Altercare Newark North Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview the facility failed to ensure Resident #53 was given the diet texture as ordered. This affected one resident (#53) of five residents reviewed for nutrition. The facility census was 68. Findings include: Review of Resident #53's medical record revealed an admission date of 04/18/24 with diagnoses including metabolic encephalopathy, chronic kidney disease, osteoporosis, scoliosis, unspecified dementia, generalized anxiety disorder, type two diabetes mellitus, mood disorder, and depression. Review of Resident #53's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a severe cognitive impairment. Review of Resident #53's progress note dated 01/07/25 revealed the resident had been noted to be pocketing food. hospice was notified and a new order was obtained to downgrade the resident's diet from regular texture to mechanical soft. Review of Resident #53's physician order dated 01/07/25 revealed the resident was to receive a mechanical soft diet.…

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

Based on medical record review, staff interview, review of facility contracts, and review of the facility policy, the facility failed to obtain laboratory tests as ordered by the physician. This affected one (Resident #24) of three residents reviewed for laboratory services. The facility census was 66 residents. Findings include: Review of the medical record for Resident #24 revealed an admission date of 10/21/24 with diagnoses including dementia, anxiety disorder, hypertension, hyperlipidemia, atherosclerosis of aorta, urinary tract infection, and mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 10/28/24 revealed the resident had severe cognitive impairment. Review of the progress note for Resident #24 dated 12/09/24 revealed the resident had bilateral edema in her extremities. The nurse contacted the physician and obtained an order for the following stat (immediate) laboratory blood tests: complete blood count (CBC), complete metabolic panel (CMP). Review of the physician's orders for Resident #24 revealed an order dated 12/09/24 for a stat CBC…

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, facility Self-Reported Incident (SRI) review, video recording review, interviews, and facility policy review, this facility failed to ensure residents were not recorded without their consent or knowledge. This affected one (Resident #300) of the four residents reviewed for respect and dignity. The facility census was 66. Findings include: Review of the medical record for Resident #300 revealed an admission date of 07/19/2025 with a discharge date of 09/26/2024. Diagnoses included burns to the left and right foot, osteomyelitis of the vertebra, sacral, and sacrococcygeal region, and Parkinson's disease. Review of Resident #300's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #300 was noted to experience delusions and rejection of care at times. Review of the facility Self-Reported Incident #252058 dated 09/19/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure physicians orders were transcribed and blood sugars were obtained as ordered. This affected one (Resident #64) of five medical records reviewed. The census was 62. Findings included: Review of Resident #64's medical record revealed she was admitted to the facility on [DATE] at 2:45 P.M. with diagnoses that included fracture of the right lower leg with surgical repair. anemia, anxiety, laceration of liver, right talus fracture, and diabetes. Review of the hospital transfer order dated 07/05/24 revealed orders for finger stick blood sugars before meals and at bedtime. Review of the facility physicians orders, treatment and medication administration record revealed no documented evidence the orders were transcribed or finger stick blood sugars were obtained. On 08/06/24 at 2:54 P.M., interview with the Director of Nursing verified the order for the finger stick blood sugars sugars before meals and at bedtime was not carried over 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 review of the medical record and staff interview, the facility failed to provide treatment as ordered for Resident #62. This affected one resident (#62) out of three residents reviewed for wound care. The facility census was 60. Findings include: Review of the closed medical record revealed Resident #62, was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses including infection following a procedure, chronic respiratory failure, type II diabetes, cellulitis of left lower limb, and chronic kidney disease. Review of the after-visit summary revealed Resident #62 was at the hospital from [DATE] through 05/02/24 for a postoperative wound infection. The hospital discharge orders revealed Resident #62 was ordered a wound vacuum system to the left upper anterior thigh/groin to be changed every Monday and Thursday for two weeks. A contact layer such as an oil emulsion gauze was to be placed at the base of the wound followed by black foam. The wound vacuum was to be at 125 millimeters of…

