Riverside Landing Nursing And Rehabilitation

Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were appropriately implemented when agreed upon by the physician. This affected one (Resident #37) of five residents reviewed for unnecessary medications/ monthly medication regimen reviews. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility 04/27/24. Her diagnoses included hypothyroidism. Review of Resident #37's physician's orders revealed the resident had an order in place to receive Levothyroxine Sodium 75 micrograms (mcg) by mouth (po) every morning for hypothyroidism. The resident also had an order to receive Ferrous Sulfate 325 milligrams (mg) po every morning and Magnesium Oxide 400 mg po every morning as supplements. Review of Resident #37's pharmacy recommendations revealed the facility's contracted pharmacist made recommendations following monthly reviews of the resident's medication regimen. There were two recommendations made by the pharmacist that addressed the administration time for 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 follow protocols for the use of an antibiotic to treat a urinary tract infection. This affected one resident (#6) of one residents reviewed for catheter use. The facility census was 42. Findings include: Review of Resident #6's medical record revealed an admission date of 10/12/24 and diagnoses including malignant neoplasm of endometrium, diabetes, chronic obstructive pulmonary disease, lumbosacral disorder, fibromyalgia, hypertension, anemia, protein-calorie malnutrition, neurogenic bladder, and lumbosacral plexus disorder. Review of Resident #6's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident also had an indwelling catheter. Review of Resident #6's progress notes revealed on 05/19/25 at 11:06 P.M. an order was obtained to obtain a urine specimen for urinalysis and culture and sensitivity related to the resident having cloudy urine with 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 review of the staffing daily posting, review of the schedule, review of timecards, review of the facility assessment, review of the quality assurance/performance improvement (QAPI), and interview the facility failed to ensure there was a Registered Nurse (RN) for eight consecutive hours and a full time Director of Nursing (DON). This had the potential to affect all 46 residents residing in the building. Findings included: 1. Review of the daily staffing posting dated 01/31/24 to 04/30/24 revealed there was no RN coverage for 01/06/24, 01/07/24, 01/13/24, 01/14/24, 01/20/24, 01/21/24, 01/27/24, and 01/28/24. Review of the facility assessment undated revealed the facility would have an RN at least eight hours daily. Review of the QAPI dated 02/01/24 to 03/01/14 revealed the problem was lack of RN coverage. The intervention was that the RDO would send out requests from other buildings to assist with coverage, offer sign on bonuses for RN coverage as of 02/22/24, and request requested others to participate from other buildings as of 03/2024. There was no evidence audits 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure enhanced barrier precautions were in place and failed to properly map infections in the facility. This had the potential to affect all 46 residents in the facility. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of bladder. Review of physician orders revealed Resident #3 had an order in place dated 04/05/23 for may change 16 French 10 cc indwelling catheter related to neurogenic bladder as needed for blockage and dislodgement. Review of a care plan dated 05/01/24 revealed Resident #3 had an alteration in elimination and neurogenic bladder which resulted in needing an indwelling foley catheter 16 French 10 milliliter balloon. Observation on 04/23/24 at 8:45 A.M. revealed Resident #3 had an uncovered catheter bag which 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, facility self-reported incident (SRI) review, policy review and interview, the facility failed to ensure residents were free from abuse. This affected five residents (#2, #6, #17, #20, and #21) of seven residents reviewed for abuse. The facility census was 46. Findings included: 1. Record review revealed Resident #2 admitted to the facility on [DATE] with diagnoses including traumatic hemorrhage of cerebrum, spastic hemiplegia affecting left nondominant side, type II diabetes, bipolar disorder, panic disorder, and anxiety disorder. Review of a personal witness statement by Licensed Practical Nurse (LPN) #328 dated 12/14/23 revealed LPN #328 was sitting in the nurse's station charting when she heard screaming from the dining room. She went to the dining room, and Resident #2 stated she had screamed due to another resident slapping her in the mouth, there was no swelling or redness noted. LPN #328 stated another male resident was in the dining area and witnessed Resident #2 getting slapped.…

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 physician's orders for the use of over the counter and narcotic pain medication ordered on an as needed (prn) basis for pain included parameters on when to use those medications, failed to ensure another resident only received prn narcotic pain medications for pain levels specified in the parameters of the physician's orders, failed to ensure a physician was notified when a resident's systolic blood pressure was outside the parameters provided by the physician with use of a beta-blocker, and failed to ensure a resident's use of prn Vistaril was clearly identified in the medical record to show the reason it was being given when the Vistaril was being used for both allergies and anxiety. This affected four (Resident #3, #14, Resident #41, and #42) of six residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a…

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

Based on observation, review of the cycle menu for Week 1, and staff interview, the facility failed to ensure residents received all food items for each meal in accordance with the cycle menu. This had the potential to affect all but six residents (Resident #6, #17, #18, #20, #25, and #42) who the facility identified as being on a pureed diet. The facility's census was 46. Findings include: On 04/24/24 at 11:25 A.M., an observation of the tray line noted Dietary [NAME] #350 was preparing the trays for the residents for the lunch meal served. She started with the hall carts and then was to prepare trays for those residents eating in the dining room. The meal included sweet and sour meatballs, parsley noodles, carrots, ice cream and beverages of their choice. The residents receiving a pureed diet was noted to be receiving pureed bread, but none of the residents receiving a mechanical soft texture diet or a regular diet was receiving any type of bread product. Review of the cycle menu for week 1 for the lunch meal to be served on Wednesday 04/24/24 revealed the meal should include a…

