Suburban Healthcare And Rehabilitation

Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents except three residents (#6, #19, and #50) who received nothing by mouth. The facility census was 111. Findings Include: Observations on 03/04/24 from 8:00 A.M. to 8:18 A.M. during a tour of the kitchen revealed on the bottom shelf of the prep table across from the walk-in freezer table there was a clear container of bulk sugar with a silver scoop stored inside of it. The blue lid of the sugar container was dirty with food debris, and the shelf itself had various food debris, crumbs, and grease. Behind the prep table there was a silver pipe that ran along the wall which had various food debris and crumbs on it. There was various food debris and crumbs on the floor behind the prep table. Observation of the walk-in cooler revealed a large stain on the floor under the rack next to the door and various food debris, crumbs, small juice containers, and liquid spillage on the floor. Interview with…

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

Based on observation, interview, and policy review the facility failed to ensure a clean, sanitary and well maintained environment. This affected 51 residents, 48 who resided on the second floor (#2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, and #120) and three who resided on the third floor (#60, #52 and #219). The facility census was 111. Findings Include: 1. Observation of Resident #75's room on 03/04/24 at 10:17 A.M. revealed an entertainment pole that held a screen. The pole down to the base had splattered dried tan colored substance on it. Observation of Resident #75's tube feeding pump and the pole that held the pump revealed dried tan colored substances along the pole and at the base of the pole. Follow-up observation of Resident #75's room on 03/05/24 at 1:48 P.M. revealed the dried tan substance remained on the entertainment and tube feeding poles and there was a hole in the wall…

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 review of the online Resident Assessment Instrument (RAI) manual, the facility failed to ensure admission and annual Minimum Data Set (MDS) assessments were completed timely for seven residents (#39, #55 #66, #76, #98, #129, and #224) of 27 residents reviewed for completed MDS assessments. The facility census was 111. Findings Include: On 03/06/24, review of the medical record for Resident #39 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #55 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #66 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #76 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #98 revealed an incomplete annual MDS assessment dated [DATE]. On 03/06/24, review of the medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility did not ensure quarterly MDS assessments were completed timely for four residents (#19, #72, #85, and #87) of 27 residents reviewed for completed MDS assessments. The facility census was 111. Findings Include: On 03/06/24, review of the medical record for Resident #19 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #72 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #85 revealed an incomplete quarterly MDS assessment dated [DATE]. On 03/06/24, review of the medical record for Resident #87 revealed an incomplete quarterly MDS assessment dated [DATE]. Interview on 03/06/24 at 3:32 P.M. with MDS coordinator/Licensed Practical Nurse #380 revealed there was not enough staff to timely complete and transmit the MDS assessments. Many of the 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 medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing the assessment. This affected 22 residents (#4, #13, #29, #33, #41, #42, #43, #48, #55, #60, #61, #63, #72, #75, #76, #77, #87, #93, #96, #98, #107, and #219) of 31 residents reviewed for submitted MDS assessments. The facility census was 111. Findings Include: On 03/06/24, review of the medical record for Resident #4 revealed a quarterly MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #13 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for Resident #29 revealed an annual MDS assessment dated [DATE] had not been transmitted. On 03/06/24, review of the medical record for…

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

Based on observation and interview the facility failed to ensure handrails were securely affixed to the walls. This had the potetntial to affect all 48 residents that resided on the second floor (#2, #5, #9 #11, #17, #22, #25, #28, #29, #31, #32, #33, #35, #39, #40, #42, #43, #45, #47, #50, #53, #54, #55, #56, #59, #66, #68, #70, #72, #73, #75, #84, #85, #87, #90, #94, #97, #98, #99, #100, #105, #106, #107, #109, #110, #118, #119, #120). The facility census was 111. Findings Include: Observation on 03/04/24 at 12:11 P.M. revealed the handrail located in the hallway outside of Resident #55 and Resident #75's room was not completely attached to the wall. Interview on 03/04/24 at 12:33 P.M. with State Tested Nurse Aide (STNA) #373 verified the observation. Observation on 03/04/24 at 12:12 P.M. revealed the handrail was broken by the women's tub room on the second floor that was under construction. Observation on 03/04/24 at 12:12 P.M. revealed the handrail was broken by Resident #9's room. Observation and interview on 03/04/24 at 12:31 P.M. with Licensed Practical Nurse #302 verified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure dignity was respected regarding emptying portable bedside commode. This affected one (Resident #371) of one resident reviewed for dignity. The facility census was 111. Findings Include: Review of the medical record revealed Resident #371 was admitted to the facility on [DATE] and readmitted after a hospitalization on 02/25/24 with diagnoses including end-stage renal disease, chronic kidney disease, alcohol cirrhosis, right lower leg cellulitis, [NAME] Parkinson [NAME] syndrome, and gastric bypass surgery. Upon return to the facility, Resident #371 received antibiotic therapy due to a diagnosis of Clostridium difficile (causes mild to moderate watery diarrhea). Resident #371 was provided with a portable bedside commode to accommodate the need for easy access to the bathroom due to frequent loose stools. Observation on 03/04/24 at 12:10 P.M. revealed Resident #371 was in her room, seated on the side of the bed near the head of the bed. Near…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility investigation, and interview the facility failed to ensure timely physician notification after a resident sustained a scald burn. This affected one resident (#39) of six residents (#39, #55, #66, #77, #98, and #221) reviewed for accidents. The facility census was 111. Findings Include: Review of the medical record for Resident #39 revealed an initial admission date of 03/06/19. Diagnoses included muscle weakness, diabetes mellitus, and systemic lupus erythematosus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition, no behaviors, and no skin issues. Review of the skin/wound note dated 01/30/24 timed 7:29 P.M. revealed upon exiting the elevator Resident #39 approached the nurse and asked the nurse to look at her thigh. The nurse observed blisters and burn areas to the right thigh. The nurse asked Resident #39 what happened, and the resident stated she was in bed for the night and asked one of the aides to warm up her…

