facility failed to ensure accurate documentation of narcotics in the electronic medical records. This affected one resident (#2) of three residents reviewed for documentation. The facility census was 58. Findings include: Review of Resident #2's medial records revealed an admission date of 01/02/24. Diagnoses included low back pain. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. Review of Resident #2's care plan dated 03/14/24 revealed Resident #2 was on opioid pain medication. Review of Resident #2's physician orders for March through April 2024 revealed Resident #2 was ordered oxycodone (narcotic pain medication) 5 milligrams (mg) every eight hours as needed. Review of Resident #2's narcotic count sheet from 03/19/24 through 03/29/24 revealed oxycodone was signed out as administered on 03/19/24 at 5:30 A.M. and 8:30 P.M.; on 03/20/24 at 10:12 P.M.; on 03/21/24 at 3:30 P.M. and 3:30 A.M.; on 03/22/24 at…

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

Based on observation, interview and facility policy review, the facility failed to ensure appropriate infection control techniques were used during and after insulin administration. This affected one resident (#2) of one resident observed for insulin administration. The facility census was 58. Findings include: Review of Resident #2's medical records revealed an admission date of 01/02/24. Diagnoses included diabetes. Review of Resident #2's physician orders for April 2024 revealed Resident #2 was ordered Lantus (long acting insulin) six units in the morning and Humalog (fast acting insulin) before meals according to a sliding scale. Observation of medication administration on 04/01/24 at 8:30 A.M. revealed Licensed Practical Nurse (LPN) #335 drawing up six units of Humalog insulin and entering Resident #2's room. LPN #335 did not don gloves and administered the Humalog insulin by injecting the insulin into Resident #2's subcutaneous tissue. LPN #335 then proceeded to exit the room without washing her hands or using hand sanitizer. Interview with LPN #335 confirmed she did not wear…

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 the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 51 residents receiving meals from the kitchen. The facility identified three residents (#24, #30, and #33) who received enteral nutrition and did not receive meals from the kitchen. The facility census was 54. Findings Include: Observation during the initial kitchen tour on 03/04/24 from 8:52 A.M. till 9:07 A.M. with [NAME] #377 revealed the following concerns: • The handwashing sink did not have paper towels to dry hands. • An open case of mixed vegetables was untied with vegetables exposed to open air in the freezer. • A 10-pound tube of ground beef was thawed on a tray dated 02/22/24 with substantial blood surrounding the tube on the sheet pan in the refrigerator. • Half of a 25-pound case of [NAME] tomatoes were moldy with a delivery date of 02/12/24. • A plastic container of unidentified substance thought to be pudding 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.

Based on review of facility spreadsheets, observation, staff interview, and facility policy review the facility failed to ensure the correct portion size of ham was provided for 40 residents provided a regular diet. The facility identified eight residents (#5, #29, #35, #38, #42, #48, #52, and #53) receiving a mechanical soft diet, three residents (#15, #28, and #34) receiving a pureed diet and three residents (#24, #30 and #33) receiving nothing by mouth. The facility census was 54. Findings Include: Review of the facility menu for week two revealed on Monday the lunch meal was to consist of a turkey open faced sandwich, four ounces of mashed potatoes, four ounces buttered peas, one dinner roll, and four ounces of pineapple tidbits. Observation in the kitchen on 03/04/24 at 11:13 A.M. revealed ham slices were the main entrée and green beans were the vegetable. Interview at the time of the observation with Foodservice Director (FD) #379 confirmed due to the turkey not being thawed and peas not being available, they had to make a substitution from the scheduled menu items and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure proper hand hygiene, glove use, and infection control barriers were utilized during wound care for Resident #13, and the facility failed to ensure proper hand hygiene materials were available during meal pass. This affected one resident (#13) of three residents reviewed for wound care and had the potential to affect 12 residents (#21, #22, #23, #25, #27, #28, #29, #30, #31, #32, #33, and #34) residing on the hallway for rooms 262 to 273. The facility identified one resident (#24) on the hallway as not receiving food by mouth. The facility census was 54. Findings Include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/24/23. Medical diagnoses included local infection of the skin and subcutaneous tissue, osteomyelitis, paraplegia, and multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact, utilized an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to follow physician ordered wound care for Resident #13 and Resident #56. This affected two residents (#13 and #56) of three residents reviewed for wound care. The facility census was 54. Findings Include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/24/23. Medical diagnoses included local infection of the skin and subcutaneous tissue, osteomyelitis, paraplegia, and multiple sclerosis. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Resident #13 had one unhealed stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling) present upon admission. Review of Resident #13's care plan dated 12/08/24 revealed Resident #13 was at risk for skin…