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

Based on observation, review of the pureed food recipes, and staff interview, the facility failed to prepare pureed food in a manner that conserved the nutritional value of the food being pureed in accordance with the recipes. This affected six residents (Resident #6, #17, #18, #20, #25, and #42) of six residents who the facility identified as being on a pureed diet. Findings include: On 04/24/24 at 10:45 A.M., an observation of the pureed food process noted Dietary [NAME] #350 to puree three different food items that were to be served with the lunch meal on 04/24/24. The first food item that was pureed was the parsley noodles. She was observed to puree the parsley noodles without referring to a recipe. She added the scoops of parsley noodles using the correct serving size (#8/ 4 ounce scoop) into the Robot Coupe food processor. She blended the noodles and then was noted to add an unmeasured amount of water to the noodles to try to obtain the desired consistency she needed. She did not add any type of broth of chicken/ beef base to the water before adding it to the noodles. The…

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

Based on observation, taste testing of the pureed food, and staff interview, the facility failed to ensure pureed food was prepared in the form that met the needs of the residents. This affected six residents (Resident #6, #17, #18, #20, #25, and #42) of six residents who the facility identified as being on pureed diets. Findings include: On 04/24/24 at 10:45 A.M., an observation of the pureed food process for the lunch meal served on 04/24/24 revealed Dietary [NAME] #350 pureed three different food items that were to be served to the residents on a pureed diet for lunch. The first item pureed was the parsley noodles, followed by the sweet and sour meatballs, and then the carrots. The dietary cook did not taste any of the three food items that were pureed. She also did not follow any recipes when she pureed the three food items. The parsley noodles were of proper consistency despite her not tasting the noodles to verify that before putting them on the steam table until they were served for lunch. The sweet and sour meatballs were not at proper texture when she reported she achieved…

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 lunch meals were served in a sanitary manner. This potentially affected all 46 residents that reside in the building. Findings included: Observation on 04/22/24 at 11:43 A.M. of lunch meal service revealed the A and B Hall trays arrived at the unit in a cart. State Tested Nurse's Assistant (STNA) #322 removed a container filled with condiments from the meal cart and placed it directly on the floor so she could get the coffee out. The STNA then picked up the condiment container and placed it back into the meal carts with the meal trays. Interview on 04/22/24 at 11:44 A.M., with STNA #322 confirmed she had placed the condiment container directly on the floor and placed it back into the meal cart with the resident meal trays. The STNA reported she didn't know what she was supposed to do because she was told she could not place anything on top of the meal cart and the kitchen staff always put the coffee behind the condiments container and she had to take the condiment container out to get to the coffee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents met infection criteria for appropriate antibiotic use. This affected three (Residents #7, #17, and #24) of 10 residents reviewed for infection control. The facility census was 46. Findings included: 1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and atherosclerotic heart disease without angina. Review of the infection control log for April 2024 revealed Resident #7 was treated for a urinary tract infection (UTI). Review of a urine culture dated 04/06/24 revealed Resident #7 tested positive for UTI with enterococcus Faecium VRE (Vancomycin resistant enterococcus). Review of McGeer Criteria for Infection Surveillance Checklist dated 04/08/24 revealed in order to be treated for a UTI criteria must be for section one (acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate; fever of leukocytes and one of the following: acute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review and interview, the facility failed to provide care in a dignified manner for Resident #3 related to the use of a urinary catheter. This affected one resident (#3) of two residents reviewed for catheters. The facility census was 46. Findings included: Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of bladder. Review of the resident's physician's orders revealed an order (dated 03/18/23) for Resident #3 to monitor and maintain 16 French 10 cubic centimeter (cc) indwelling catheter related to neurogenic bladder. On 04/23/24 at 8:45 A.M. Resident #3 was observed laying in bed and his urinary catheter bag was hanging from a lower bar of the bed, uncovered and half full of yellow urine which was visible from the hallway. Interview with Resident #3 at the time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review and interview, the facility failed to ensure residents were provided a clean, comfortable and homelike environment. This affected three residents (#3, #17, and #23) of three residents reviewed for environment. The facility census was 46. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with heart failure, type II diabetes, and neuromuscular dysfunction of bladder. On 04/23/24 at 8:40 A.M. interview with Resident #3 revealed concerns related to the condition of his room. The resident revealed he could not recall his floors being stripped or waxed since he had been in the room and thought the floors looked dirty and scuffed up. Observation of the floors at the time of the interview revealed the floors had several black scuffs from Resident #3's bedside to the doorway along with small amounts of debris 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 record review, observations, interview and facility policy review, the facility failed to ensure Resident #1 was free of restraints. This affected one resident (#1) of one resident reviewed for restraints. The facility census was 46. Findings included: Record review revealed Resident #1 admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, hemiplegia affecting right dominant side, and type II diabetes. Observation on 04/22/24 at 9:44 A.M. revealed Resident #1 in his motorized wheelchair with a seatbelt on. Observation on 04/24/24 at 11:31 A.M. revealed Resident #1 in his wheelchair with a seatbelt on. Interview on 04/24/24 at 2:34 P.M. with Licensed Practical Nurse (LPN) #327 revealed the facility did not have anyone with restraints in place, and the only type of assessments in place would be paperwork for bed rails. LPN #327 confirmed Resident #1 had a seatbelt on while 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 record review, review of facility self-reported incidents (SRI's), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner for Residents #8 and #2, and an injury of unknown origin for Resident #17. This affected three (#8, #2, and #17) of six residents reviewed for abuse. The facility census was 46. Findings include: 1. A review of Resident #8's medical record revealed he was admitted to the facility on [DATE] with diagnoses including paraplegia; unspecified psychosis not due to a substance or known physiological condition; anxiety disorder; depression; panic disorder; abnormal posture; muscle wasting and atrophy; muscle weakness; and generalized anxiety disorder. Review of SRI tracking number 244564 and the facilities investigation dated 02/26/24 revealed the incident was discovered on 02/25/24 that there was a physical altercation between Resident #8 and another male resident. The SRI was not reported to the state…