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

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 who were dependent for activities of daily living (ADL) received nail care. This affected one resident (#75) of two residents (#19 and #75) reviewed for ADLs. The facility census was 111. Findings Include: Review of the medical record for Resident #75 revealed an admission date of 07/12/22. Diagnoses included stroke, muscle weakness, and contractures. Review of the plan of care revised 07/21/23 revealed Resident #75 had an ADL self-care performance deficit related to weakness, contracture, wounds, and pain. Interventions included check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #75 had intact cognition and was dependent on staff for personal hygiene. Observation of Resident #75 on 03/04/24 at 10:17 A.M. revealed the resident's nails were long and dirty with black debris…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of a shipping receipt, the facility failed to provide corrective eye glasses in a timely manner. This affected one (Resident #37) of one resident reviewed for vision services. Findings Include: Review of medical record for Resident #37 revealed an admission date of 11/11/21. Diagnoses included chronic obstructive pulmonary disease and chronic kidney disease. The resident had intact cognition. Interview on 03/04/24 at 9:30 A.M. with Resident #37 revealed he had an eye exam in 2023 and ordered glasses. Resident #37 had not received the glasses nor had he heard from staff regarding the glasses. Interview on 03/06/24 at 11:06 A.M. with Social Services (SS) #338 revealed Resident #37's eye glasses were in the back room of SS #338's office. SS #338 was not sure why Resident #37 had not been given the glasses. SS #338 had no information related to when the eye glasses were delivered to the facility. Interview on 03/06/24 at 11:32 A.M. with Optometrist #446, who completed…

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

Based on record review, interview, and policy review the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two residents (#55 and #221) of five residents (#55, #77, #80, #92, and #221) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility census was 111. Findings Include: 1. Review of the medical record for Resident #55 revealed an admission date of 05/21/19. Diagnoses included disorder of central nervous system, quadriplegia, anoxic brain injury, delusional disorders, traumatic brain injury, mood disorder, and anxiety disorder. Review of the Pharmacist's Recommendation to Prescriber form dated 02/16/23 revealed Resident #55 was currently receiving Lexapro 20 milligrams (mg) daily. The form indicated within the first year in which a resident was admitted on a psychotropic medication or after the prescribing practitioner had initiated a psychotropic medication, the facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month between the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure a rationale for extending an as needed psychotropic medication beyond 14 days was documented in the resident's medical record and failed to monitor for side effects of psychotropic medication use. This affected one resident (#221) of five residents (#55, #77, #80, #92, and #221) reviewed for unnecessary medications and psychotropic medications. The facility census was 111. Findings Include: Review of the medical record for Resident #221 revealed an admission date of 10/26/22. Diagnoses included dementia with behavioral disturbance, psychosis, delusional disorders, hypertension, and schizoaffective disorder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #221 had severely impaired cognition, had physical behaviors during one to three days of the seven day look back period, and received antipsychotic medications routinely. Review of the plan of care dated 01/19/24 revealed Resident #221 used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to provide meals according to preferences and/or food allergies. This affected one (Resident #37) of five residents observed for meals. Findings Include: Review of medical record for Resident #37 revealed an admission date of 11/11/21. Diagnoses included chronic obstructive pulmonary disease and chronic kidney disease. The resident had intact cognition. Review of the nutritional assessment dated [DATE] revealed Resident #37 had allergies to asparagus, mint, apples, and intolerance to dairy. Resident #37 stated allergy to eggs was not an allergy. Interview on 03/04/24 at 9:30 A.M. with Resident #37 revealed staff brought him food that he was allergic to. Resident #37 stated he could only eat egg whites because regular eggs made his throat feel funny and he could not have milk. Resident #37 stated he kept telling staff that he could not eat regular eggs and milk but staff kept serving him scrambled eggs and whole or two percent milk. 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 observation, resident interviews, staff interviews, record review, and review of food committee notes, the facility failed to ensure food was served at the preferred temperature and was palatable. This had the potential to affect all residents except Resident #27, #95, and #96 who received nothing by mouth (NPO). The facility census was 113. Findings include: Record review of the food committee meeting dated 11/02/23 at 2:30 P.M., revealed concerns by residents to Dietary Manager #351 which included staff needed more training, concerns with how food gets to residents, burgers are not good, oatmeal was runny, pancakes were hard, and soups were cold. Observation and interview on 01/09/24 12:50 P.M., revealed dietary [NAME] #272 plated the lunch meal from a steam table in the kitchen. As [NAME] #272 plated the vegetables, observation with Dietary Manager #351 revealed [NAME] #272 quickly scooped the undrained vegetables (with the watery liquid the vegetables were cooked in), onto each plate saturating all food items. As the tray line neared an end, the surveyor requested a…

