Momentous Health At Richfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure the power of attorney (POA) was notified of a change in condition. This affected one resident (#32) of four residents reviewed for notification of change in condition. The facility census was 51. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity. Review of the banner bar of Resident #32's electronic medical record revealed special instructions which stated: POA (power of attorney) would like to be notified of any behaviors or concerns. Review of Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #32 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #32 was dependent upon staff 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 and interview, the facility failed to ensure weights were obtained upon readmission from the hospital and refusals were consistently documented. This affected one resident (Resident #32) of four residents reviewed for weights. The facility census was 51. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) indicated Resident #32 was dependent upon staff for ADLs. Review of the physician order dated 04/18/25 and discontinued on 05/22/25 for Resident #32 revealed an order for monthly weights every day shift starting on the 18th…

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

Based on observations, staff and resident interviews, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, door frames, and hand rails were without the need for repair. This affected all residents residing in the facility. The facility census was 54. Findings include: 1. Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed the water was cold and the water pressure was low. Resident #48 indicated the shower room was broken. Interview on 03/10/25 at 10:29 A.M. with Resident #203 revealed the shower was broken and he had been unable to get a shower. Observation and interview on 03/10/25 at 10:29 A.M. with Resident #23 revealed her toilet had not been working for a week and Resident #23 reported the shower room was broken. Observation of Resident #23's toilet revealed it was not secured to the floor. Resident #23 reported hot water was also an issue, stating it was either too hot or too cold. Observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the personnel files, review of the facility assessment and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) #305 and #329 received annual performance reviews. This affected two of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility. Findings include: 1. Review of the personnel file for CNA #305 revealed there were no annual performance evaluations in her file or 12 hours of in-services as required. Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not have an annual performance evaluation in her personnel file. She stated the facility was unable to provide evidence of CNA #305 receiving 12 hours of in-services as required annually. Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment also stated training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to follow the menu spreadsheets as written to ensure proper portion sizes were served to the residents. This affected 53 residents receiving food from the kitchen as Resident #10 was ordered nothing by mouth (NPO). Facility census was 54. Findings include: Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop (one each), seasoned rice (four ounces), Price [NAME] vegetable blend (four ounces), yellow cake with frosting (one slice) and beverage of choice (four ounces). Review of the facility production sheet for lunch on 03/11/25 revealed those receiving a mechanical-soft diet received a #10-scoop (three ounces) of ground pork and those on a low-concentrated sweets (LCS) diet were to have a half-portion of yellow cake with frosting. Review of the facility's diet list as of 03/10/25 revealed Resident #10 was NPO, eight residents were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the menu, the facility failed to serve palatable meals at appetizing temperatures. This had potential to affect all 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth. The facility census was 54. Findings include: Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop, seasoned rice, Prince [NAME] vegetable blend, yellow cake with frosting and beverage of choice. Interview on 03/10/25 at 10:20 A.M. with Resident #48 revealed the hot food was served cold and terrible. Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and he bought his own food because it is so bad and the hot food was really cold. Interview on 03/10/25 at 1:23 P.M. with Resident #42 revealed the food at the facility was terrible as it was cold, tasted awful and was a low quality of food. Observation on 03/11/25 starting at 11:23 A.M.…

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

Based on observation, interview, review of the facility policy and record review the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth (NPO). The facility census was 54. Findings include: Observation of the kitchen on 03/10/25 from 9:20 A.M. to 9:54 A.M. with Dietary Manager (DM) #361 revealed the following areas of concern: • In the walk-in cooler, there were two expired cartons of cream dated 02/27/25 and 03/02/25, a package of bologna that did not have a date nor a label, two expired bags of salad lettuce dated 01/14/25 and expired coleslaw dated 01/28/25. • In the dry stock room, there were nine expired cartons of thickened dairy beverage dated 02/13/25 that were in between rows of thickened beverages that still had appropriate dates. Interviews with DM #361 verified the above findings at the time of observation. DM #361 stated the first shift cook was responsible for checking for expired food and this was documented 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.

Based on record review, review of facility job descriptions and interview the facility failed to ensure effective administration to manage the facility and identify care concerns, implement appropriate and sustainable corrective actions to prevent reoccurrence and attain or maintain the highest practicable physical, mental and psychosocial well being of all 54 residents residing in the facility. Findings include: 1. Review of the Administrator's job description, dated May 2022 and signed by the Administrator on 01/20/25, revealed the Administrator would provide overall direction for all activities related to administration, personnel, physical structure, information systems, office management and marketing of the entire facility. The Administrator works closely with all members of the management team and others to ensure their responsibilities are effectively and consistently discharged . The Administrator will ensure all facility operations are in compliance with federal, state and local regulations. The essential functions included developing and implementing facility policies 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 record review and interview, the facility failed to ensure the facility assessment was accurately completed. The facility also did not implement their facility assessment in regard to staff training and education. This had the potential to affect all 54 residents residing at the facility. Findings include: 1. Review of the letter dated 05/25/23 from the state survey agency to the facility revealed the facility had their request approved to decrease the capacity and licensed beds to 72 residents. Review of the facility assessment dated [DATE] revealed the resident profile portion was incorrect. The number of residents the facility was licensed to care for stated 118. Their average daily census ranged from 35 to 85 residents (the capacity for the facility was 72 as of 05/25/23). On 03/17/25 at 12:05 P.M. interview with the Administrator verified the facility assessment was inaccurate and did not reflect the correct capacity. 2. Review of in-services provided by the facility from 05/13/24 through 02/20/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, contract review, review of the facility policy and staff interview, the facility failed to ensure the medical director fulfilled his responsibilities related to the coordination of medical care, the implementation of facility policies and procedures and evidence of participation in Quality Assurance and Performance Improvement to ensure quality care is provided to residents. This affected all 54 residents who reside in the facility. Findings include: Review of available Medical Director reports from January 2024 through February 2025 revealed one report from February 2025. The report indicated the environment was clean and hazard free and residents appeared to be clean and comfortable with safety measures in place. There were no documented concerns relating to pressure areas, falls or changes in condition. During an interview on 03/17/25 at 12:05 P.M., Medical Director #366 stated he had been the facility's Medical Director since 07/01/24. Medical Director #366 did not voice concerns relating to effective administration of the facility or indicate any areas…