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

Based on observation, interview, record review, and facility policy review the facility failed to ensure drinking water was within reach for hydration for Resident #5. This affected one resident (#5) of seven residents reviewed for hydration. The facility census was 54. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 01/20/21. Diagnoses included amyotrophic lateral sclerosis, moderate protein calorie malnutrition, chronic respiratory failure with hypoxia, emphysema, type II diabetes mellitus, dysphagia following cerebrovascular disease, encounter for gastrostomy, and anxiety disorder. Review of 12/24/23 quarterly Minimum Data Set (MDS) assessment for Resident #5 revealed a Brief Interview of Mental Status (BIMS) score of 14 of 15 which indicated the Resident #5 was cognitively intact. Review of activities of daily living (ADL) revealed Resident #5 was incontinent of bowel and bladder and was dependent on staff for ADL. Review of Resident #5's care plan last reviewed on 01/01/24 revealed she was dependent upon staff for ADL and 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.

Based on observation, interview, record review, and facility policy review the facility failed to ensure call lights were within reach for Resident #5. This affected one resident (#5) of six residents reviewed for call lights. The facility census was 54. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 01/20/21. Diagnoses included amyotrophic lateral sclerosis, moderate protein calorie malnutrition, chronic respiratory failure with hypoxia, emphysema, type II diabetes mellitus, dysphagia following cerebrovascular disease, encounter for gastrostomy, and anxiety disorder. Review of 12/24/23 quarterly Minimum Data Set (MDS) assessment for Resident #5 revealed a Brief Interview of Mental Status (BIMS) score of 14 of 15 which indicated the Resident #5 was cognitively intact. Review of activities of daily living (ADL) revealed Resident #5 was incontinent of bowel and bladder and was dependent on staff for ADL. Review of Resident #5's care plan last reviewed on 01/01/24 revealed she was dependent upon staff for ADL and was encouraged to use 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.

Based on observation, staff interview, and facility policy, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition and proper hand washing was being performed by dietary staff. This had the potential to affect 49 residents receiving food from the kitchen. The facility identified Residents #11 and #18 as receiving no food from the kitchen. The facility census was 51. Findings include: 1.Observation of the kitchen during initial tour conducted on 10/31/23 between 10:44 A.M. and 11:40 A.M. revealed the following concerns: -In the walk-in cooler there were two slices of bologna in a plastic bag not labeled or dated, one square plastic storage container with a green lid of applesauce not dated or labeled, one 18-quart storage container of grape Kool-Aid not labeled or dated, one 18-quart storage container of lemonade not labeled or dated, three ham and cheese sandwiches wrapped in plastic wrap not labeled or dated and one square plastic storage container with a green lid of chocolate syrup not labeled or dated. -In the walk-in freezer there were…

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

Based on review of facility spreadsheets, observation, staff interview, the facility failed to serve the correct portion size of fried rice was provided for 45 residents on a regular and mechanical soft consistency diets. The facility identified four residents (#5, #15, #23, and #35) as being on a pureed diet and two residents (#11 and #18) as receiving nothing by mouth. The facility census was 51. Findings include: Review of the 2023 fall and winter menu revealed the lunch meal on Thursday week four for regular and mechanical soft diets included the following items: one three-ounce chicken breast, four ounces of fried rice, four ounces of vegetable blend, one dinner roll, and four ounces of mixed fruit. Observation of the tray line on Thursday 11/02/23 from 11:39 A.M. to 12:30 P.M. revealed residents who were on a regular or mechanical soft consistency diet were served by Dietary [NAME] (DC) #333 one three-ounce chicken breast, one two-ounce spoodle (the combination of a serving spoon with the accurate portion control of a ladle) of fried rice, one four-ounce spoodle of vegetable…

