New Lebanon Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, observations, and resident and staff interviews, the facility failed to maintain a pest free environment. This affected three (#49, #61, and #96) residents out of six residents reviewed for pest control. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis, unspecified schizophrenia, and narcolepsy without catatonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had moderately impaired cognition, had verbal behaviors, did not wander, and routinely rejected care. Observation on 09/22/25 at 10:16 A.M. revealed Resident #61 lay in bed in a hospital gown with a sheet covering him. There were two flying insects observed on the the bed sheet, and one flying insect had landed on the privacy curtain. During an interview in 09/22/25 at 10:16 A.M. Activities Director #199 verified Resident #61 had three flying insects flying…

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, staff interviews and review of facility policy the facility failed to ensure smoking items were properly stored according to policy. This affected two (#49 and #16) of four residents reviewed for smoking. The facility census was 96. Findings include: Review of medical record for Resident #16 revealed admission date of 07/29/25. The resident was admitted with diagnoses including hemiplegia right dominant side following stroke, type two diabetes mellitus, dementia without behavior, anxiety, depression and congestive heart failure. The resident remained at the facility. The admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. He was independent with eating and required moderate assistance from staff with toileting hygiene, bed mobility Observation on 09/22/25 at 10:51 A.M. revealed an unopened pack of cigarettes located on the bedside table during an interview with Resident #16. Observation…

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, review of the directive from Centers for Medicare and Medicaid Services (CMS), and facility policy review, the facility failed to notify the local health department of a COVID-19 facility outbreak that began on 11/16/24 and ended on 12/24/24. This had the potential to affect all residents in the facility. The facility census was 88. Findings include: Review of the facility infection control log and map confirmed the facility had an outbreak of COVID-19 on 11/16/24 through 12/24/24. Interview on 12/30/24 at 4:51 P.M. with the Administrator confirmed the facility experienced an outbreak of COVID-19 from 11/16/24 though 12/24/24. The Administrator confirmed the facility was not aware of a requirement to contact the local health department and failed to notify the local health department of the outbreak. Review of the directive from CMS titled, QSO-20-39-NH, dated May 08, 2023, revealed facilities are expected to contact their health department when responding to COVID-19 transmission within their facility. Review of the facility policy titled,…

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, staff interview, review of hospital documentation, review of Omnicell (automatic medication dispensing cabinet) documentation, and policy review, the facility failed to administer medication as ordered. This affected one (#97) out of three residents reviewed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #97 revealed an admission date of 09/13/24 with medication diagnoses of staphylococcal arthritis of left ankle and foot, schizophrenia, anxiety, bipolar disorder, and mild cognitive impairment. Review of the medical record for Resident #97 revealed an admission Minimum Data Set (MDS) assessment, dated 09/20/24, which indicated Resident #97 had severe cognitive impairment and was independent with toilet hygiene, bed mobility, and transfers and required supervision with bathing. The MDS indicated Resident #97 received antipsychotic and antianxiety medications. Review of the medical record for Resident #97…

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, and policy review, the facility failed to follow infection control procedures during medication administration. This affected one (#09) out of the two residents observed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #09 revealed an admission date of 02/22/23 with medical diagnoses of right above the knee amputation, diabetes mellitus, asthma, schizoaffective disorder, and chronic respiratory failure. Review of the medical record for Resident #09 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/24, which indicated Resident #09 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #09 revealed physician orders dated 03/20/24 for Ascorbic acid 500 milligram (mg) one tablet by mouth two times per day, multivitamin one tablet by mouth two times per day, senna 8.6-50 mg one tablet by mouth two times per day, loratadine 10…

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 reviews, staff interviews, observations, and pest control invoices, the facility failed to ensure resident rooms were free from flies and gnats. This affected two (#11 and #13) out of the three reviewed for environment. The facility census was 96. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 04/26/23 with medical diagnoses of cervical disc disorder with myelopathy, mood disorder, metabolic encephalopathy, diabetes mellitus, congestive heart failure, and hypertension. Review of the medical record for Resident #11 revealed a quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, which indicated Resident #11 was cognitively intact and was dependent for toilet hygiene, bathing, bed mobility, and transfers. The MDS indicated Resident 311 was always incontinent of bladder, frequently incontinent of bowel, and refused care at times. 2. Review of the medical record for Resident #13 revealed an admission date of 07/11/23 with medical diagnoses of emphysema, cerebral infarction, diabetes mellitus, vascular…