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 Minimum Data Set (MDS) assessments were completed accurately to reflect a resident's dental status, vision status, proper diagnoses, and medications received. This affected three residents (#8, #23, and #31) of 22 residents reviewed for assessments. Findings include: 1. Review of Resident #31's medical record revealed she was admitted to the facility on [DATE] with diagnoses including vascular dementia and hemiplegia and hemiparesis following a stroke (CVA) affecting his right dominant side. Review of Resident #31's physician's orders revealed the resident was receiving Atorvastatin (medication used to lower blood cholesterol levels) 80 milligrams (mg) by mouth (po) every night at bedtime for hyperlipidemia (high cholesterol in the blood). The Atorvastatin had been in place since 03/15/23. The resident also used Plavix (an anti-platelet) 75 mg po every morning for a CVA. The resident's physician's orders did not reveal the use of 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 reviews, interviews and facility policy review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRRs) reviews for Residents #6 and #17 were accurate. This affected two residents (#6 and #17) of two residents reviewed PASRRs. The facility census was 46. Findings included: 1. Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, obsessive compulsive disorder (OCD), mild cognitive impairment, major depression. Diagnoses of anorexia nervosa and psychosis were added on 01/04/23. Review of a PASRR dated 03/28/24 revealed Resident #6 had a mood disorder and a panic disorder but did not list Resident #6's diagnoses of psychosis or anorexia nervosa. Interview on 04/25/24 at 3:39 P.M. with Social Services Designee (SSD) #347 confirmed Resident #6's most recent PASRR did not list diagnoses of anorexia nervosa or psychosis. 2. Record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and facility policy review, the facility failed to provide nail care for Resident #1, who was dependent on staff for assistance with hygiene. This affected one resident (#1) of three residents reviewed for personal hygiene. The facility census was 46. Findings included: Record review revealed Resident #1 admitted to the facility on [DATE] with diagnoses including other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, hemiplegia affecting right dominant rise, type II diabetes, aphasia, hypertension, contracture of muscle of right upper arm and hand, and Alzheimer's disease. Review of a care plan dated 01/28/10 revealed Resident #1 had a self-care deficit related to brain injury with hemiparesis and mobility impairment with a goal of Resident #1 having his activity of daily living (ADL) needs met daily. Interventions included providing needed assistance with self-care daily. Review of a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure residents were provided timely care when a change of condition was noted, failed to ensure specialist appointments were made, and failed to ensure the bowel protocol was implemented timely. This affected one resident (#41) of two reviewed for hospitalization, one resident (#27) of six reviewed for pain management, and one resident (#32) of one reviewed for constipation. Findings included: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, acute kidney failure, chronic kidney disease, hepatitis, and mental disorders. Review of Resident #41's admission assessment dated [DATE] revealed the resident was alert and oriented times three (person, place, and time), coherent, speech was clear, understood others, and able to make self-understand. a. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of therapy notes, and interview the facility failed to ensure range of motion (ROM) services were implemented per plan of care and failed to ensure therapy services were provided when a resident had a noted decline. This affected two residents (#8 and #41) of four residents reviewed for positioning/restorative. Findings included: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic kidney disease, hepatitis, mental disorder, and wedge compression fracture. Review of Resident #41's admission assessment dated [DATE] revealed the resident had no neurological or mobility impairments. The resident was alert and oriented times three and able to make needs known. Review of Resident #41's hospital discharge notes dated 10/04/23 revealed the resident was hospitalized from [DATE] to 10/04/23 for multifocal pneumonia, acute hypoxic respiratory failure, acute toxic metabolic encephalopathy, acute…

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, staff interview and facility policy review, the facility failed to ensure Resident #14, who had a history of falls, had fall prevention interventions in place according to the physician's orders and plan of care. This affected one resident (#14) of four residents reviewed for accidents. Findings included: Review of Resident #14's medical record revealed she was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the frontal lobe, unspecified psychosis, Type I (juvenile onset) diabetes mellitus, epilepsy (seizures), unsteadiness on her feet, abnormalities of gait and mobility, and a history of falling. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not indicated to have displayed any behaviors or reject care during the seven-day assessment period. No mobility devices were indicated to have been used. Review of 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 tube feeding was administered as ordered by the physician and failed to ensure new orders were implemented timely. This affected one resident (#44) of one resident reviewed for tube feedings. Findings included: Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including aphasia, dysphagia, and gastrostomy. a. Review of Resident #44's dietary note dated 04/18/24 revealed to discontinue Jevity 240 milliliters (ml) with meals if oral intake was less than 50%. The resident reported she preferred house supplements eight ounces if she doesn't eat more than 50% of meals. New orders for houses supplement eight ounces if meal intakes are less than 50% per resident preference. Review of Resident #44's order dated 04/22/24 at 2:33 P.M., revealed the order for Jevity was still active, and there was no evidence the new order for house supplement was implemented. Interview on 04/25/24 at 9:39 A.M., with Assistant…