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

Based on observation, staff interview, and facility policy, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition and proper hand washing was being performed by dietary staff. This had the potential to affect 49 residents receiving food from the kitchen. The facility identified Residents #11 and #18 as receiving no food from the kitchen. The facility census was 51. Findings include: 1.Observation of the kitchen during initial tour conducted on 10/31/23 between 10:44 A.M. and 11:40 A.M. revealed the following concerns: -In the walk-in cooler there were two slices of bologna in a plastic bag not labeled or dated, one square plastic storage container with a green lid of applesauce not dated or labeled, one 18-quart storage container of grape Kool-Aid not labeled or dated, one 18-quart storage container of lemonade not labeled or dated, three ham and cheese sandwiches wrapped in plastic wrap not labeled or dated and one square plastic storage container with a green lid of chocolate syrup not labeled or dated. -In the walk-in freezer there were…

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

Based on observation and interview the facility did not ensure food was served at a palatable temperature. This had the potential to affect the 56 residents who received meals prepared by the kitchen. The facility identified three residents (#18, #49 and #57) as receiving no food from the kitchen. The facility census was 59. Findings include: Observation on 03/28/23 at 11:58 A.M. the food cart arrived on floor. Staff started passing the trays right away. Observation on 03/28/23 at 12:11 P.M. revealed all trays on the unit had been passed and a sample tray was tested for temperature. The spaghetti with meat sauce was 152 degrees Fahrenheit. The hot three-bean salad was 107 degrees Fahrenheit. The facility ran out of Italian style vegetable blend. The coffee was 119 degrees Fahrenheit, and the milk was 53 degrees Fahrenheit. There was no bread or cookies on the tray because they ran out of both before the test tray. The residents received them, but there would have been no seconds available per request and not available for any late trays. Interview on 03/28/23 at 12:16 P.M. 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.

Based on observation and interview the facility did not ensure food items were labeled and dated and failed to ensure preparation equipment and surrounding areas were kept clean and sanitary. This had the potential to affect the 56 residents who received meals prepared by the kitchen. The facility identified three residents (#18, #49 and #57) as receiving no food from the kitchen. The facility census was 59. Findings include: Observation on 03/27/23 starting at 9:21 A.M. a tour of the kitchen with Certified Dietary Manger (CDM) #352 revealed one bulk container of cereal had the lid left open, three containers of bulk cereal were not labeled and dated, and a bulk bag of flour was not closed. The microwave had liquid spilled inside. The inside top of microwave had not been cleaned. The vents over the cooking area had accumulated grease, and the wall behind the cooktop was greasy. The front of the oven had accumulated baked on food spills and grease. The control knobs on oven and cooktop had accumulated dirt and grease. The hood was last cleaned on 07/14/22, more than eight months ago.…

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 maintain the dumpsters in a manner to prevent pests. The lids were left open on all three dumpsters. This had the potential to affect all 59 residents residing in the facility. Findings include: Observation on 03/27/23 starting at 9:21 A.M. a kitchen tour with Certified Dietary Manger (CDM) #352 revealed the lids were open on three of three dumpsters, some boxes and other garbage was blown around dumpster area. Interview on 03/28/23 during the kitchen tour, CDM #352 verified the above findings.

Based on interview and record review, the facility failed to have the required members, Infection Preventionist (IP) #374, attend the quarterly Quality Assessment and Assurance (QAA) meetings. This had the potential to affect all residents. The facility census was 59. Findings include: Interview on 03/30/23 at 2:30 P.M. with the Administrator revealed IP #374 did not consistently attend Quality Assessment and Performance Improvement (QAPI) meetings at least quarterly. The Administrator revealed IP #374 was also the Corporate Nurse, and she was too busy at additional facilities to attend each quarterly meeting. Record review with the Administrator of the QAPI Committee participants from 03/09/22 through 03/30/23 confirmed IP #374 had not attended a QAPI meeting during the first quarter of 2022 held 03/09/22, the second quarter held 06/17/22, the third quarter held 09/14/22, or the first quarter of 2023 held 02/03/23.