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

Based on observation, staff interview, and policy review, the facility failed to safely store food and maintain a clean and sanitary kitchen and follow up on dietitian sanitation audits. This had the potential to affect all residents except Resident #27, #95, and #96 who received nothing by mouth (NPO). The facility census was 113. Findings include: Observation and interview on 01/09/24 at 11:06 A.M., with Dietary Manager #351 of the kitchen revealed the burners on the stove top had a large amount of charred black build up on each burner. Overflow of charred spilled food items were on the stove below the burners. Under the fryer and grill on the floor located next to the stove was a large amount of grease and dirt build up. Black and brown French fries and food crumbs were throughout the thick grease build up. Inside the fryer was black oil covered with floating food particles including blackened French fries. The food steamer door was very oily, the shelves had a buildup of oil debris and food particles. The convection oven also had a large amount of grease and particle build up.…

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 personnel file review and staff interview, the facility failed to employ a qualified social worker on a full-time basis as required. This had the potential to affect all 113 residents residing in the facility. The facility census was 113. Findings include: Interview on 01/09/24 at 10:16 A.M., with Social Worker Designee (SWD) #238 revealed she was not a licensed social worker (LSW). SWD #238 revealed she worked with all the residents in the facility, she was the only SWD and there was no LSW employed at the facility. SWD #238 revealed she had no prior experience in long term care as a social worker prior to starting at this facility and revealed she received no training by a LSW during employment at the facility. Interview on 01/09/24 at 10:32 A.M., with the Administrator confirmed the facility was certified and licensed for 150 beds. The Administrator confirmed the facility did not employ a LSW and had not employed a LSW for over two years. The Administrator confirmed he was aware the facility was required to employ a LSW based on the number of beds the facility had.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility policy, the facility failed to secure medications on a secured behavioral unit where 45 residents resided. This had the potential to affect 31 (#37, #42, #103, #4, #11, #107, #3, #80, #23, #26, #100, #21, #19, #45, #88, #60, #16, #31, #71, #5, #99, #115, #90, #75, #94, #69, #32, #91, #13, #49, and #56) independently mobile residents of 45 residents residing on the unit. The facility census was 113. Findings include: Observation on 01/09/24 at 1:13 P.M., on the third-floor behavioral unit revealed the medication cart, located near the nurses station, was unlocked and unattended. Observation revealed multiple residents were wandering near and around the nurses station. Unit Manager #273 was made aware and confirmed the medication cart with multiple residents medications, was left unsecured and unattended. Interview at the time of the observation, Licensed Practical Nurse (LPN) #317 returned to the medication cart and confirmed she left the cart unlocked…

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, staff interviews and policy review, the facility failed to complete wound care per the physician orders. This affected one (#5) of three residents reviewed for wound care. The facility census was 113. Findings include: Review for Resident #5's medical record revealed an admission date of 10/26/22. Diagnoses included dementia, and unspecified psychosis. Record review of the Modification of Interim Payment Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was severely cognitively impaired. Resident #5 was dependent on staff for activities of daily living. Review of the care plan for Resident #5 dated 01/02/24 revealed Resident #5 had potential for pressure ulcer and other skin integrity issue development related to weakness, incontinence, and impaired mobility. Resident #5 had a left lower leg skin tear. Interventions included to administer treatments as ordered and monitor for effectiveness. Review of the physician order revised 01/05/24 for Resident #5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and policy review, the facility failed to provide timely incontinence care for a resident. This affected one (#86) of three residents reviewed for incontinence care. The facility census was 113. Findings include: Review for Resident #86's medical record revealed an admission date of 06/26/23. Diagnoses included heart failure, muscle weakness, failure to thrive, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was severely cognitively impaired. Resident #86 required extensive assistants of two persons with bed mobility, transfers, extensive assistants of one for toilet use and personal hygiene. Resident #86 was always incontinent of bowel and bladder. Review of the care plan dated 12/20/23 revealed Resident #86 had bladder incontinence related to vascular dementia and impaired mobility. Interventions included Check Resident #86 every two hours and as needed for incontinence. Wash…