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, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, and staff interview, the facility failed to be administered in a manner to ensure proper care and services for residents. This had the potential to affect all 105 residents residing in the facility. The census was 105. Findings include: During the annual, extended survey, and complaint survey, many area of deficient practice were identified under resident quality of life and quality of care area. Those areas included providing residents with activities of daily living assistance, providing wound care, assisting residents with range of motion needs, preventing accidents and hazards, providing catheter care, obtaining resident weights to address nutritional needs, care of a gastrostomy tube, and treatment pressure ulcers which resulted in an Immediate Jeopardy. Additionally, the facility was identified deficient in the area of sufficient staffing which also resulted in an Immediate Jeopardy. Review of the QAPI sign-in sheets for 08/14/23, 12/04/23, 02/12/24, and 06/10/24 revealed…

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

Based on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, staff interview, and policy review, the facility failed to have an effective governing body to oversee the functions of the facility. This had the potential to affect all 105 residents in the facility. The census was 105. Findings include: Review of the QAPI sign-in sheets for 08/14/23, 12/04/23, 02/12/24, and 06/10/24 revealed multiple people in the role of Director of Nursing (DON). The sheets also lacked information regarding the governing body's involvement with the QAPI meetings. Review of a list provided by the facility revealed there had been four individuals in the DON position since 09/21/23. Interview on 08/29/24 at 11:25 A.M. via telephone with Physician #232 verified there had been significant turnover in nursing management at the facility. Interview on 08/29/24 at 3:15 P.M. with [NAME] President of Operations (VPO) #242 revealed the information he was learning regarding staffing levels at the facility had given him great pause and concern. Interview on 08/29/24 at 3:27…

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 facility assessment review and staff interview, the facility failed to include staffing needs for each resident unit within the facility and time frames for adjustments as necessary with changes in the resident population. This has the potential to affect all residents in the facility. The facility census was 105. Findings include: Review of the facility assessment dated 2023 and 2024 revealed an initial approval signature page with three signatures on it. The signatures included the Administrator, the Director of Nursing (DON), and the Medical Director with a date of 05/31/24. Review of the Letter B of the facility assessment addressed staffing and staffing assignments. Further review revealed staffing would be determined using various reports to analyze the number of patients, velocity of expected admission and discharges, diagnoses and the total number and types of tasks and services required of nursing, nursing assistants and ancillary personnel. The facility assessment did not address the staffing…

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 ensure appropriate and adequate oversight by the Medical Director. This had the potential to affect all 105 residents residing in the facility. The census was 105. Findings include: Review of the facility documentation revealed no evidence of the Medical Director's participation in addressing identified concerns and overall coordination of resident care and services. Interview on 08/29/24 at 11:25 A.M. via telephone with Physician #232 revealed he was unaware of the severity of identified concerns despite being a member of the Quality Assurance and Performance Improvement (QAPI) committee. Physician #232 stated he had not always provided the facility with his completed documentation related to resident visits. Review of the facility policy titled, Medical Director, dated 09/2021, revealed the Medical Director should be meeting periodically with nursing and other professional staff to discuss clinical and administrative issues, care problems, and offering solutions to problems.

Based on record review, staff interview, and policy review, the facility failed to make good faith attempts to correct identified concerns with appropriate oversight from leadership as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 105 residents residing in the facility. The census was 105. Findings include: During the annual, extended survey, and complaint survey, many area of deficient practice were identified under resident quality of life and quality of care area. Those areas included providing residents with activities of daily living assistance, providing wound care, assisting residents with range of motion needs, preventing accidents and hazards, providing catheter care, obtaining resident weights to address nutritional needs, care of a gastrostomy tube, and treatment pressure ulcers which resulted in an Immediate Jeopardy. Additionally, the facility was identified deficient in the area of sufficient staffing which also resulted in an Immediate Jeopardy. Review of the facility QAPI program revealed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure staff followed infection control precautions related to handling soiled linens, providing care for residents on enhanced barrier precautions, and providing meals and eating assistance with proper hand hygiene. This had the potential to affected all 105 residents residing in the facility. The facility census was 105. Findings include: 1. Observation on 08/29/24 at 7:15 A.M. of the facility laundry room revealed Laundry Staff #176 was on the side of the room designated for sorting dirty laundry from the units. Laundry Staff #176 was sorting linens from a large plastic laundry bin with dark brown stains on them. Laundry Staff #176 was wearing a cotton uniform jacket over her uniform with gloves and no goggles. Interview on 08/29/24 at 7:20 A.M. with Laundry Staff #176 verified she was not wearing the approved personal protective equipment (PPE) when she should have been. Laundry Staff #176 verified a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to thoroughly investigate resident-to-resident altercations. This affected six (Residents #69, #72, #74, #79, #91, and #152) of six residents reviewed for abuse. The facility census was 105. Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 01/03/23. Diagnoses included type two diabetes mellitus without complications, acute kidney failure, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, insomnia, neurocognitive disorder with Lewy bodies, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 was rarely/never understood and had impaired cognitive skills. Resident #69 was assessed to require set-up assistance for eating, substantial/maximal assistance for oral hygiene,…