Based on record review and interview, the facility failed to ensure state-tested nursing aides (STNAs) received twelve hours of annual in-service training. This affected two STNA's (#353 and #325) of seven employees reviewed for personnel requirements and had the potential to affect all 59 residents in the facility. Findings include: Record reviews of the employee files for STNA #353 and STNA #325 revealed both were hired by the facility over one year ago. The facility could not locate evidence they had received 12 hours in-service training from 2022 to 2023. The surveyor confirmed these findings with Human Resources Director #309 on 03/30/23 at 11:54 A.M.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents' status. This affected one resident (#2) of 23 residents whose MDS assessments were reviewed. The facility census was 59. Findings include: Review of the medical record for Resident #2 revealed an admission date of 11/22/22. Diagnoses included paraplegic, pressure ulcer, weakness, and paranoid schizophrenia. Review of the wound note dated 11/23/22 revealed Resident #2 had a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss) on his right ischium. Review of the of the plan of care dated 12/13/22 revealed Resident #2 refused medications and declined wound dressing changes. Review of the progress notes dated 03/07/23 through 03/12/23 revealed resident was alert times three, used a wheelchair, and was able to make needs known.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop care plans related to methadone use, pancreatic insufficiency, and constipation/impaction/chronic colonic dilatation. This affected one resident (#44) of five residents reviewed for care plans. The facility census was 59. Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/26/20. Diagnoses included paraplegia, bipolar disorder, opioid abuse, exocrine pancreatic insufficiency, abdominal distension, abdominal pain, and megacolon. Review of the modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition. Resident #44 was independent for bed mobility and eating. He required supervision for transfers, walking in his room, locomotion, dressing, toilet use, and personal hygiene. Review of the physician orders for March 2023 revealed Resident #44 had orders dated 05/12/21 for Methadone (Methadose) (a narcotic medication) and Creon capsule delayed…

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 the observation, record review, and interview, the facility failed to ensure care plans were revised to include Resident #3 had a stage III pressure ulcer on his right posterior ear and Resident #22 self-managed his CPAP (continuous positive airway pressure) machine. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date 09/15/03. Diagnoses included anxiety disorder, cerebral infarction, Tourette's disorder, Asperger's syndrome, paranoid schizophrenia, and muscle weakness. Review of the plan of care dated 05/03/21 revealed Resident #3 had a potential for altered skin integrity related to impaired mobility at times, urinary and bowel incontinence, preventive measures in place to bony prominences of hip and spine, and toes. The care plan was updated on 09/22/22 to include a stage IV (full thickness tissue loss with exposed bone, tendon or muscle) was now to the sacrum versus an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist Resident #35 with grooming his beard per his preference and the facility failed to assist Resident #55 with showers as scheduled. This affected two residents, (#35 and #55) of three residents reviewed for grooming and hygiene. The facility census was 59. Findings include: 1. Record review for Resident #35 revealed an admission date of 09/28/18 with diagnoses including heart block, acute kidney failure, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required extensive assistance of two staff for bed mobility, transfers, and was totally dependent on staff for dressing and personal hygiene. Review of the care plan dated 02/01/23 revealed Resident #35 was at risk for activity of daily living (ADL) self-performance deficit. Interventions included Resident #35 required extensive staff assistance with personal hygiene. Observation 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, interview, record review, and review of the facility policy the facility failed to monitor Resident #43's blood sugar prior to meals. This affected one resident (#43) of three residents reviewed for blood sugar monitoring related to diabetes mellitus. The facility census was 59. Findings include: Record review for Resident #43 revealed an admission date of 10/21/17. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) for Resident #43 was not completed. Resident #43 required extensive assistance of two staff for bed mobility, locomotion, toilet use, and personal hygiene. Resident #43 had a diagnosis of type two diabetes mellitus. Review of the care plan dated 12/28/22 revealed Resident #43 was on insulin related to diabetes. Interventions included monitoring blood sugar and lab results as ordered by the physician. Record review of the physician orders for March 2023…