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

Based on observation, staff interview and record review, the facility failed to maintain accurate medical records for residents. This affected two (#5 and #65) of five medical records reviewed. The facility census was 113. Findings include: 1. Review for Resident #5's medical record revealed an admission date of 10/26/22. Diagnoses included dementia, and unspecified psychosis. Review of the physician order dated 01/05/24, for Resident #5 revealed an order to clean the left lower leg with normal saline, pat dry, apply xeroform, an abdominal dressing (ABD) and kerlix every day shift. Observation on 01/08/24 at 2:53 P.M., with Wound Care Nurse/Registered Nurse (RN) #257 and Assistant Director of Nursing (ADON) #273 complete wound care for the wound on Resident #5's left lower leg revealed the old dressing on Resident #5's wound to the left lower leg was dated 01/04/24. ADON #273 removed the old dressing and confirmed the dressing was dated 01/04/24. ADON #273 revealed they probably got behind and forgot, they probably thought the wound nurse would look at it Monday anyway. 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 record review, interview and policy review the facility failed to ensure monthly weights and/or weights on newly admitted residents were obtained in a timely manner and did not ensure residents with specialized weight orders were obtained according to the physician orders. This affected all residents in the facility excepts for two (Resident's #10 and #52) who were documented as refusing to be weighed in the facility. The facility census was 81. Findings include: The facility Administrator was asked for a list of residents who were dependent on enteral tube feeding for their main source of nutrition and hydration. The list identified eight residents (Resident's #1, #2, #3, #21, #26, #40, #56 and #66). Review of the medical records for weights for these eight residents revealed Resident #21 had not been weighed since 10/29/21, Resident #1 had not been weighed since 11/16/21, Resident's #3 and #40 had not been weighed since 11/22/21, and Resident's #2, #26, #56 and #66 had not been weighed since 12/04/21.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, review of the staffing schedules, review of the staffing tool and policy review, the facility failed to maintain staffing levels to adequately meet the needs of the residents. This had the potential to affect all 81 residents residing in the facility. Findings include: 1.Record review was conducted for Resident #66 who was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, unstageable pressure ulcer (obscured full-thickness skin and tissue loss) of the left heel, mild protein calorie malnutrition, functional quadriplegia, chronic osteomyelitis of the right ankle and foot, anxiety, major depression, dementia, gastrostomy, and tremor. Resident #66's mother was his legal guardian. Review of the physician's order dated 09/09/21 revealed Resident #66 was 100 percent (%) dependent on enteral tube feeding formula, Isosource 1.5 continuous at 80 milliliters (ml) per hour with a 150 ml water flush every four hours for his only source…

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 staff interview the facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 81 residents residing in the facility. Findings include: Review of the posted nursing staff information and staff schedule revealed on 01/22/22 and 01/23/22 there was no RN present working in the facility. Interview on 01/25/22 at 2:00 P.M. with Nursing Staff Scheduler (NST) #173 verified the facility did not have a RN on duty in the facility on 01/22/22 and 01/23/22. Interview on 01/26/22 at 2:35 P.M. with the Director of Nursing (DON) revealed there was always an on-call RN when one was not in the building. The DON revealed sometimes the facility had a RN in the building and sometimes the facility did not. This deficiency substantiates Complaint Numbers OH00114399 and OH00114239.

Based on observations and interviews the facility failed to date open insulin vials and aerosol inhalers for six (Resident's #8, #9, #25, #28, #31 and #65) and failed to ensure loose unidentifiable/unsecured medications in the medication carts were disposed of properly. This had the potential to affect all 81 residents residing in the facility. Findings include: Observations on 01/26/22 at 9:45 A.M. of the medication cart on the third floor revealed opened and undated Combivent inhalers for Resident's #25 and #28 and 29 unidentifiable/unsecured medications lying on the bottom of drawers. Interview during the observations, Licensed Practical Nurse (LPN) #170 verified all observations. Observations on 01/26/22 at 10:00 A.M. of medication cart on the third floor revealed opened undated vials of Lispro and Lantus with no name of the resident they belonged to. Continued observations revealed opened undated vials of Novolog for Resident's #8 and #31 and 37 loose unidentifiable/unsecured medications lying on the bottom of drawers. Interview during the observations, LPN #144 verified all…

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

Based on record review, observation, and interview the facility failed to employ dietary staff who could demonstrate competence in how to properly run a high temperature dish machine. This had the potential to affect all residents receiving meals from the kitchen except for six (Resident's #1, #2, #21, #26, #56 and #66) who did not receive food by mouth. The facility census was 81. Findings include: Observation on 01/25/22 at 9:50 A.M. of Dietary Aide (DA) #169 using the dish machine to wash dishes revealed she was working both sides of the high temperature dish machine loading the dirty dishes and with the same gloved hands catching and putting away the clean dishes. She did not wash her hands nor change gloves at any time during the observation. When asked by the surveyor if that was how she usually does the dishes, she remarked if she was doing dishes without anyone helping that was how she washed the dishes. When asked if she had checked and recorded the dish machine wash and rinse temperatures before she started doing the dishes, she said she did not take the temperatures. The…