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, interview and policy review, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received care and services in a timely manner. This affected four (Residents #4, #6, #41 and #50) of four residents reviewed for care and services. The facility census was 105. Findings include: 1. Record review revealed Resident #41 was admitted on [DATE]. Diagnoses included traumatic hemorrhage of cerebrum, hemiplegia on right and left side, epilepsy, respiratory failure, coma, persistent vegetative state, acute cystitis without hematuria, hypertension, anxiety disorder, tracheostomy status and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment for Resident #41 revealed resident was in a persistent coma state and was dependent for all care. The resident had a gastrostomy tube and received 51 percent of calories through parenteral feedings, had a tracheostomy in place and received oxygen via compressor at 20 pounds per square…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility to ensure residents did not have their smoking equipment in their rooms. This affected three (Residents #51, #68 and #77) residents. The facility identified 47 residents who used tobacco products. The facility census was 105. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 08/31/23 with diagnoses of emphysema, unspecified and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51 with moderate cognitive impairment. Review of physician orders revealed an order dated 07/24/24 for oxygen two liters via nasal cannula as needed to maintain oxygen saturations greater than 90 percent. Review of Other Smoking Evaluation dated 08/19/24 revealed Resident #51 is able to be an unsupervised smoker. Review of the care plan for smoking, revised 08/19/24, 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 observation, record review, interview and policy review, the facility failed to ensure resident privacy. This affected one (Resident #5) of two residents reviewed for dignity and respect. The facility census was 105. Findings include: Review of the medical record for Resident #5 revealed an admission date of 04/26/23. Diagnoses included cervical disc disorder with myelopathy, mid-cervical region, contracture, right hip, contracture, left hip, contracture, right knee, and contracture, left knee. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. She was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and wheelchair mobility. Review of the Care Plan dated 01/17/24 revealed Resident #5 has an Activities of Daily Living (ADL) self-care performance deficit with interventions of assist with activities of daily living (i.e.: dressing, grooming, personal hygiene,…

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, interview and policy review, the facility failed to ensure call lights were within reach. This affected one (Resident #15) of four residents reviewed for accommodations of needs. The facility census was 105. Findings include: 1. Medical record review for Resident #15 revealed an admission on [DATE], with diagnoses including chronic obstructive pulmonary disease, asthma, type 2 diabetes with polyneuropathy, hypertension, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had impaired cognition. Resident #15 had no impairments for bilateral upper extremities. Resident #15 required supervision for eating, total staff dependence for toileting and transfers, maximal assistance for bed mobility. Review of the plan of care for Resident #15 dated 05/15/24 revealed the resident had an activities of daily living self-care performance deficit. Interventions include assist with activities of daily living (dressing,…

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 notify a resident representative of a change in condition. This affected one (Resident #87) one resident reviewed for notification. The facility census was 105. Findings include: Review of the medical record for Resident #87 revealed an admission date of 05/13/24. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system and major depressive disorder. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact. Resident was independent for eating, oral hygiene, personal hygiene, and bed mobility. Resident required partial assistance with toileting hygiene, transfers, and ambulating 10 feet. Resident required substantial assistance with bathing and dressing. Review of progress notes revealed no documentation of Resident #87 leaving the facility and being transferred to the hospital on [DATE]. There was no documentation that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit a resident to remain in the facility and not transfer or discharge a resident from the facility without the proper documentation. This affected one (Resident #100) of three residents reviewed for transfer or discharge. The facility census was 105. Findings include: Review of the Resident #100's chart revealed Resident #100 admitted to the facility on [DATE] with diagnoses including spinal stenosis, polyneuropathy, paresthesia of skin, radiculopathy, major depressive disorder and other specified arthritis. Resident #100 was discharged from the facility on 05/22/24. Review of Resident #100's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #100 required set up with eating, oral hygiene, toileting, and personal hygiene. Resident #100 required supervision with showering, upper body dressing, and moderate assistance with lower body dressing, putting on and taking off footwear, sitting…