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 transit receipt, and interview the facility failed to ensure a resident was referred to pain management clinic timely. This affected one (Resident #8) of six resident reviewed for pain. Findings included: A review of Resident #8's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included paraplegia; unspecified psychosis not due to a substance or known physiological condition; anxiety disorder; depression; panic disorder; abnormal posture; muscle wasting and atrophy; muscle weakness; chronic pain; cerebral infarction; nondisplaced fracture of medial malleolus of right tibia; osteoporosis; and generalized anxiety disorder. Review of Resident #8's current plan of care revealed the resident had alteration in comfort related to chronic pain, chronic wound to back with hardware visible, neuropathic pain, and gastric reflux disease. The resident intervention included an appointment with a pain specialist as needed. Review of Resident #8's order…

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 policy review, the facility failed to ensure insulin flexpens were properly dated after they had been removed from the refrigerator and was used for the first time. This affected three residents (Resident #10, #13, and #16) whose insulin flexpens were found when reviewing two of two medication administration carts used by the facility for the storage of medications. Findings include: On 05/01/24 at 1:50 P.M., an observation of the medication administration cart for the A and B-hall revealed there were insulin flexpens found in the pull out drawer that had not been properly dated, after they had been removed from refrigeration during storage and used for the first time for the residents they were ordered for. Resident #16 was noted to have a Lantus flexpen (long acting insulin) 100 units/ milliliter (ml) that was in a plastic bag marked with a sticker to refrigerate. There was a label on the Lantus flexpen where the nurse was to date the flexpen, after it had been removed from the refrigerator and used for the first time. The label was 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, interview, and policy review the facility failed to ensure laboratory testing was completed as ordered. This affected one (Resident #41) of two reviewed for hospitalization. Findings included: Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, acute kidney failure, chronic kidney disease, hepatitis, and mental disorders. Review of Resident #41's written orders dated [DATE] revealed the Nurse Practitioner (NP) wrote orders for complete blood count (CBC) and Chem 8. There were no diagnoses or rational for order. Review of Resident #41's nurses note dated [DATE] written by the Assistant Director of Nursing (ADON) #361 revealed the NP visited and new orders were received for labs (CBC and Chem 8) in the morning. The resident and resident representative aware. Review of Resident #41's Medication and Treatment Records dated 09/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure dental services were arranged in a timely manner. This affected one (Resident #8) of two reviewed for dental services. Findings included: A review of Resident #8's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included paraplegia; unspecified psychosis not due to a substance or known physiological condition; anxiety disorder; depression; panic disorder; abnormal posture; muscle wasting and atrophy; muscle weakness; and generalized anxiety disorder. Review of Resident #8's dental plan of care dated 05/16/22 revealed the resident had dental caries and abscess teeth. Intervention included to coordinate arrangement for dental care, monitor for any dental problems needing attention, and to provide mouth care. Review of Resident #8 significant change minimum data set (MDS) dated [DATE] revealed the resident has no dental issues. Review of Resident #8 dental note dated 07/26/23 revealed the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, and review of the alternate meal menu, the facility failed to ensure a resident was provided a nutritious meal of choice when she declined the main meal being served for the lunch meal on 04/23/24. This affected one resident (Resident #37) of one residents reviewed for alternate meal choices. Findings include: Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included schizo-affective disorder of the bipolar type, morbid obesity due to excess calories, post traumatic stress disorder, Asperger's syndrome, anxiety disorder, psychotic disorder with delusions from known physiological condition, borderline personality disorder, and gastroesophageal reflux disease (GERD). Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was able to make herself understood 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer the pneumococcal vaccine to a resident who consented to receiving it. This affected one (Resident #21) of five residents reviewed for vaccinations. The facility census was 46. Findings included: Record review revealed Resident #21 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, metabolic encephalopathy, type II diabetes, and hypertension. Review of a consent form for a pneumococcal vaccination revealed Resident #21's responsible party consented to Resident #21 receiving the vaccine on 11/08/23. Review of the medical record provided no evidence the vaccination had been administered. Interview on 04/24/24 at 11 A.M. with Licensed Practical Nurse #361 confirmed Resident #21 had a consent to receive the pneumococcal vaccination on 11/08/23 but had not yet received it. Review of an undated policy titled Influenza, Pneumococcal, Shingles, and COVID-19 Immunization revealed each resident will be offered 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 offer vaccinations for COVID-19. This affected three (Resident #3, #8, and #21) of five residents reviewed for vaccinations. The facility census was 46. Findings included: 1. Record review revealed Resident #3 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease, type II diabetes, and respiratory failure. Review of vaccination consents revealed Resident #3 had not been offered a vaccination for COVID-19 since 11/14/22. Review of a handwritten statement dated 04/24/24 signed by Resident #3 revealed facility had offered the vaccine and he had declined. Interview on 04/24/24 at 11 A.M. with Licensed Practical Nurse (LPN) #361 confirmed the only consent available from Resident #3 was from 2022 2. Record review revealed Resident #8 admitted to the facility on [DATE] with diagnoses including paraplegia, chronic hepatitis, unspecified atherosclerosis, hypertension, 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 record review, observation, resident interview, staff interview, review of the facility menu, and review of the food committee minutes the facility failed to ensure meals, snacks and alternate menu items were offered and provided to the residents per their preferences and requests. This had the potential to affect all the residents residing at the facility who received food prepared in the kitchen. The facility census was 42. Findings include: Review of the medical record for Residents #5 revealed an admission date of 06/16/23 with diagnoses including chronic obstructive pulmonary disorder, type two diabetes mellitus, obesity, borderline personality disorder and schizoaffective disorder. Review of the January 2024 physician orders for Resident #5 revealed the resident was ordered a regular diet with regular texture and thin liquids and double portions. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 11/17/23 revealed the resident was cognitively intact and required set-up help only for meals. Resident #5 had no problems with chewing 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, staff interview, and review of the facility's catheter care protocols, the facility failed to ensure a resident's dressing to his midline catheter was changed in accordance with his physician's orders. This affected one resident (#50) of three residents reviewed for dressing changes. Findings include: A review of Resident #50's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of sepsis (life threatening medical emergency when an infection you have triggers a chain reaction throughout your body) and Methicillin resistant staphylococcus aureus (MRSA) as the cause of a disease classified elsewhere. A review of Resident #50's physician's orders revealed he had an order to maintain a midline catheter (a long, thin, flexible tube that was inserted into a large vein in the upper arm to safely administer medication into the bloodstream) to the left upper arm every shift until the antibiotic therapy treatment was complete. There was also an order to provide…