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

Based on record review, observation, and interview the facility failed to ensure sufficient dietary staffing to provide meals to the residents in a timely manner. This affected all residents except six (Resident's #1, #2, #21, #26, #56 and #66) who received nothing by mouth. The facility census was 81. Findings include: Record review was conducted of the undated facility documented titled Meal Times provided by Dietary Manager (DM) #156. The meal times were listed for the second floor for breakfast at 7:45 A.M., lunch 11:45 A.M., and dinner at 4:45 P.M. For the third floor the meal times were breakfast 8:30 A.M., lunch 12:30 P.M., and dinner 5:30 P.M. Record review of the Facility Assessment, dated 05/05/21, revealed there was no representative from dietary included in the development of the staffing plan for dietary services. The average daily census listed on the assessment was 89. The total number of dietary staff needed was indicated as eight staff at 64 hours per day plus one part-time dietitian or other clinically qualified staff. Review of the dietary staffing schedule dated…

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

Based on record review, observation, and interview the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This affected all residents in the facility except for six (Resident's #1, #2, #21, #26, #56 and #66) who received no food by mouth. The facility census was 81. Findings include: Observations of the kitchen began on 01/24/22 at 8:29 A.M. revealing two large, approximately 30-inch diameter wall mounted circular fans in the dish room were heavily coated with dust on the blades and both sides of the blade covers. The fans were positioned to blow in the direction of the clean side of the dish machine. Observation on 01/25/22 at 9:50 A.M. of Dietary Aide (DA) #169 using the dish machine to wash dishes. She was working both sides of the high temperature dish machine loading the dirty dishes and with the same gloved hands catching and putting away the clean dishes. When asked by the surveyor if that was how she usually does the dishes, DA #169 remarked if she was doing dishes without anyone helping that was how she washed the dishes. When asked…

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 staff interview, the facility failed to ensure the facility assessment was accurate and contained all required information. This had the potential to affect all 81 residents residing in the facility. Findings include: Review of the facility assessment revealed it did not contain the following required information: • The staffing plan information contained in the assessment was inaccurate and did not provide a clear definitive plan to address resident census and acuity needs. • Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations, and emergencies were noted to not include agency staffing. Interview on 01/26/22 at 2:35 P.M. with the Director of Nursing (DON) verified the facility assessment did not contain all of the required information as noted above.

Based on record review and staff interview the facility failed to ensure the quality assurance (QA) committee meet at least quarterly as required and failed to ensure the medical director attended the QA committee meetings as required. This had the potential to affect all 81 residents residing in the facility. Findings include: Review of the facility QA sign in sheets from January through December 2021 revealed the facility held QA meetings on 10/18/21, 11/15/21 and 12/12/21. The facilities medical director did not attend any of the meetings. No other sign in sheets for QA meetings were provided by the facility from January through December 2021. Interview on 02/02/22 at 10:07 A.M. with the Administrator verified the lack of quarterly QA meetings and medical director attendance for January through December 2021.

Based on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) guidance review the facility failed to implement infection control practices on proper use of personal protective equipment (PPE). This had the potential to affect all 81 residents residing in the facility. Findings include: Interview on 01/24/22 at 8:54 A.M. with Licensed Practical Nurse (LPN) #175 revealed the facility currently had no COVID-19 positive residents in the building. Observation at this time of the double doors to the COVID-19 unit revealed the doors were opened and the zipper to the plastic partition was unzipped. LPN #175 stated the residents back on that unit were all cleared. Observation of LPN #175 revealed he was wearing a N95 mask over a surgical mask. LPN #175 stated he had left but had to come back up to the nursing unit to chart and that was why he had the N95 mask over his surgical mask. LPN #175 stated he knew the proper way to wear a N95 mask. Observation on 01/24/22 at 9:04 A.M. of Assistance Director of Nursing (ADON) #119 revealed her wearing a surgical…

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 plate warmer and pellet warmer in the kitchen were maintained in proper and safe manner. This had the potential to affect all residents in the facility except for six (Resident's #1, #2, #21, #26, #56 and #66) who received no food by mouth. The facility census was 81. Findings include: Observation during the initial kitchen tour on 01/24/22 at 8:30 A.M. revealed a three-column plate warmer with red tape over two of the three columns designed to hold and heat stacks of plates. In addition, a two-column pellet warmer designed to hold stacks of stainless-steel pellets was not heating properly in one column. These findings were reported and verified by Dietary [NAME] (DC) #190 who was present in the kitchen at the time of the tour. Interview was conducted on 01/11/22 at 10:11 A.M. with Dietary Manager (DM) #156 who verified the pellet warmer and plate warmer did not operate properly. Observation of the lunch meal service on 01/26/22 at 11:35 A.M. revealed the plate warmer and pellet warmer were being used by Dietary…