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 provide notification to a resident of the transfer or discharge and the reasons for the move to a resident that was discharged to a homeless shelter. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105. Findings include: Review of the Resident #100's chart revealed Resident #100 admitted to the facility on [DATE] with diagnoses including spinal stenosis, polyneuropathy, paresthesia of skin, radiculopathy, major depressive disorder and other specified arthritis. Resident #100 was discharged from the facility on 05/22/24. Review of Resident #100's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #100 required set up with eating, oral hygiene, toileting, and personal hygiene. Resident #100 required supervision with showering, upper body dressing, and moderate assistance with lower body dressing, putting on and taking off…

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 sufficiently prepare and orient a resident to ensure a safe and orderly discharge from the facility. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105. Findings include: Review of the Resident #100's chart revealed Resident #100 admitted to the facility on [DATE] with diagnoses including spinal stenosis, polyneuropathy, paresthesia of skin, radiculopathy, major depressive disorder and other specified arthritis. Resident #100 was discharged from the facility on 05/22/24. Review of Resident #100's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #100 required set up with eating, oral hygiene, toileting, and personal hygiene. Resident #100 required supervision with showering, upper body dressing, and moderate assistance with lower body dressing, putting on and taking off footwear, sitting to standing, chair transfers,…

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, interview, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately. This affected three (Residents #41, #62, and #77) of twelve residents reviewed for MDS accuracy. The facility census was 105. Findings include: 1. Record review revealed Resident #41 was admitted on [DATE]. Diagnoses included traumatic hemorrhage of cerebrum, hemiplegia or right and left sides, epilepsy, respiratory failure, systemic inflammatory response syndrome, persistent vegetative state, acute cystitis without hematuria, hypertension, anxiety disorder, tracheostomy status, encephalopathy, and gastrostomy. Review of the active physician orders for Resident #41 revealed an ordered dated 03/20/24 for nothing by mouth (NPO), an order dated 03/21/24 for tube feeding, Jevity 1.5- 60 milliliters/hour (ml/hr) until 1320 ml has infused, allow two hours off for nursing care. Review of the annual MDS assessment for Resident #41 dated 08/15/24 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 record review and interview, the facility failed notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for residents with a change in their mental health or physical condition. This affected two (Residents #04 and #79) of five resident reviewed for PASARR. The facility census was 105. Findings include: 1. Review of the Resident #04's medical record revealed an admission date of 08/31/22. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, dementia in other diseases classified elsewhere severe with other behavioral disturbance, major depressive disorder, other seizures, adult failure to thrive, anorexia, cerebral palsy, schizoaffective disorder, depression, insomnia, age related osteoporosis without current pathological fracture and cerebral infarction. Review of Resident #04's PASARR dated 08/31/22 revealed Resident #04 had no indications of serious mental illness. There were no diagnoses of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and policy review, the facility failed to develop comprehensive care plans for residents. This affected three (Residents #04, #62, #77) of twelve residents reviewed for care plans. The facility census was 105. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 11/09/22. Diagnoses included Alzheimer's disease, type 2 diabetes mellitus with other specified complication, and bipolar disorder. Review of the care plan dated 03/10/24 revealed resident is at risk for altered nutritional / hydration status related to history of mouth sores with interventions of refer to ancillary services i.e. dental, vision etc. as needed. Further review of the care plan revealed no documentation related to resident has multiple dental cavities. During an interview on 08/19/24 at 2:20 P.M., Resident #62 stated he was to be referred to an oral surgeon quite a while agodue to cavities to left posterior teeth. The resident complaint of tooth…

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 revise the plans of care timely and failed to conduct care conferences as required. This affected three (Residents #46, #77, and #92) of three residents reviewed for care planning. The facility census was 105. Findings include: 1a. Review of the medical record for Resident #46 revealed an admission date of 03/01/21. Diagnoses included Parkinson's disease, type two diabetes mellitus (DM II), epilepsy, and paraplegia. Review of the five-day Medicare Minimum Data Set (MDS) assessment, dated 08/02/24, revealed Resident #46 was not able to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. The resident required supervision with eating, dependent with toileting, bathing, dressing, and transfers. Resident #46 had an indwelling catheter and was always incontinent of bowel. Review of the care plan dated 08/25/23 revealed Resident #46 had a need for suprapubic catheter related to neurogenic bladder.…