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

Based on observation, record review, and interview the facility failed to ensure weekly skin assessments were completed to prevent the development of a stage III pressure ulcer. This affected one resident (#3) of three residents reviewed for pressure ulcers. The facility census was 59. Findings include: Review of the medical record for Resident #3 revealed an admission date 09/15/03. Diagnoses included anxiety disorder, cerebral infarction, Tourette's disorder, Asperger's syndrome, paranoid schizophrenia, and muscle weakness. Review of the plan of care dated 05/03/21 revealed Resident #3 had a potential for altered skin integrity related to impaired mobility at times, urinary and bowel incontinence, preventive measures in place to bony prominences of hip and spine, and toes. The care plan was updated on 09/22/22 to include a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed) to the sacrum versus an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy the facility failed to complete a smoking assessment and care plan for Resident #8 prior to allowing him to independently smoke with no supervision and allowing him to keep his cigarettes and lighter in his room unsupervised. This affected one resident (#8) of three residents reviewed for smoking. The facility census was 59. Findings include: Record review for Resident #8 revealed an admission date of 12/16/22. Diagnosis included suicidal ideation's, weakness, schizoaffective disorder, anxiety disorder, muscle weakness, and need for assistance with personal care. Review of the modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. Resident #8 required supervision with bed mobility, transfers, personal hygiene, and ambulation. Review of the smoking assessments on 03/27/23 in the medical records for Resident #8 revealed Resident #8 had no smoking assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a bladder retraining program for Resident #267 per the Minimum Data Set (MDS) and care plan for. This affected one resident (#267) of three residents reviewed for incontinence. The facility census was 59. Findings include: Record review for Resident #267 revealed an admission date of 02/21/23. Diagnoses included difficulty in walking, syncope, and collapse. Record review of the admission assessment for Resident #267 dated 02/21/23 revealed there was no change in bladder function, resident was incontinent of urine, pads and brief were used, and the resident was continent of bowel. Review of the admission MDS assessment dated [DATE] revealed Resident #267 was cognitively intact. Resident #267 required extensive assistance of one staff member for toilet use and personal hygiene. Resident #267 was on a urinary toileting program and had decreased wetness. The resident was frequently incontinent of bowel and bladder. The current toileting program or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pharmacy recommendations were timely addressed by the physician. This affected one resident (#2) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of the medical record for Resident #2 revealed an admission date of 11/22/22. Diagnoses included paraplegic, pressure ulcer, weakness, and paranoid schizophrenia. Review of the pharmacy recommendations dated 12/23/22 and 02/09/23 revealed recommendation was to discontinue the as needed use of Haloperidol (antipsychotic) five milligrams (mg) every four hours as needed for this resident prescribed for [blank line] per the following federal guideline. Both recommendations were not documented as being addressed, but a handwritten note at the bottom of the pharmacy recommendation dated 02/09/23 revealed d/c [discontinue] per MD [medical doctor] via TO [telephone order] for non-use and was dated 03/28/23. Review of the quarterly Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure blood pressure parameters for medications were measured and followed. This affected one resident (#52) of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Record review of Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses including hypertension, anxiety disorder, and major depressive disorder. She had an order for Lisinopril (an anti-hypertensive) to be given once daily unless her systolic blood pressure was under 100. Review of her record revealed no clear evidence her blood pressure was assessed before each dose to ensure it was given within parameters. Interview with the Director of Nursing (DON) on 03/28/23 at 5:39 P.M. confirmed the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to ensure COVID-19 positive residents received appropriate orders, monitoring, and documentation of their COVID-19 status. This affected one resident (#43) of three residents reviewed for transmission-based precautions. The facility also failed to ensure resident mechanical ventilation machines were stored in a sanitary manner, affecting one resident (#22) of two residents reviewed for respiratory care. The total census was 59. Findings include: 1. Observation of Resident #43 and #24's room on 03/27/23 at 1:57 P.M. revealed a clear plastic barrier over the doorway, posted instructions for proper donning and doffing of personal protective equipment, and a drawer with gowns, masks, gloves, and sanitation supplies placed outside. Interview with Resident #43 on 03/27/23 at 2:02 P.M. revealed she did not know why the room was on placed on isolation precautions. Observation of Resident #24 on 03/27/23 at 2:03 P.M. revealed she was not able to be…