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 staff interview the facility failed to maintain a clean and sanitary environment. This had the potential to affect all 81 residents residing in the facility. Findings include: 1. Observation of the third-floor dining room on 01/24/22 at 12:30 P.M. revealed the following: • Multiple areas of leftover food debris on the floor from the morning meal. • The light fixtures above resident seating areas contained multiple dead bugs. • Multiple chairs in the dining room were noted to be torn and dirty. Housekeeper #171 verified the condition of the dining room during an interview on 01/24/22 at 12:35 P.M. 2. Observation of the third-floor shower room on 01/25/22 at 11:00 A.M. with the Administrator revealed the following: • Upon entrance to the shower room a strong fecal odor was noted. • Observation of the toilet next to the shower area revealed the toilet was covered with a trash receptacle lid. Upon removing the lid, the toilet was noted to be almost filled with saturated adult briefs that contained urine, fecal matter, and other unknown substances. The…

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

Based on record review and staff interview, the facility failed to ensure grievance/complaints brought forth in Resident Council were addressed timely and appropriately. This affected ten (Resident's #8, #10, #46, #60, #69, #181, #182, #183, #184 and #185) of ten residents reviewed for grievances. The facility census was 81. Findings include: Review of the Resident Council meeting minutes from 01/20/21, 02/26/21, 03/25/21, 04/29/21, 05/26/21, 06/23/21, 07/28/21, 08/11/21, 09/22/21, 10/27/21, 11/24/21 and 12/29/21 attended by Resident's #8, #10, #46, #60, #69, #181, #182, #183, #184 and #185 revealed no evidence that resident complaints and concerns brought forth by the resident council were addressed timely or appropriately. Review of the Resident Council meeting minutes revealed the facilities documented follow-up to all concerns was the repeated phrase each month stating, All concerns were addressed and resolved from previous month, as evidenced by staff reading concern log during Council Meeting. No other documented evidence of follow-up was noted. Interview on 01/26/22 at 11:05…

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 observations, record review, resident and staff interviews, and policy review the facility failed to provide adequate activities of daily living (ADL) assistance for five (Resident's #15, #16, #18, #67 and #71) of five residents reviewed for ADL care for dependent residents. The facility census was 81. Findings include: 1. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness, and acquired absence of the left eye. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 was alert with cognitive impairment and required assistance of at least one staff for ADL care including personal hygiene. Observations on 01/24/22 at 11:13 A.M., 01/25/22 at 3:19 P.M., and 01/26/22 at 10:15 A.M., revealed Resident #16 lying in bed with facial hair on her chin. Review of the tasks section of the electronic medical record revealed Resident #16 had personal hygiene performed 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 review of the activity calendar, observations and interviews the facility failed to provide activities to meet the interests of the third-floor residents. This affected seven (Resident's #11, #71, #61, #7, #20, #24 and #36) had the potential to affect all 39 (Resident's #3, #6, #7, #11, #12, #15, #16, #17, #20, #22, #23, #24, #26, #27, #29, #31, #32, #34, #35, #36, #37, #39, #40, #41, #44, #49, #50, #54, #55, #58, #61, #63, #65, #68, #71, #72, #76, #77 and #283) residing on the third-floor of the facility reviewed for activities. The facility census was 81. Findings include: Review of the medical record for Resident #11 revealed an admission date of 11/26/19 with diagnoses including heart failure, severe protein-calorie malnutrition, adult failure to thrive, and granulomatous disorder of the skin. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/06/22, revealed Resident #11 had impaired cognition. Review of plan of care dated 09/27/21 revealed Resident #11 had little or no…