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 had an order for a dressing change and failed to change the dressing as ordered; failed to ensure transportation was provided to appointments; and failed to timely address a change in condition. This affected three (Residents #86, #87 and #303) residents. Seven residents were reviewed for wound care, and two residents were reviewed for transportation and changes in condition. The facility census was 105. Findings include: 1a. Record review revealed Resident #86 was admitted on [DATE] with diagnoses including fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, right leg and paraplegia. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated, 05/24/24 revealed Resident #86 was cognitively intact. Resident #86 had an order for a follow up appointment on 08/15/24 at 9:30 A.M. at [NAME] Health [NAME] Wound Care. Review of the nursing note dated…

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

Based on observation, record review, interview, and policy review, the facility failed to ensure catheter care was provided appropriately. This affected one (Resident #46) of two residents reviewed for urinary concerns. The facility census was 105. Findings include: Review of the medical record for Resident #46 revealed an admission date of 03/01/21. Diagnoses included Parkinson's disease, type two diabetes mellitus (DM II), epilepsy, and paraplegia. Review of the Five-day Medicare Minimum Data Set (MDS) assessment, dated 08/02/24, revealed Resident #46 was not able to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. Resident #46 was dependent with toileting. Resident #46 had an indwelling catheter and was always incontinent of bowel. Review of the care plan, dated 08/25/23, revealed Resident #46 had a need for a catheter related to neurogenic bladder. Interventions included enhanced barrier precautions for indwelling catheter. Staff monitor for signs and symptoms of urinary tract infections including blood in urine, cloudiness, foul smell,…

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 the physician approved admission to the facility in writing. This affected three (Residents #58, #85, and #92) out of five residents reviewed for physician services. The facility census was 105. Findings include: 1. Record review revealed Resident #58 was admitted on [DATE]. Diagnoses included schizophrenia, severe intellectual disabilities, morbid (severe) obesity due to excess calories, autistic disorder, type two diabetes mellitus without complications, constipation, hypothyroidism, vitamin d deficiency, drug induced akathisia, insomnia, attention-deficit hyperactivity disorder, generalized anxiety disorder, and restlessness and agitation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had severely impaired cognition. Resident #58 was assessed to require set-up assistance for eating, oral hygiene, dressing, personal hygiene, supervision for bathing, and was independent for toileting, bed mobility,…

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 ensure medically related social services was provided to a resident discharging from the facility. This affected one (Resident #100) out of three residents reviewed for transfer or discharge. The facility census was 105. Findings include: Review of the Resident #100's chart revealed Resident #100 admitted to the facility on [DATE] with diagnoses including spinal stenosis, polyneuropathy, paresthesia of skin, radiculopathy, major depressive disorder and other specified arthritis. Resident #100 was discharged from the facility on 05/22/24. Review of Resident #100's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #100 required set up with eating, oral hygiene, toileting, and personal hygiene. Resident #100 required supervision with showering, upper body dressing, and moderate assistance with lower body dressing, putting on and taking off footwear, sitting to standing, chair transfers, toilet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure laboratory tests were obtained per physician orders. This affected two (Residents #16 and #77) of five reviewed for unnecessary medications. The facility census was 105. Findings include: 1. Review of Resident #16's medical record revealed an admission date of 09/23/18 with diagnoses including but not limited to syncope and collapse, cognitive communication deficit, dementia severe with other behavioral disturbance, schizoaffective disorder, paranoid personality, insomnia, major depressive disorder, anxiety disorder, hypertension and anxiety. Review of the plan of care for Resident #16 dated 03/18/22 revealed the resident had an impaired neurological status related to dementia. Interventions include administer medications as ordered, monitor and report to physician of declines in cognitive functioning, orientation, changes in communication, and monitor laboratory and diagnostic testing per physician orders. Review of the active…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to schedule an oral surgeon appointment timely for one (Resident #62) of one resident reviewed for dental concerns. The facility census was 105. Findings include: Review of the medical record for Resident #62 revealed an admission date of 11/09/22 with diagnoses of Alzheimer's disease, type II diabetes mellitus with other specified complication, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was cognitively intact, had impairment to bilateral upper and lower extremities, and required set-up assistance with eating, oral hygiene, and wheelchair mobility. Review of the care plan dated 03/10/24 revealed Resident #62 was at risk for altered nutritional/hydration status related to therapeutic diet and history of mouth sores with intervention of refer to ancillary services, i.e. dental. Review of Resident #62's dental health service post-visit 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.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents received drinks of their preference and request in a timely manner. This affected one (Resident #13) of 25 residents residing in the memory care unit. The facility census was 105. Findings include: Medical record review for Resident #13 revealed an admission date of 02/18/20 with diagnoses including but not limited to schizophrenia, protein calorie malnutrition, chronic obstructive pulmonary disease (COPD), alcohol abuse, tachycardia, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #13 revealed the resident was assessed with impaired cognition. Resident #13 required set up for eating, and supervision for toileting, transfers, and bed mobility, Resident #13 was on a mechanically altered diet with thin liquids. Review of the plan of care for Resident #13 dated 04/15/22, and revised on 08/19/24, revealed the resident was at risk for altered nutritional status/dehydration related to diagnosis of COPD, dementia, depression, consumed less than 75 percent (%)…