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

Based on review of resident council minutes, observations, staff interviews, and resident and family interviews, the facility failed to ensure residents had adequate fluids available per the resident's preferences. This affected seven residents (#14, #18, #22, #26, #28, #35, and #50). The facility census was 60. Findings include: Review of the resident council minutes dated 08/16/23 revealed the residents were helping themselves to ice from the ice chests in the hallways. The ice chest was removed, and residents had to ask for ice. The resident council minutes dated 09/13/23 revealed residents had concerns with ice water not getting passed each shift. Staff education was provided. During the initial tour of the facility on 11/06/23 from 7:19 A.M. to 7:36 A.M. revealed there were several residents who did not have fluids within their reach. Resident #19 was the only resident observed with ice water. Interview on 11/06/23 at 11:15 A.M. with State Tested Nursing Aide (STNA) #22 revealed fresh water was passed twice a shift. Interview on 11/06/23 at 2:47 P.M. with a family member 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 record review and resident and staff interview, the facility failed to administer medications to the residents as physician ordered. This affected two (Residents #34 and #61) of three residents reviewed for medication administration. The facility census was 60. Findings include: 1. Review of Resident #34's medical record revealed the resident was admitted to the facility on on 10/13/23. Diagnoses included urinary tract infection (UTI), type II diabetes mellitus, chronic heart failure, wound to left lower leg, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact. Review of the progress note dated 10/13/23 at 3:26 P.M. revealed Resident #34 was admitted to the facility. Review of the physician orders dated 10/13/23 revealed Resident #34 had physician orders to receive the following medications: cephalexin (antibiotic) 500 milligrams (mg) four times daily; carvedilol (to treat high blood pressure and heart…

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 pressure ulcer prevention interventions were implemented for residents with known pressure ulcers as per their physician's orders and plan of care. This affected two residents (#3 and #52) of three residents reviewed for pressure ulcers. Findings include: 1. A review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with behavioral disturbances, low back pain, obesity, restlessness and agitation, and muscle weakness. A review of Resident #3's quarterly Minimum Data Set (MDS) completed on 08/16/23 revealed the resident had unclear speech and rarely/ never made herself understood. She was sometimes able to understand others. She had short and long term memory impairment. Her cognitive skills for daily decision making was severely impaired. She did not display any behaviors during the seven day assessment period, nor was she…

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

Based on observation, facility staff interview, and policy review the facility failed to store food in a sanitary manner. This had the potential to affect all residents as the facility identified all residents receive food from the kitchen. The facility also failed to store food items correctly in the secured unit which had the potential to affect all residents who lived on the secured unit. The total facility census was 47. Findings Include: 1. Observation of the reach in refrigerator in the main kitchen on 12/04/22 at 8:55 A.M. revealed there was a large plastic container labeled vegetable soup dated 11/26, one 112 ounce open can of vanilla pudding covered with plastic wrap dated 11/17/22 -11/21/11. In the refrigerator were also two pitchers of milk, one pitcher of sweet tea, and one pitcher of orange cool aid that were undated and unlabeled. Interview with Dietary Worker (DW) #309 on 12/04/22 at 9:00 A.M. it was confirmed the reach in refrigerator had a large plastic container labeled vegetable soup dated 11/26, an open can of vanilla pudding covered with plastic wrap dated…

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

Based on observation, interview and facility policy review the facility failed to implement appropriate infection and control practices. This had the potential to affect one (Unit One) of three units. Unit One housed 21 of 47 residents residing in the facility. Findings included: Observation on 12/06/22 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #331 washing his hands and donning (putting on) gloves for finger stick blood sugar check of Resident #42. He then collected his equipment of a glucometer (a device to measure blood glucose level), a lancet, a, test strip, alcohol wipes and Novolog pen for the Resident #42. LPN #331 laid the glucometer on Resident #42's bed and then cleaned Resident #42's finger, punctured the finger for a drop of blood and obtained a finger stick blood sugar of 99. No insulin was needed for this blood glucose reading. LPN #331 then put the lancet and the test strip he had just used on Resident #42 in one of his gloved hands, removed his glove over the lancet and test strip, put the first glove removed with lancet and test strip in his other hand…

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, resident, and facility staff interview and policy review the facility failed to have quarterly care conference meetings for two (#17 and #32) of two residents reviewed for care planning. The total facility census was 47. Findings Include: 1.Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses that include but are not limited to cerebral palsy, dementia, and anxiety disorder. Review of the most recent annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident had cognitive impairment, had hallucinations and delusions during the review period. Resident #17 had trouble falling asleep or staying asleep two to six days of the review period. Resident #17 required extensive assist for bed mobility, dressing, toileting, and hygiene, and limited assist with eating and locomotion on the unit, and was dependent on staff for transfers. Resident #17 had documented care conference meetings in 2022 on 11/14/22, 04/11/22, and 01/11/22. The medical…