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 a resident received treatments to her pressure ulcer consistently as ordered by the physician. This affected one resident (#47) of three residents reviewed for wound care. Findings include: A review of Resident #47's medical record revealed she was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE], after a hospitalization. Her diagnoses included a cutaneous abscess of the buttocks. She developed an Unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar) to her right buttock that was present upon her re-admission to the facility on [DATE]. The unstageable pressure ulcer revealed a Stage III pressure ulcer (full-thickness loss of skin, in which fat was visible in the ulcer and it may or may not contain slough and/ or eschar) to the right buttock after the slough/ eschar was removed.…

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, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented to prevent avoidable falls. This affected one resident (#25) of three residents reviewed for falls. Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included toxic encephalopathy, hypertension, transient ischemic attacks, seizure disorder, atrial fibrillation, abnormalities of gait and mobility, unsteadiness on his feet, muscle weakness, insomnia, and disorientation. A review of Resident #25's fall risk assessment dated [DATE] revealed the resident was at risk for falls related to impaired decision making, needing assistance with activities of daily living (adl's), unsteady gait, use of assistive devices for mobility, and bladder incontinence. A review of Resident #25's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he did not have any communication issues and 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 record review and staff interview, the facility failed to ensure a resident receiving Coumadin (an anticoagulant) had Prothrombin (PT)/ International Normalized Ratio (INR) levels monitored consistently as ordered by the physician. This affected one resident (#25) of three residents reviewed for unnecessary medications. Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that commonly caused poor blood flow). He was hospitalized between 10/08/23 and 10/12/23. A review of Resident #25's physician's orders revealed he was receiving Coumadin 1 milligrams (mg) by mouth (po) once a day at bedtime. The Coumadin dosage had been ordered since 12/01/23. Prior dosages included 8 mg po daily (08/25/23- 09/11/23), 9 mg po daily (09/11/23- 10/04/23), and 10 mg po daily (10/04/23- 12/01/23). His physician's orders also included the need to obtain a PT/ INR (blood test that determined 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 staff interview, the facility failed to ensure the resident's physician was notified of laboratory test results timely after they were obtained. This affected one resident (#25) of three residents reviewed. Findings include: A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included atrial fibrillation (an irregular heart rhythm that commonly caused poor blood flow). He was hospitalized between 10/08/23 and 10/12/23. A review of Resident #25's physician's orders revealed he was receiving Coumadin 1 milligrams (mg) by mouth (po) once a day at bedtime. That Coumadin dosage had been ordered since 12/01/23. Prior dosages included 8 mg po daily (08/25/23- 09/11/23), 9 mg po daily (09/11/23- 10/04/23), and 10 mg po daily (10/04/23- 12/01/23). A physician order dated 11/28/23 revealed an order was received to repeat a PT/ INR due to a clinically high INR of 6.4 (therapeutic INR was between 2.0 and 3.0). A review of Resident #25's…

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

Based on interview, facility infection control log review and facility policy review the facility failed to ensure they had a complete infection control monitoring system which included the organisms causing the infection. This had the potential to affect all 43 residents. Findings included: Review of the facility infection control logs dated May 2023 to July 2023, revealed an inability for the facility to note trends or patterns of infection due to the facility did not track the organism causing the infection on the log. Review of the infection control mapping, dated May 2023 to July 2023, revealed the facility was tracking what body system (respiratory, skin, and etc.) but not what organism affected the body system. Interview on 08/24/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #121, who was also the Infection Preventionist, verified the infection control log was not complete and the missing piece of the infection control log was what organism caused the infection. She verified the mapping the facility used noted what body system (skin, respiratory, and etc.) was affected…

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, resident record review and facility policy review the facility failed to provide dignity and respect to one resident (#39) of three residents reviewed. The facility census was 43. Findings included: Review of Resident #39's medical record revealed an initial admission date of 11/10/22 and a readmission dated of 02/14/23 with diagnoses including metabolic encephalopathy, altered mental status, essential hypertension, and age related physical debility. Review of Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/12/23, revealed he was cognitively impaired. Further review revealed he needed extensive assistance from one person to physically assist him with eating. Review of Resident #39's plan of care, dated 02/27/23, revealed he had an activity of daily living self-care performance deficit related to debility, progression of aging, and needing assistance. Intervention included she required supervision by one staff to eat. Observation on 08/24/23 at 7:40 A.M. of State Tested Nursing Assistant (STNA) #129 assisting resident #39 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on daily staffing posting review, schedule review, Facility Assessment review and staff interview the facility failed to ensure registered nurse services were provided eight hours daily, seven days per week. This had the potential to affect all 39 residents residing in the facility. Findings include: Review of the Facility assessment dated [DATE] revealed the facility's staffing levels are based upon the acuity of their residents and resident population. The staffing pattern may fluctuate depending upon daily census and residents' needs. The facility provides a Registered Nurse at least eight hours daily. Review of the daily staffing postings from 12/16/22 through 02/16/23 revealed no registered nurse coverage on the following dates: 12/17/22, 12/18/22, 12/19/22, 12/21/22, 12/22/22, 12/23/22, 12/24/22, 12/31/22, 01/01/23, 01/02/23, 01/07/23, 01/08/23, 01/14/23, 01/15/23, 01/21/23, 01/22/23, 01/23/23, 01/24/23, 02/03/23, 02/04/23, 02/05/23, and 02/12/23. Review of the January and February 2023 Nursing Staff…