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

Based on observation, record review, and interview the facility failed to ensure call lights were kept plugged in and within reach. This affected three residents (#21, #43, and #117) of 27 residents surveyed for call light access. The facility census was 59. Findings include: 1. Observation of Resident #117 on 03/27/23 at 9:25 A.M. revealed her call light was clipped to her privacy curtain out of reach. An interview with her at this time revealed she was able to use the call light and had no concerns with staff response. Interview with Licensed Practical Nurse (LPN) #337 on 03/27/23 at 9:26 A.M. confirmed the above observation. 2. Observation of Resident #21 on 03/27/23 at 9:30 A.M. revealed her call light was in reach but was unplugged from the wall. Interview with State Tested Nursing Aide (STNA) #357 on 03/27/23 at 9:33 A.M. confirmed the above observation. 3. Observation of Resident #43 on 03/28/23 at 1:53 P.M. revealed her call light was on the floor beneath her bed. An interview with her at this time revealed she did not know where her call light was. Interview with LPN #378…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility Housekeeping policy the facility failed to ensure Resident #22's room was maintained in clean and sanitary condition. This affected one resident (#22) of 23 residents reviewed in the survey sample. The facility census was 59. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/28/13. Diagnoses included chronic diastole congestive heart failure (CHF), morbid obesity, obstructive sleep apnea, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition and required supervision and set up help with bed mobility, transfers, and ambulation. Interview on 03/27/23 at 9:33 A.M. with Resident #22 revealed the window blinds were dirty and were never cleaned. Observation at this time revealed one window blind slat was broken and the blinds were dusty. Observation on 03/28/23 at 12:23 P.M. of Resident #22 revealed he was up in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain a clean, safe and homelike environment. This affected all 49 residents (Residents #32, #38, #92, #4, #100, #76, #54, #23, #11, #56, #61, #13, #16, #30, #9, #93, #36, #44, #60, #95, #71, #65, #24, #111, #103, #99, #74, #86, #27, #59, #27, #48, #41, #94, #2, #66, #77, #63, #34, #6, #8, #31, #33, #40, #28, #104, #37, #80, and #79) that resided on the second floor. The facility census was 107. Findings include: 1. Observation on 11/03/19 at 7:59 A.M. revealed the second floor dining room was dirty. Six of the nine tables had chocolate cake crumbs and napkins underneath them. At this time, Minimum Data Set (MDS) Nurse #56 verified these findings. The facility identified 49 residents (Residents #32, #38, #92, #4, #100, #76, #54, #23, #11, #56, #61, #13, #16, #30, #9, #93, #36, #44, #60, #95, #71, #65, #24, #111, #103, #99, #74, #86, #27, #59, #27, #48, #41, #94, #2, #66, #77, #63, #34, #6, #8, #31, #33, #40, #28, #104, #37, #80, 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 ensure night time snacks were provided consistently. This had the potential to affect all residents except four residents (Residents #87, #110, #15, and #20) who received nothing by mouth. The facility census was 107. Findings include: Record review of the nourishment list and a handwritten list of residents revealed 42 residents of 104 residents for scheduled snacks and nutritional supplements. Interviews on 11/05/19 at 2:19 P.M. with residents during the resident council meeting revealed snacks are not being given at night. Interview on 11/05/19 at 4:28 P.M. with Dietary Supervisor (DS) #102 revealed resident complaints about snacks had come up, and he had a snack list of residents who wanted specific snacks. DS #102 stated there wasn't a par level for additional snacks for other residents. DS #102 stated he depended on the nursing aides to inform him of the snack needs, and snacks were a work in progress. DS #102 stated nine times out of ten the snack bins come back to the kitchen empty, and he had heard that they are…