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

Based on observation, interview, and facility document review the facility failed to ensure resident privacy curtains were clean. This affected two Residents (#37 and #41) of 47 residents reviewed for environment. The facility census was 47. Findings included: Observation on 12/04/22 at 9:51 A.M. of Resident #37's privacy curtain revealed multiple dark soiled areas noted on the edge of the curtain used to pull it closed for privacy and approximately 24 inches from the bottom of the curtain. The soiled areas were easily noted when the privacy curtain was open. Resident #41 was Resident #37's roommate. Observation on 12/05/22 at 9:10 A.M. of Resident #37's privacy curtain with the same multiple dark soiled areas as noted on 12/04/22. Observation on 12/05/22 at 9:55 A.M. of Resident #37's privacy curtain with the same multiple dark soiled areas as noted on 12/04/22 with Licensed Practical Nurse (LPN) #338. She verified the privacy curtain was soiled and unsanitary. On 12/05/22 at 10:07 A.M. an interview with Maintenance Coordinator (MC) #332 revealed privacy curtains were only washed…

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 facility staff interview the facility failed to accurately code minimum data set (MDS) 3.0 assessments for one (#2) of one resident reviewed for insulin. The total facility census was 47. Findings include: Review of Resident #2's medical record revealed the resident was admitted on [DATE] with diagnoses that include but are not limited to end stage renal disease, weakness, unsteadiness on feet, congestive heart failure and pain in right knee. Review of the quarterly MDS dated [DATE] revealed the resident is cognitively intact had delusions and verbal behaviors one to three days of the review period. Resident #2 had the following medications coded as administered during the review period, seven days of injections, zero days of insulin injections, seven days of antidepressant and diuretic medications. Review of the 10/12/22 quarterly MDS revealed the resident had seven days of injections coded and zero days of insulin provided to the resident. Review of the 09/30/22 quarterly MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to develop care plans completely and timely upon admission. This affected two residents (#39 and #42) of three residents reviewed for urinary catheter/urinary tract infection and two residents reviewed for behavior and emotional needs. The facility census was 47. Findings included: 1. Review of Resident #39's record revealed she was admitted on [DATE] with the diagnoses of muscle weakness, type two diabetes mellitus without complications, major depression disorder, and urinary tract infection. Review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent and entered the facility with a urinary/Foley catheter (a flexible tube that drains urine from the bladder to a urine bag). Review of Resident #39's care plan, dated 10/28/22, revealed a care plan for her having an alternation in elimination related to a Foley catheter. This care plan was developed 27 days after admission. 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 interview, record review, and facility policy review the facility failed to update care plans timely. This affected one resident (#37) of one resident reviewed for anticoagulant use. The facility census was 47. Findings included: Review of Resident #37's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of type two diabetes mellitus without complications, pressure ulcer of sacral region (Stage 4), muscle weakness, major depressive disorder, and generalized anxiety. Review Resident #37's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively impaired and had received an anticoagulant (medication used to prevent blood clots) for the seven lookback days. Review of Resident #37's physician order dated 09/27/22 revealed an order for Enoxaparin (an anticoagulant medication) 40 milligram/0.4 milliliters subcutaneous once every morning which was discontinued on 11/04/22. After 11/04/22 Resident #37 no longer had an order for an anticoagulant. 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 observation, interview, record review and facility policy review the facility failed to ensure a care planned nutritional intervention for weight loss was followed. This affected one resident (#39) of four residents reviewed for nutrition. The facility census was 47. Findings included: Review of Resident #39's record revealed she was admitted on [DATE] with the diagnoses of muscle weakness, type two diabetes mellitus without complications, major depression disorder, and urinary tract infection. Review of Resident #39's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively independent, needed supervision and setup only for eating and no dental concerns, oral concerns, or swallowing difficulties. Review of Resident #39's weights revealed on 10/03/2022, the resident weighed 143.0 pounds and on 11/29/2022, the resident weighed 136.6 pounds which was a -4.48% weight loss. Review of Resident #39's care plan dated 10/04/22 revealed she was at risk for altered nutrition and the goal was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident #13's oxygen was in place and being administered as ordered. This affected one (Resident #13) of two residents reviewed for respiratory care. The facility census was 47. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease and emphysema. Resident #13 had a physician order for continuous oxygen at three liters per nasal cannula. An observation on 12/06/22 at 8:17 A.M. revealed Resident #13 was sitting in a wheelchair in the dining room on the secure unit. The resident had her head down and eyes closed. The resident's oxygen tubing was observed hanging over the handle on the back of the wheelchair. At the time of the observation, Licensed Practical Nurse (LPN) #307 verified Resident #13's oxygen tubing was not in place and was located where the the resident could not have placed it. LPN #307 also verified Resident #13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review the facility failed to proper assess residents for trauma-informed care. This affected one resident (#42) of two residents reviewed for behavioral/emotional services. The facility census was 47. Findings included: Review of Resident #42's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of dehiscence of amputation stump, acquired absence of left leg below the knee, muscle weakness, infection following a procedure, major depressive disorder, schizoaffective disorder and post-traumatic stress disorder (PTSD), and suicidal ideations. Review of Resident #42's admission minimum data set (MDS) assessment dated [DATE] revealed he was cognitively independent and had an active diagnosis of PTSD. Review of Resident #42's care plans revealed no care plan for his PTSD. Review of Resident #42's Clinical admission Documentation dated 09/28/22 revealed Resident #42 was admitted with no psychiatric diagnosis.…