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 the Dietary Manager met the requirements for the position. This had the potential to affect all 39 residents residing in the facility and receiving food from the kitchen. Findings included: Review of the kitchen staff ServSafe Certifications revealed the following staff were certified: Dietary [NAME] (DC) #204, DC #232, Dietary Aide (DA) #211, and DA #218. There was no documentation to support Dietary Manager (DM) #52 had ServSafe certification. Interview on 02/15/23 at 11:25 A.M. with DM #52 verified he did not have a ServSafe Certification or a Food Protection Certification. Interview on 02/16/23 at 7:35 A.M. with DM #52 verified there was no full-time dietitian or diet tech in the facility. He verified he did not meet the requirements as director of food and nutrition services. He reported he had more than two years of experience in the position of director of food and nutrition services in a nursing facility setting but had not completed a course of study in food safety and management. He reported he has had…

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

Based on observation, interview, record review and policy review the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect all 39 residents residing in the facility and receiving food from the kitchen. Findings included: 1. Observation on 02/13/23 at 6:18 P.M. revealed one gallon of apple cider vinegar one-half full and one gallon of paint propping the pantry door open. Interview on 02/13/23 at 6:25 P.M. with Dietary Aide (DA) #211 verified a container of apple cider vinegar was on the floor and food items are not to be on the floor and a gallon of paint should not be in the pantry. 2. Observation on 02/13/23 at 6:19 P.M. revealed a container of brown sugar in the pantry with a plastic spoon in the container. Interview on 02/13/23 at 6:25 P.M. with DA #211 verified there should not be a spoon in the brown sugar. 3. Observation on 02/13/23 at 6:21 P.M. revealed both ovens in the range were noted to be dirty with burnt food. Interview on 02/13/23 at 6:25 P.M. with DA #211 verified the ovens were dirty and had been dirty 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.

Based on observation, interview, maintenance request review, the facility failed to ensure the commercial washing machine remained in service. This had the potential to affect all the residents in the facility. Findings include: Observation of the laundry room on 02/15/23 at 1:46 P.M. revealed the only commercial washing machine had a broken sign on it. Interview on 02/15/23, at the time of the observation, with Laundry #221 included the facility laundry had one Electrolux W5240H commercial washing machine and two residential washing machines. The commercial washing machine was currently broken. The service company will not service it any longer. Maintenance is aware. Since there is only one commercial washer when it is out of service staff can not keep up with the washing of personals and linens for the facility. Interview on 02/15/23 at 2:27 P.M. with Housekeeping/Laundry Supervisor (HLS) #201 included the industrial washing machine had been really bad the last year. HLS #201 affirmed occupational therapy and assisted living washer and dryers are used to provide enough clean linen…

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

Based on resident funds review, interview, and policy review, the facility failed to adequately notify resident and/or representative to assure they received spend-down notifications and reimburse overage due to the possibility of lost Medicaid eligibility for reaching and exceeding the maximum resource limit. This affected one of two current residents reviewed for facility-managed funds (#19) spend-down notice. The facility managed 18 resident accounts. The total resident census was 39. Findings include: Resident funds review revealed Resident #19 had $3268.39 in their personal funds account as of 02/09/23. Review of the quarterly statements since June 2022 revealed the account had been over the Medicaid limit since 06/03/22 when the account had $3154.76, ($954.76 over the funds limit allowed taking into account the grace period for government stimulus check). Review of the account revealed the balance had not dropped below the $2200.00 limit since 06/03/22. Review of the quarterly statements revealed they were signed by the resident's representative. A spend-down letter dated…

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

Based on record review, staff interview and policy review the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form to Resident #28 when the resident was cut from skilled nursing services and remained in the facility. This affected one resident (#28) of three residents reviewed for cut letters. The census was 39. Findings include: Review of Resident #28's medical record revealed an admission date of 12/13/22 with diagnoses including metabolic encephalopathy, diabetes, and schizoaffective disorder. The resident/resident representative was notified on 02/01/23 that skilled services would end on 02/03/23. There was no appeal of the notice and Resident #28 remained in the facility to current date for long term care. There was no evidence the facility provided a SNFABN as required to allow the resident to choose to continue the services when the resident was discharged from skilled care. On 02/16/23 at 5:18 P.M. interview with Social Service Designee (SSD) #209 verified the resident was cut from skilled services, remained in the facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a self reporting incident (SRI), resident interview, staff interview and policy review, the facility failed to ensure a resident's concerns/ grievance was resolved timely by the facility. This affected one (#26) of two residents reviewed for personal property. Findings include: A review of Resident #26's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity due to excess calories, muscle wasting and atrophy, muscle weakness, and difficulty walking. A review of Resident #26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. No behaviors was noted during the seven day assessment period. A review of Resident #26's care plans revealed he did not have any care plans in place that indicated he was known to have any behaviors or make false accusations. A review of Resident #26's progress notes revealed a nurse's note dated 09/04/22 at 12:00…