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

Based on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures affecting Resident's #8, #10, #28, #50, #52, #57, #60 and #73 who were reviewed for food and had the potential to affect all residents in the facility except for six (Resident's #1, #2, #21, #26, #56 and #66) who received no food by mouth. The facility census was 81. Findings include: 1. Observation of the lunch meal service on 01/26/22 at 11:35 A.M. revealed the heat retention system being used in the kitchen to keep the food warm besides the steam table was a plate warmer, pellet warmer, thermal bases, thermal domes to cover the plates, and enclosed meal delivery carts. The plate warmer and pellet warmers needed repair and did not heat as both should. The surveyor observed only one of three columns on the plate warmer were working and only one side of the two-column pellet warmer got hot to touch. This was verified at the time of the observation by Dietary Aide (DA) #162 who was loading pellets onto the thermal bases and DA #158 who was putting the food on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility self-reported incident review, the facility failed to ensure a complete and accurate medical record for five (Resident's #2, #21, #47, #66 and #75) of 22 resident records reviewed. The facility census was 81. Findings include: 1. Record review was conducted for Resident #66 who was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, unstageable pressure ulcer (obscured full-thickness skin and tissue loss) of the left heel, mild protein calorie malnutrition, functional quadriplegia, chronic osteomyelitis of the right ankle and foot, anxiety, major depression, dementia, gastrostomy, and tremor. Resident #66's mother was his legal guardian. Review of a physician's order dated 09/09/21 revealed Resident #66 was 100% dependent on enteral tube feeding formula Isosource 1.5 continuous at 80 milliliters per hour with a 150-milliliter water flush every four hours for his only source of nutrition and hydration. An order dated 07/30/21 read 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 record review, interview, and observation the facility failed to ensure staff always wore easily identifiable name badges and failed to ensure Resident #52 was able to use her choice of blood glucose monitoring device without unnecessary interruption. This affected three (Resident's #52, #38 and #57) of 32 residents reviewed for dignity. The census was 81. Findings include: 1. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two, stroke, and hemiplegia affecting the right side of her body. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had no cognitive impairment. A physician's order dated 11/22/21 indicted Resident #52 was to have a Freestyle Libre 14-day glucose sensor to inject one on the back of her arm every two weeks on Thursday for monitoring her blood sugars. Review of the Medication Administration Record (MAR) dated 01/01/22 to 01/31/22 revealed on Thursday 01/06/22 the sensor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to allow Resident #52 to have a personal refrigerator in her room. This affected one (Resident #52) of three (Resident's #21, #52 and #71) residents reviewed for personal property. The facility census was 81. Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type two, stroke, and hemiplegia affecting the right side of her body. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had no cognitive impairment, and she was independent in her room using a wheelchair. Resident #52 lived on the secured third floor of the facility until moving downstairs to the unsecured unit on 07/15/21. The plan of care with a date initiated of 07/09/21 revealed Resident #52 had hoarding behaviors, but the plan of care was silent regarding concerns about a refrigerator. Review of the progress notes dated 10/19/21 and 11/02/21 authored by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review the facility failed to ensure request for personal care needs were honored. This affected two (Resident's #15 and #28) of two residents reviewed for choices. The facility census was 81. Findings include: 1. Record review of Resident #28 revealed an admission date of 11/11/21. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and lymphedema. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and required extensive assistance of one staff for personal hygiene. Review of the plan of care revised on 01/24/22 for Resident #28 activities of daily living (ADL) self-care performance deficit. Interventions included Resident #28 required one staff participation with personal hygiene and oral care. Interview on 01/24/22 at 12:01 P.M. with Resident #28 stated he asked to be shaved and it hadn't happened. Observation of Resident #28 revealed a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review the facility failed to ensure Resident #21's Power of Attorney (POA) was notified of a change in condition and hospital transfers. This affected one (Resident #21) of three (Resident's #21, #42, and #75) reviewed for change in condition. The facility census was 81. Findings include: Review of the medical record for Resident #21 revealed an initial admission date of 04/27/20. Diagnoses included gastrostomy, heart failure, chronic obstructive pulmonary disease (COPD), dependence of supplemental oxygen, paraplegia, hemiplegia, and hemiparesis of left non-dominate side following a stroke, and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/27/21, revealed Resident #21 had intact cognition. Review of the nurses' notes dated 12/25/21 at 6:24 A.M. revealed Resident #21 was in bed resting, was short of breath (S.O.B.) and observed with a pulse oxygen (SpO2) level of 85%. Resident #21's temperature was 100.7…

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 transfer notices were provided as required for two (Resident's #21 and #42) of two residents reviewed for hospitalizations. The facility census was 81. Finding include: 1.Review of the medical record for Resident #21 revealed an initial admission date of 04/27/20. Diagnoses included gastrostomy, heart failure, chronic obstructive pulmonary disease (COPD), dependence of supplemental oxygen, paraplegia, hemiplegia, and hemiparesis of left non-dominate side following a stroke, and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had intact cognition. Further review of Resident #21's medical record revealed he was transferred to the hospital on [DATE], 12/25/21, and 01/21/22. Review of copies of the Notice of Bed Hold/Transfer Policy for Resident #21 dated 11/21/21, 12/25/21, and 01/21/22 revealed the notices were not signed by Resident #21 or his representative. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure bed hold notices were provided as required in written form for two (Resident's #21 and #42) of two residents reviewed for hospitalizations. The facility census was 81. Finding include: 1. Review of the medical record for Resident #21 revealed an initial admission date of 04/27/20. Diagnoses included gastrostomy, heart failure, chronic obstructive pulmonary disease (COPD), dependence of supplemental oxygen, paraplegia, hemiplegia, and hemiparesis of left non-dominate side following a stroke, and neuromuscular dysfunction of bladder. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/27/21, revealed Resident #21 had intact cognition. Further review of Resident #21's medical record revealed he was transferred out to the hospital on [DATE], 12/25/21, and 01/21/22. Review of copies of the Notice of Bed Hold/Transfer Policy for Resident #21 dated 11/21/21, 12/25/21, and 01/21/22 revealed no explanation of why or where Resident #21 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure weights were obtained for Resident #21 to ensure an accurate re-admission nutritional assessment for a tube fed resident. This affected one (Resident #21) of two (Resident's #21 and #66) reviewed for tube feeding. The facility census was 81. Findings include: Review of the medical record for Resident #21 revealed an initial admission date of 04/27/20. Diagnoses included gastrostomy, heart failure, chronic obstructive pulmonary disease (COPD), dependence of supplemental oxygen, paraplegia, hemiplegia, and hemiparesis of left non-dominate side following a stroke, and neuromuscular dysfunction of bladder. Review of the plan of care dated 11/12/21 revealed Resident #21 had a nutrition problem or potential nutrition problem related to enteral nutrition needs, swallowing difficulty, and history of significant change in weight. Intervention included monitor weights as ordered. Review of the annual Minimum Data Set (MDS) 3.0 assessment,…