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

Based on observation, interview and facility policy review the facility failed to ensure a resident room and bathroom was free of pests. This affected two residents (#9 and #32) of 47 residents residing in the facility. Findings included: Observation on 12/04/22 at 10:58 A.M. of Resident #9 sitting in his room with a back scratcher which he was using as a fly swatter. There were several small flying insects observed to be flying around the room. An interview at the time with Resident #9 revealed flies had been in his room and bathroom for about two months. He reported that he has informed the facility of the problem, and nothing is getting done. Observation on 12/04/22 at 11:00 A.M. of Resident #9's bathroom, which he shared with Resident #32, of approximately 20 to 30 small flying insects on the walls, sink, toilet and floor. There was also a small red fruit fly trap on the bathroom counter. Observation on 12/05/22 at 9:00 A.M. of Resident #9's bathroom with an increase from the day before of flying insects, approximately 30 to 40 insects. Observation on 12/05/22 at 9:50 A.M. 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 and interview the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed for nail care, the removal of unwanted facial hair and/or the application of glasses. This affected two residents (#36 and #48) of two residents reviewed for communication-sensory and two residents (#15 and #38) of four residents reviewed for activities of daily living (ADL) care. Findings include: 1. A review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Huntington's disease (an inherited disease that causes the breakdown of nerve cells in the brain affecting functional abilities and results in movement, thinking and psychiatric disorders), unspecified psychosis, major depressive disorder, muscle weakness, lack of coordination and chronic fatigue. A review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment, an assessment tool used by the facility to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, activity calendar review and interview the facility failed to ensure cognitively impaired residents on the secured unit were being offered preferred activities and offering scheduled activities after 6:00 P.M This affected two resident (#36 and #365) of two residents reviewed for activities and had the potential to affect all residents on the secured unit (Resident #2, #4, #8, #11, #13, #14, #16, #18, #19, #21, #22, #26, #27, #28, #29, #30, #31, #32, #34, #37, #39, #40, #41, #48, #50, #51, #53, #54, #55, #56, #58, #59, #60 and #366) on the evening shift. Findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, cognitive communication deficit and muscle weakness. Review of Resident #36's activity assessment dated [DATE] revealed the resident was religious, had a history of drawing/coloring and required engagement for activity involvement due to cognitive impairments. Activity time…

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 pneumococcal immunizations were offered and/or provided to residents. The facility also failed to ensure written procedures were in place to identify who and when pneumococcal vaccines would be offered (in accordance with Centers for Disease Control (CDC) guidelines). This affected five residents (#11, #20, #23, #34 and #60) of five residents reviewed for pneumococcal immunizations. Findings include: Review of Resident #11, Resident #20, Resident #23, Resident #34 and Resident #60's medical records revealed vaccination records were maintained as part of the medical record. Each resident reviewed was noted to have a vaccination authorization form. The form included influenza and pneumococcal vaccines (both PCV-13 and PPSV-23). The records identified each of the residents had either consented or refused the influenza vaccines. However, the pneumococcal vaccine section for each of the above five residents were blank. The record identified no evidence any education was provided to the residents/families, in order to make…