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 resident medical records were complete and accurately documented. This affected one (Resident #87) one resident reviewed for notification. The facility census was 105. Findings include: Review of the medical record for Resident #87 revealed an admission date of 05/13/24 with diagnoses of acute transverse myelitis in demyelinating disease of central nervous system and major depressive disorder. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #87 was cognitively intact. Resident #87 was assessed as independent for eating, oral hygiene, personal hygiene, and bed mobility. Resident #87 required partial assistance with toileting hygiene, transfers, and ambulating 10 feet, and required substantial assistance with bathing and dressing. Review of Resident #87's physician orders revealed no documentation that the resident was ordered to be sent to the hospital on [DATE]. Review of Resident #87's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure residents received pneumococcal vaccinations as ordered. This affected two (Residents #38 and #71) of five residents reviewed for immunizations. The facility census was 105. Findings include: 1. Medical record review for Resident #38 revealed an admission date of 08/03/22 with diagnoses including but not limited to schizophrenia, type two diabetes, peripheral vascular disease, and Charcot's joint. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. The resident was assessed as dependent with eating, toileting, bathing, dressing, and transfers. Review of the facility's vaccine informed consent form for Resident #38 dated 11/21/23 at 7:17 A.M. revealed the resident was offered and accepted pneumococcal vaccinations of Pneumococcal 15-valent conjugate vaccine (PCV-15) PVC-20, 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, medical record review, and staff interview, the facility failed to maintain a safe environment. This affected one (Resident #76) out of one resident reviewed for environment. The facility census was 105. Findings include: Review of the medical record for Resident #76 revealed an admission date of 03/03/23. Diagnoses included schizoaffective disorder, bipolar disorder, hypertension, paranoid schizophrenia, and unspecified psychosis not due to a substance or known physiological condition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 was assessed to require set-up assistance for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfer. Interview on 08/29/24 at 10:00 A.M. with the Administrator revealed Resident #76 fell while engaging in an activity outside the facility. The Administrator stated there was an uncovered pipe in the grassy area near the facility's sign. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, review of pest control visit documentation, and review of a facility policy, the facility failed to maintain an environment which was free from pests. This affected two (Residents #4 and #5) of two reviewed for environment. The facility census was 105. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 04/26/23 with diagnoses of cervical disc disorder with myelopathy, mid-cervical region and contractures of bilateral hips and knees. Review of the Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #5 required set-up assistance with eating and oral hygiene, and was dependent on staff assistance for toileting hygiene, bathing, dressing, personal hygiene, bed mobility, and wheelchair mobility. Review the care plan dated 01/17/24 revealed Resident #5 required a two-person assistance with bed mobility. Observation on 08/19/24 at 2:03 P.M. revealed Resident #5 lying in bed with multiple flies flying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff, resident and resident representative interviews, the facility failed to provide adequate supervision to ensure a resident, that had an order for supervised Leave of Absence (LOA), did not leave the facility unsupervised. This affected one (#06) out of three reviewed for elopement. The facility census was 96. Findings include: Review of the medical record for Resident #06 revealed an admission date of 12/30/20 with medical diagnoses of epilepsy, right sided hemiplegia due to cerebral infarction, chronic obstructive pulmonary disease, depression, and anxiety. Review of the medical record for Resident #06 revealed an annual Minimum Data Set (MDS) assessment, dated 04/19/24, which indicated Resident #06 had moderate cognitive impairment and required set-up assistance with eating, wheelchair mobility, and bed mobility, partial staff assistance with transfers and supervision with toilet hygiene, and bathing. The MDS did not indicate Resident #06 had any wandering behaviors.…

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, and staff interviews, the facility failed to ensure staff implemented assistance and/or supervision with meals in accordance with a resident's care plan. This affected one (#20) out of three residents reviewed for assistance with feeding. The facility census was 94. Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/20/18 with diagnoses of vascular dementia, anxiety, spastic hemiplegia affecting right dominant side and dysphagia, oropharyngeal phase. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #20 requires set-up assistance with eating. Resident #20 was dependent on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and wheelchair mobility. Resident #20 has coughing or choking during meals or when swallowing medications and has complaints of difficulty or pain when swallowing and is on a mechanically altered diet of pureed food and thickened liquids.…