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

Based on observation, interview and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 121 out of 123 residents who received meals from the facility's kitchen. Two Residents (#34 and #89) received nothing by mouth. The facility census was 123. Findings include: A tour of the kitchen was conducted on 01/12/20 with the Dietary Aide (DA) #90 from 8:35 A.M. through 8:49 A.M. Observation of the kitchen at the time of the tour revealed food residue was on the plate warmer and meat residue on the slicer blade. The dish machine area revealed the baseboard peeling off the wall in the dish room, food residue on the drain board of the dish machine where the clean dishes dry, and the dish room and kitchen had food and pieces of paper on the floor. This was verified by DA #90 at the time of observation. Interview with Registered Dietitian (RD) #162 on 01/13/20 at 11:30 A.M. revealed she does kitchen sanitation audits monthly. Review of the kitchen policy titled Cleaning, dated 2015, revealed all equipment, food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for Residents #36, #75 and #110. This affected three of 24 residents sampled. The facility census was 123. Findings include: 1. Resident #36 was admitted to the facility on [DATE] with diagnoses including atrial flutter, dysphagia, syncope and collapse. Review of the current physicians orders for Resident #36 revealed an order for Tylenol 500 milligrams (mg) twice a day for pain. Review of the section J of the most recent MDS assessment dated [DATE] revealed the facility answered no to the question is the resident on a scheduled pain medication regimen. MDS Nurse #121 verified the inaccurate coding of the MDS during an interview on 01/15/20 at 10:15 A.M 2. Resident #75 was admitted to the facility on [DATE] with diagnoses including dementia, epilepsy and major depressive disorder. Review of the section P of the quarterly MDS assessment dated [DATE] revealed the facility marked 1 next to limb…

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

Based on observation, interview and review of the pureed food policy, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected 14 of 14 Residents (#10, #16, #23, #24, #31, #38, #51, #52, #56, #60, #61, #63, #75 and #91) who were prescribed a pureed diet of 153 residents who consumed meals from the facility's kitchen. Two Residents (#34 and #89) received nothing by mouth. The facility census was 123. Findings include: Observation of the tray line on 01/13/20 from 11:30 A.M. to 12:27 P.M. revealed the pureed rice did not appear to be of proper consistency. A portion of pureed rice was requested to sample. The pureed rice was not smooth and contained pieces of rice that were not pureed. This was verified by Registered Dietitian (RD) #162 on 01/13/20 at 12:00 P.M. Review of resident diet list revealed Residents (#10, #16, #23, #24, #31, #38, #51, #52, #56, #60, #61, #63, #75 and #91) were prescribed a pureed diet. This was verified by RD #162 on 01/13/20 at 3:27 P.M. Review of the pureed diet policy, dated July 2019, stated purees should be in…

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

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #20 and #110) rooms and 11 (Residents #6, #27, #29, #49, #59, #64, #73, #87, #90, #100 and #116) who utilized the second-floor dining room. The facility census was 123. Findings include: 1. Observations on 01/12/20 at 09:24 A.M. of Resident #110's room revealed dirty gloves on the floor and air conditioner louvers broken. This was verified by State Tested Nursing Assistant (STNA) #37 at the time of observation. 2. Observation on 01/12/20 at 10:01 A.M. of Resident #20's room revealed the bed linens were stained and contained food crumbs. This was verified by STNA #163 at the time of observation. 3. Observation on 01/12/20 at 12:36 P.M. of the second-floor dining room revealed that four of seven tables had dried liquid on them, and one table had scrambled eggs directly on the table while 11 (Residents #6, #27, #29, #49, #59, #64, #73, #87, #90, #100 and #116) were seated at the tables waiting for lunch to be served. The dining room floor had…

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