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 the environment was maintained in a safe, clean and sanitary manner. This affected nine residents (#12, #15, #20, #23, #35, #38, #45, #60, and #62) of 24 residents whose rooms were observed. Findings include: 1. On 01/06/20 at 12:29 P.M., an observation of Resident #38 and #35's room revealed the tile floor between the two beds and in front of the bathroom had a blackish-gray colored substance on the floor where the tiles met. The substance was dried and looked like grime buildup or adhesive that had worked it's way up between the tile cracks. Resident #38's tilt and space wheelchair in her room was observed to have a padded cushion on her footrests that was torn. The wall next to Resident #38's bed was observed to have scuff marks in it. The drywall had some covering over it but the covering had not been painted and was scuffed by the bed being raised and lowered while against the wall. Resident #35's wall by her bed also had scuff marks on it. On 01/13/20 at 12:42 P.M., a follow up observation of Resident #38 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, record review and interview the facility failed to ensure Resident #35 was treated in a dignified manner when a notice was posted in the resident's room in plain view that provided information regarding her care. This affected one resident (#35) of two residents reviewed for dignity. Findings include: A review of Resident #35's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, senile degeneration of the brain, above knee amputations of the bilateral lower extremities, and overactive bladder. A review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 11/21/19 revealed the resident's cognition was severely impaired. The assessment revealed the resident was totally dependent on two staff for transfers and was always incontinent of her bowel and bladder. On 01/06/20 at 1:45 P.M., an observation of Resident #35…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #12's call light was within reach and accessible for the resident to use. This affected one resident (#12) of 20 residents whose care plans were reviewed. Findings include: A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, lack of coordination, unsteadiness on her feet, and repeated falls. A review of Resident #12's quarterly MDS 3.0 assessment dated [DATE] revealed the resident did not have any communication issues. She was able to make herself understood and was able to understand others. Her cognition was moderately impaired. She was not known to have any behaviors nor was she known to reject care. She required supervision with set up help for transfers, walking in her room and toilet use. Balance issues were noted with surface to surface transfers, moving from a seated to standing position, walking, turning around and 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 2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, schizoaffective disorder and major depressive disorder. Review of the electronic physician progress note, dated 01/30/19 revealed a new delusional disorder diagnosis for Resident #56. Review of Resident #56's PAS/RR dated 02/16/19 revealed diagnoses including mood disorder and schizoaffective disorder. There was no evidence delusional disorder was captured on the PAS/RR. On 01/09/20 at 11:25 A.M., interview with Administrator #24 verified Resident #56's PAS/RR dated 02/16/19 was inaccurate as it did not include the resident's diagnosis of delusional disorder. Based on record review and interview the facility failed to ensure Preadmission Screening and/or Assessment Resident Review(PAS/RR and/or PASARR) documentation was accurate and submitted as required. This affected two residents (#34 and #56) of four residents reviewed for PASRR. Findings include: 1.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #48's care plan was revised to reflect the use of eyeglasses. This affected one resident (#48) of two residents reviewed for communication-sensory. Findings include: Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including mild macular degeneration and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #48 was severely impaired for daily decision-making and had adequate vision with the use of eyeglasses. Review of Resident #48's electronic physician's orders dated January 2020 revealed Resident #48 was to wear glasses. Review of the care plan titled At Risk for Impaired Vision revised 12/02/19 revealed no evidence the care plan included macular degeneration or that the resident wore glasses. On 01/09/20 at 8:49 A.M., observation revealed Resident #48 was in his bed, awake and was not wearing glasses. At the time…

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 implement a comprehensive and individualized bowel protocol for Resident #418 when the resident did not have a bowel movement recorded for eight days. This affected one resident (#418) of five residents reviewed for unnecessary medication use. Findings include: A review of Resident #418's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included osteomyelitis (infection involving the bone), Stage III pressure ulcer (a full thickness skin loss potentially extending into the subcutaneous tissue layer) of the sacral region, muscle weakness, and chronic back pain. A review of Resident #418's physician's orders revealed the use of Norco (an opioid narcotic analgesic that contains Hydrocodone and Acetaminophen) 10- 325 milligrams (mg) by mouth (po) every four hours as needed for pain and Methadone (opioid narcotic analgesic) 10 mg three times a day on a scheduled basis for pain. To help with constipation 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 observation, record review and interview the facility failed to ensure Resident #12's fall prevention interventions, including the use of a call light was in place as per the resident's plan of care. This affected one resident (#12) of three residents reviewed for accidents. Findings include: A review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, lack of coordination, unsteadiness on her feet, and repeated falls. A review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident did not have any communication issues. She was able to make herself understood and was able to understand others. Her cognition was moderately impaired. She was not known to have any behaviors nor was she known to reject care. She required supervision with set up help for transfers, walking in her room and toilet use. Balance issues were noted with surface to surface transfers, moving from a seated…

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 #58's admission bladder assessment was accurate. This affected one residents (#58) of 20 residents whose assessments and care plans were reviewed. Findings include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including renal insufficiency and history of urinary incontinence. Review of the Point of Care History level of control with bladder function dated 12/16/19 revealed Resident #58 was incontinent of urine twice. Review of the New admission Bladder Observation dated 12/16/19 revealed Resident #58 was continent of bladder. On 01/13/20 at 1:50 P.M., interview with Registered Nurse #81 verified Resident #58's admission bladder assessment was inaccurate.