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 a self reporting incident (SRI), resident interview, staff interview and policy review, the facility failed to ensure allegations of misappropriation was reported to the state survey agency timely as required. This affected one (#26) of two residents reviewed for misappropriation. Findings include: A review of Resident #26's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included morbid obesity due to excess calories, muscle wasting and atrophy, muscle weakness, and difficulty walking. A review of Resident #26's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. No behaviors was noted during the seven day assessment period. A review of Resident #26's care plans revealed he did not have any care plans in place that indicated he was known to have any behaviors or make false accusations. A review of Resident #26's progress notes revealed a nurse's note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure allegations of abuse were thoroughly investigated. This affected one resident (#29) of two residents reviewed for abuse. The census was 39. Findings include: Review of Resident #29's medical record revealed an admission date of 08/22/22 with diagnoses including diabetes with foot ulcer, chronic ulcer of the left foot, post-traumatic stress disorder and homicidal ideations. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The resident also displayed physical and verbal behavioral symptoms directed toward others. The resident required extensive assistance of one to two staff members with activities of daily living. Review of Self-Reported Incident Number 230304 dated 12/19/22 revealed at 2:00 P.M. the resident stated he got $2.00 out of his wallet on 12/17/22 in the evening and still had $93.00 remaining. The resident stated he put his wallet back in the drawer Saturday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review the facility failed to provide residents with the bed hold notice prior to a transfer to an acute care setting. This affected one resident (#39) of one resident reviewed for hospitalization. The census was 39. Findings include: Review of the closed medical record for Resident #39 revealed an admission date of 01/26/23 with diagnoses including encephalopathy, acute and chronic respiratory failure with hypoxia, alcoholic cirrhosis and anxiety. Review of the five day Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living. Review of the progress notes revealed on 01/31/23 at 7:00 P.M. Resident #39 was transferred to the emergency room for evaluation of altered mental status. Further review of the medical record revealed no evidence a bed hold notice was provided to the resident or responsible party when the resident was transferred to the hospital. On 02/15/23 at…

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

Based on record review, interview, and facility policy review the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) was updated after mental health diagnoses additions. This affected one resident (#6) of two residents reviewed for PASARR. The facility census was 39. Findings included: Review of Resident #6's medical record revealed an admission date of 08/20/22 with diagnoses including bipolar disorder entered on 08/20/22, schizoaffective (psychotic) disorder, bipolar type entered on 08/22/22, and anxiety disorder entered on 08/22/22. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/22/22, revealed he was cognitively independent and had active psychiatric disorders of anxiety, bipolar, and schizophrenia. Review of Resident #6's most recent Pre-admission Screening and Resident Review (PASARR), dated 08/18/22, revealed in Section E: indication of Serious Mental Illness, the only disorder marked was mood disorder. The box beside other psychotic disorder was not marked. Interview on 02/14/23 at 10:40 A.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review the facility failed to ensure care conferences were completed quarterly. This affected one resident (#23) of two residents reviewed for care planning. The facility census was 39. Findings included: Review of Resident #23's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of type two diabetes, unilateral primary osteoarthritis, and essential hypertension. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 01/04/23, revealed she was mildly cognitively impaired. Review of Resident #23's Multidisciplinary Care Conferences dates documented in the electronic health record revealed she had conferences completed on 07/01/21, 08/16/21, 05/09/22, 08/02/22, and 12/02/22. There was no documentation of care conferences between 08/16/21 and 05/09/22. An interview on 02/14/23 at 7:47 A.M. with Resident #23 revealed she did not remember having care conferences every three months. An interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, shower list review, staff and resident interview and policy review the facility failed to ensure residents were assisted with shaving as needed. This affected one resident (#32) of one resident reviewed for activities of daily living. The census was 39. Findings include: Review of Resident #32's medical record revealed an admission date of 10/19/22 with diagnoses including Alzheimer's Disease, major depression and schizoaffective disorder. Review of the shower sheets revealed the resident showered: 10/27/22 shower and shave documented 01/30/23 refused to be shaved but had a shower 01/31/23 had a shower (no shave documented) 02/02/23 had a shower (no shave documented) 02/07/23 resident refused 02/09/23 had a shower (no shave documented) 02/10/23 had a shower (no shave documented) 02/13/23 refused three times Review of the activity of daily living for personal hygiene electronic health record documentation revealed the resident required independence to limited assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents with orders for constipation treatment were assessed and provided intervention. This affected two residents (#23 and #24) of five residents reviewed for unnecessary medications. The facility census was 39. Findings included: 1. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of type two diabetes, unilateral primary osteoarthritis, and essential hypertension. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 01/04/23, revealed she was mildly cognitively impaired. Review of Resident #23's physician order dated 01/20/21 revealed Dulcolax suppository 10 mg insert one suppository rectally as needed for daily constipation and Milk of Magnesia Suspension (400 milligrams/5 milliliters) give 30 milliliters by mouth as needed daily for constipation, and Fleet Enema 7-19 grams/118 milliliters insert one application rectally every 24 hours as needed 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 Based on record review, interview, and policy review the facility failed to ensure a resident with a pressure ulcer had comprehensive pressure ulcer assessments completed to determine the status of the ulcer to include progression or healing of the ulcer and the potential need to alter treatment. This affected one resident (#11) of three residents assessed for pressure ulcers. The facility census was 39. Findings included: Review of Resident #11's medical record revealed he was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included mechanical complications of other internal orthopedic devices, a non-pressure chronic ulcer of the back with necrosis of bone, paraplegia, and unspecified protein-calorie malnutrition. Review of Resident #11's Significant Change Minimum Data Set (MDS) 3.0 assessment, dated 01/25/23, revealed he was cognitively impaired and was at risk for pressure ulcers, had a pressure ulcer, and had a Stage III unhealed pressure ulcer…