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

Based on observation, interview and record review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all but four residents (Residents #87, #110, #15, and #20) who received nothing by mouth. The facility census was 107. Findings include: Initial tour of the kitchen on 11/03/19 at 6:46 A.M. with Dietary Assistant (DA) #108 revealed the dry storage area floor had various food debris under a rack that housed three large white food storage bins. The back entrance had several packets of salt on the floor. The walk-in freezer had a moderate amount of ice build-up on the floor near the back wall and various debris on the floor. The mixer stored on a table outside of the walk-cooler was not in use and was covered, but in the bottom of the bowl there appeared to be an oily substance. The walk-in cooler had various debris on the floor including an orange on the floor underneath the rack. There were crumbs and various food debris on the bottom shelf of the rack that housed the toaster, and the toaster had various greasy food debris and crumbs. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments. This affected two residents (Residents #73 and #99) of 26 residents' MDS assessments reviewed. The facility census was 107. Findings include: 1. Review of Resident #73's medical record revealed an initial admission date of 01/04/17 and re-entry date of 10/07/19. Diagnoses included intestinal transplant, ileostomy, lymphedema, chronic kidney disease. The admission MDS 3.0 assessment dated [DATE] revealed Resident #73 had intact cognition, required supervision with set-up assistance for eating and no significant weight loss or gain. Review of Resident #73's weights revealed on 08/06/19 260.0 pounds (lbs.), 08/13/19 261 lbs., 09/24/19 222.4 lbs., 10/07/19 219.6 lbs. and on 10/08/19 219.6 lbs. Review of the Nutrition and Dietary notes dated 09/25/19 at 10:49 A.M. revealed Resident #73 was readmitted on [DATE] from the hospital. Recent weight of 222.4 lbs. indicated a significant loss from the…

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

Based on interview and record review, the facility failed to provide a copy of the baseline plan of care to residents or resident representatives. This affected two residents (Resident #4 and #64) of two residents reviewed for baseline care plans. The facility census was 107. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 8/30/19. Diagnoses included atrial fibrillation, diabetes mellitus, major depressive disorder, anxiety disorder and cognitive deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/18/19, revealed Resident #4 had intact cognition and was on a pain management regimen. Review of the Baseline Plan of Care dated 08/30/19 revealed no nurses signature. There was no evidence of Resident #4 or the Resident #4's representative's signature stating they received a copy of the Baseline Care plan. 2. Review of the medical record for Resident #64 revealed an admission date of 10/04/19. Diagnoses included right artificial hip joint, intellectual disabilities, hypertension and depression. 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 medical record review, staff interview and resident interview, the facility failed to ensure all residents received showers according to their preferences. This affected two (Resident #58 and Resident #66) of three residents reviewed for showers. The facility census was 107. Findings include: 1. Review of the medical record for the Resident #66 revealed an admission date of 11/11/16. Diagnoses included quadriplegia, adult failure to thrive and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/07/19, revealed the resident had intact cognition. The resident required limited assistance of one staff for transfers. Review of the plan of care dated 05/13/18 revealed the resident had a self-care deficit related to physical limitations. Interventions included total assistance for bathing. The plan of care dated 08/22/17 revealed the resident was noncompliant with treatment/care including refusing showers at times. Review of Preferences for Everyday Living Inventory (PELI) dated 06/25/19 stated it is very important to choose between a bath,…

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 review of manufacture's guidelines, the facility failed to properly administer a physician ordered medication to meet the needs of Resident #91 and failed to ensure a physician ordered medication was readily available in a timely manner for Resident #106. This affected two (Residents #91 and #106) of eight residents reviewed for medication administration. The facility census was 107. Findings include: 1. Review of medical record for Resident #91 revealed a re-admission date of 11/01/19 with diagnoses of end stage renal disease, type II diabetes and hypertension. Physician's orders dated 11/01/19 require daily administration of three units of insulin Glargine (Lantus Solostar) 100 units per milliliter subcutaneously every morning. During medication administration observation on 11/03/19 at 7:49 A.M., Registered Nurse (RN) #27 prepared Resident #91's Lantus Solostar insulin KwikPen (a disposable prefilled insulin pen used for injection) by securing a new needle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure as needed (PRN) medication orders for psychotropic drugs were limited to 14 days or that the facility physician justified in the medical record continued use of such medications. This affected one (Resident #32) of six residents (Residents #32, #46, #64, #90, #99 and #106) reviewed for unnecessary medications. The facility census was 107. Findings include: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, major depressive disorder, Alzheimer's disease, dementia without behavioral disturbances and diabetes mellitus. Review of the physician's orders for September 2019 revealed an order for Lorazepam (anti-anxiety medication) 1 milligram (mg) every four hours PRN. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 revealed the resident was not assessed for cognitive impairment and required extensive…

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.