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, observations, staff and resident interviews, the facility failed to ensure resident beds were working properly. This affected three (#14, #15 and #16) of four residents reviewed for the physical environment. The facility census was 91. Findings include: Review of medical record for Resident # 14 revealed admission date of 02/21/22. Diagnoses include cardiomegaly. The resident remains in the facility. Review of medical record for Resident #15 revealed admission date of 1/23/24. Diagnoses include dementia with behaviors. The resident remains in the facility. Review of medical record for Resident #16 revealed admission date of 12/13/21. Diagnoses include diabetes mellitus and congestive heart failure. The resident remains in the facility. Interview on 02/28/24 at 10:02 A.M. with State Tested Nursing Assistant (STNA) #102 revealed Resident #14's bed had not been working properly. STNA #102 stated the facility was aware the beds had been of concern. Observation revealed when STNA #102 pressed the head control button, the bed worked as it should. When STNA #102…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure wound dressings were changed in a clean and sanitary manner. This affected two (#56 and #36) of three residents reviewed for wound care. The census was 86. Findings include: 1. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of unspecified thoracic thoracolumbar and lumbosacral intervertebral disc disorder, cervical disc disorder with myelopathy, unspecified cervical region, dorsalgia, unspecified, and osteomyelitis of vertebra, lumbar region. with diagnoses of Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 indicating the resident was cognitively intact. Review of the care plan dated 12/16/23 revealed Resident #36 had impaired skin integrity. Interventions included Resident #36 will comply with recommendations/treatments to minimize further skin impairment, will show signs…

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 3. Review of the medical record for Resident #10 revealed an admission date of 11/06/21. Diagnoses included end stage renal disease, venous insufficiency, morbid obesity, chronic venous hypertension with inflammation of bilateral lower extremity, acute respiratory failure with hypercapnia, protein-calorie malnutrition, hypotension, cardiomegaly, secondary hyperparathyroidism of renal origin, heart failure, hypothyroidism, and type two diabetes mellitus with diabetic nephropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This resident was assessed to require limited assistance for transfer and toileting as well as supervision for bed mobility, dressing, and eating. Review of the nursing progress note dated 06/06/22 revealed Resident #10 was transported to the hospital from dialysis for evaluation. There was no evidence of notification to the Ombudsman. 4.…

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, staff and resident interviews and review of the facility policy, the facility failed to ensure baseline plan of care was completed within 48 hours of admission and failed to provide the baseline plan of care to a resident. This affected four (#225, #28, #285, #10) out of four residents reviewed for baseline plan of care. The facility census was 84. Findings include: 1. Review of the medical record for Resident #225 revealed an admission on [DATE] with diagnoses including but not limited to Coronavirus Disease 2019 (COVID-19), chronic obstructive pulmonary disease, type two diabetes, malnutrition, hypothyroidism, essential hypertension, and dependence on oxygen. Review of the Minimum Data Set (MDS) dated [DATE] was noted in progress for Resident #225. Further record review for Resident #225 revealed there was no evidence of a baseline plan of care. Review of the dietary plan of care dated 10/06/22 for Resident #225 revealed resident is at risk for altered nutritional status 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 medical record review, observations, staff interviews and policy review, the facility failed to secure the maintenance room which contained multiple hazardous items. This had the potential to affect 23 (#18, #15, #11, #286, #42, #279, #3, #20, #38, #26, #25, #44, #65, #27, #34, #9, #50, #276, #12, #4, #63, #64 and #44) residents the facility identified as confused and independently mobile that could access the unlocked/unsecured area. The facility census was 84. Findings include: Medical record review for Resident #50 revealed an admission date of [DATE] with diagnoses including but not limited to schizoaffective disorder, Alzheimer's disease, dementia, and adult personality disorder. Review of the Minimum Data Set (MDS) assessment for Resident #50 revealed a severely impaired cognition. Resident #50 requires extensive assistance with activities of daily living. Review of the plan of care for Resident #50 dated [DATE] and revised on [DATE] revealed resident has behaviors related to physically aggressive…