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

Based on observation, interview, and record review the facility failed to ensure resident's oxygen was administered as ordered. This affected one resident (#24) of two residents reviewed for respiratory care. The facility census was 39. Findings included: Review of Resident #24's medical record revealed an admission date of 12/10/22 with diagnoses including encounter for other orthopedic aftercare, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and essential hypertension. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/23, revealed she was cognitively independent, had active diagnoses of asthma (chronic obstructive pulmonary disease or chronic lung disease), respiratory failure and received oxygen. Review of Resident #24's physician order, dated 12/10/22, revealed she was to have oxygen at three liters per minute (L/min) via a nasal cannula continuously every shift for shortness of breath. Review of Resident #24's current comprehensive care plan revealed a focus of alteration in respiratory function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview the facility failed to create a comprehensive behavioral health plan to assist the resident in achieving his highest practical level of well-being while keeping the other residents safe. This affected one resident (#29) of one residents reviewed for mood and behavior. The census was 39. Findings include: Review of Resident #29's medical record revealed an admission date of 08/26/22 with diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, major depressive disorder and homicidal ideations. Review of the hospital documents from 06/28/22 through 08/26/22 revealed the resident was admitted to the hospital with PTSD in addition to depressive disorder and had homicidal ideation and aggressive behavior on admission but not anymore. Review of the at risk for alteration in mood/behavior care plan- at former facility hit staff member, shaking fist in the air, secondary to potential body image concerns related to a right below 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, interview, and policy review the facility failed to ensure an attending physician reviewed the Medication Regimen Review (MRR) for pharmacy recommendations and took action on recommendations or provided a rationale if no action was taken. This affected one resident (#24) of five residents reviewed for unnecessary medications. The facility census was 39. Findings included: Review of Resident #24's medical record revealed an admission date of 12/10/22 with diagnoses including encounter for other orthopedic aftercare, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, essential hypertension, and anxiety disorder. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/23, revealed she was cognitively independent and had an active diagnosis of anxiety. Review of Resident #24's physician order dated 12/22/22 to 01/12/23 revealed Alprazolam (Xanax, an antianxiety medication) tablet 0.25 milligram (mg) by mouth every 10 hours as needed (PRN) for anxiety. Further review of the orders dated 01/12/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview the facility failed to ensure residents did not receive medications in excessive doses. This affected one resident (#29) of five residents reviewed for unnecessary medications. The census was 39. Findings include: Review of Resident #29's medical record revealed an admission date of 11/06/22 with diagnoses including hypertension, diabetes, homicidal ideations and bipolar disorder. Review of the physician orders revealed metoprolol succinate (antihypertensive) 50 milligrams (mg) give 50 mg daily in the morning dated 11/11/22 and metoprolol succinate 100 mg give 100 mg by mouth in the morning for elevated blood pressure dated 12/22/22. Review of the progress notes dated 12/22/22 at 12:38 P.M. revealed Licensed Practical Nurse (LPN) #54 documented the resident's physician ordered metoprolol succinate 100 mg orally daily. Further review of the medical record revealed both doses of metoprolol succinate were administered concurrently since 12/23/22. 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 record review, interview, and policy review the facility failed to ensure as needed (PRN) psychoactive medications were limited to 14 days unless the attending physician documented a rationale to extend the medication. This affected one resident (#24) of five residents reviewed for unnecessary medications. The facility census was 39. Findings included: Review of Resident #24's medical record revealed an admission date of 12/10/22 with diagnoses including encounter for other orthopedic aftercare, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, essential hypertension, and anxiety disorder. Review of Resident #24's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/23, revealed she was cognitively independent and had an active diagnosis of anxiety. Review of Resident #24's physician order dated 12/22/22 to 01/12/23 revealed Alprazolam (Xanax, an antianxiety medication) tablet 0.25 milligram (mg) by mouth every 10 hours PRN for anxiety. Further review of the orders dated 01/12/23 and no stop dated revealed Alprazolam (Xanax)…

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 laboratory studies were completed per physician orders. This affected one resident (#39) of one resident reviewed for hospitalization. The census was 39. Findings include: Review of the closed medical record for Resident #39 revealed an admission date of 01/26/23 with diagnoses including encephalopathy, acute and chronic respiratory failure with hypoxia, alcoholic cirrhosis, anxiety and unspecified convulsions. Review of the five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required staff assistance with activities of daily living. Review of the progress notes dated 01/30/23 at 11:20 A.M. revealed the resident was presenting with increased confusion at times. Presents with odd behaviors and was emptying a soda bottle to make a booby trap. Continuously manipulating post-surgical drain. State Tested Nurse Aide (STNA) assisting with care as much as the resident will allow. 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, observation, staff interview, policy review, the facility failed to ensure dressing changes were performed following acceptable infection control practices. This affected one (#31) of three residents observed for dressing changes. The facility's census was 39. Findings include: 1. A review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included a Stage IV pressure ulcer (full thickness skin loss exposing underlying muscle, tendon, cartilage, or bone) of the coccyx. A review of Resident #31's physician's orders revealed she had an order in place for the wound to her coccyx to be packed with Alginate Silver then covered with an absorbent dressing. The treatment was to be done daily in the afternoon and as needed. The order had been in place since 01/03/23. A review of Resident #31's care plans revealed she had a care plan in place for having been admitted with actual impaired skin integrity/ Stage IV pressure ulcer to her coccyx.…

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.