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

Based on observations, staff interviews and review of a daily cleaning list, the facility failed to ensure the kitchen equipment was kept sanitary. This had the potential to affect all resident receiving food from the facility kitchen, except four residents (#19, #229, #278, #14) that did not receive food prepared in the facility kitchen. The facility census was 84. Findings include: 1. Observation on 10/04/22 at 11:35 A.M. of the facility kitchen steam table (a table having openings to hold containers of cooked food over steam circulating beneath them) revealed accumulation of brown unknown material located at each of the forward screws connected the self above the steam table to the actual steam table unit. Additionally, on both sides of the steam table there was white and brown streaks from unknown spillage streaking down to the floor. 2. Observation on 10/04/22 at 11:35 A.M. of the metal side table in the facility kitchen revealed multiple streaks of unknown material from the top to the bottom of the unit that was used for food service. 3. Observation on 10/04/22 at 11:35 A.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews, and review of facility policy, the facility failed to issue bed hold notices to residents. This affected three (#21, #50, and #73) of six residents reviewed for hospitalization. Facility census was 84. Findings include: 1. Review of Resident #50's medical record revealed an admission date of 12/27/21. Diagnoses listed included moderate intellectual disabilities, anxiety disorder, major depressive disorder, dementia, schizoaffective disorder, and Alzheimer's disease. Further review of Resident #50's medical record revealed he was discharged to a hospital on [DATE], 07/20/22, and 08/03/22. No documentation of a bed hold notice being given to Resident #50 on 03/09/22, 07/20/22, and 08/03/22 was found. 2. Review of Resident #73's medical record revealed an admission date of 08/03/22. Diagnoses listed included bipolar disorder, anxiety disorder, major depressive disorder, dementia, psychotic disturbance, and schizophrenia. Further review of Resident #73'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 medical record review and staff interview, the facility failed to ensure a resident's preadmission screening and resident review (PASARR) was accurate. This affected one (#73) of two reviewed for PASARR. The census was 84. Findings include: Review of Resident #73's medical record revealed an admission date of 08/03/22. Diagnoses listed included bipolar disorder, anxiety disorder, major depressive disorder, dementia, psychotic disturbance, and schizophrenia. Review of Resident #73's PASARR dated 07/29/22 revealed in section D the box was check no for a diagnosis of dementia and in section E part one the box was checked no for any of the mental disorders listed. Resident #73 was assessed as not having a serious mental illness. However, further medical record review for Resident #73 revealed there were diagnoses which included bipolar disorder, anxiety disorder, major depressive disorder, dementia, psychotic disturbance, and schizophrenia. During an interview on 10/05/22 at 10:45 A.M. Social Services (SS) #86 confirmed that Resident #73's PASARR dated 07/29/22 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff interview, the facility failed to ensure residents were properly groomed. This affected two (#19 and #50) of four residents reviewed for activities of daily living (ADL's) in the sample. The census was 84. Findings include: 1. Review of Resident #50's medical record revealed an admission date of 12/27/21. Diagnoses listed included moderate intellectual disabilities, anxiety disorder, major depressive disorder, dementia, schizoaffective disorder, and Alzheimer's disease. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #50 was moderately cognitively impaired and required limited assistance for personal hygiene and total dependence for bathing. Review of admission paperwork dated 12/27/21 revealed podiatry services had been accepted for Resident #50. Further review of Resident #50's medical record revealed no documentation of any podiatry services since admission. Observation of Resident #50 on 10/03/22 at 10:01 A.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and staff and resident interviews, the facility failed to ensure resident had privacy curtains. This affect two (#21, #22) out of two residents reviewed for privacy. The facility census was 84. Findings include: 1. Medical record review for Resident #22 revealed an admission date of 05/03/22 with diagnoses including but not limited to stroke, cellulitis, hemiplegia and hemiparesis, osteoarthritis, respiratory failure, kidney failure and dysphagia. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #22 revealed an intact cognition. Resident #22 required extensive assistant with bed mobility, total assist for transfers and toileting and supervision for eating. Review of the plan of care for Resident #22 dated 10/06/22 reveals resident has behaviors related to masturbation with the door open, curtains open and is openly exposed to the hallway. Observation on 10/04/22 11:19 A.M. of Resident #22 revealed only one curtain between the beds that was not long…

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, and policy review, the facility failed to ensure all residents had a functioning call light. This affected one (#72) out of eight residents reviewed for call lights. The facility census was 84. Findings include: Review of the medical record for Resident #72 revealed an admission date of 12/13/21. Diagnoses included anemia, acute and chronic respiratory failure with hypoxia, thrombocytosis, protein-calorie malnutrition, chronic obstructive pulmonary disease, peripheral vascular disease, wedge compression fracture of unspecified lumbar vertebra, hypertension, congestive heart failure, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the significant change Minimum Data Set (MDS) assessment, dated 09/13/22, revealed this resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of two out of 15. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating.…

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.