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

Based on record review, facility policy and procedure review and interview the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified concerns timely and effectively. This had the potential to affect all 54 residents in the facility. Findings include: Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the following plans without continued corrective action, evidence the plan was revised when necessary or changed once identified to be ineffective: 1. Review of QAPI meeting minutes revealed for the month of April 2024 (date not specified) there was an action plan to a (unidentified date) state agency survey with citations for dignity, not providing private communication, quality of care, notification of condition change, homelike environment, reporting allegations of abuse, investigating allegations of abuse, assistance with activities of daily living, activities to meet the needs of the residents, accidents/hazards, nutrition, significant medication errors, medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy, the facility failed to ensure all required members of the quality assurance performance improvement (QAPI) committee met quarterly as required. This affected all 54 residents residing in the facility. Findings include: Review of the QAPI meeting minutes and sign-in sheets from January 2024 through February 2025 revealed QAPI met on 03/19/24, 04/16/24, 05/21/24, 06/18/24, 07/16/24, 08/16/24, 09/17/24, 10/15/24, January 2025 and February 2025. There was no evidence the facility's previous Medical Director, Physician #367, attended the QAPI meetings on 03/19/24, 04/16/24, 05/21/24, 06/18/24 and 07/16/24. There was no evidence a member of the facility's governing body attended the QAPI meetings until the January 2025 meeting. Additionally, there was no identification of the facility's Infection Preventionist (IP) on the sign-in sheets provided to ensure the IP was involved as required. On 03/17/25 at 12:05 P.M. telephone interview with Physician #366 revealed he had been the Medical Director at the facility since…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, review of hospital discharge summaries, review of the Ohio Department of Health (ODH) Ohio Disease Reporting System (ODRS), review of the Summit County Public Health (SCPH) Public Health Nurse (PHN) communications, and facility policy review, the facility failed to develop, maintain, and implement an effective infection control program. This had the potential to affect all 54 residents residing in the facility. The failed to follow the local health department's directives for Resident #24 with a MDRO. This affected one resident (#24) of one resident reviewed for a MDRO and had the potential to affect all residents. The facility failed to ensure infection control tracking was not complete or accurate. This had the potential to affect all residents. The facility failed to have effective COVID-19 outbreak testing, or infection surveillance for staff and residents. The affected 20 residents (#2, #9, #11, #16, #18, #21, #22, #31, #35, #36, #37, #38, #40, #41, #42,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Quality Assurance and Performance Improvement (QAPI) meetings, staff interview, review of staff certificates and personnel files, the facility failed to ensure there was a qualified infection preventionist (IP) working on at least a part time basis. This had the potential to affect all residents residing in the facility. The facility census was 54. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets from March 2024 to February 2025 revealed no designation of an IP or evidence of an IP participation in meetings, except for in January 2025 and February 2025 when Chief Operating Officer (COO) #300 was present. Interview on 03/10/25 at 12:01 P.M. with COO #300 revealed there was not currently an infection preventionist (IP) employed at the facility. COO #300 indicated she held an IP certificate and Registered Nurse (RN) #374 was a Director of Nursing and IP for another facility, who was assisting with the changeover in staff. COO #300 indicated former Assistant Director of Nursing (ADON) #368 was the IP from May…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of a facility immunization report, facility policy review, review of facility census, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to ensure residents were offered, screened, educated and received influenza and pneumococcal vaccinations as required. This affected nine residents (#23, #24, #25, #26, #31, #38, #43, #55 and #204) reviewed/interviewed as part of the survey and the lack of an effective system to manage vaccinations and prevent incidents of influenza/pneumonia had the potential to affect all 54 residents residing in the facility. The facility census was 54. Findings include: 1.Review of the facility census on 12/04/24 revealed there were 45 residents, Resident #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #27, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #45, #46, #50, #51, #55, #56, #57, and #58 who resided in the facility on this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility immunization report, review of staff vaccination reports, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed ensure residents and staff were educated, screened, and offered COVID-19 vaccinations as required. This affected seven residents (#23, #24, #25, #31, #38, #55 and #204) of seven reviewed for immunizations and the lack of an effective program to manage vaccinations affected all residents in the facility. The facility census was 54. Findings include: 1. Review of the Immunizations Report from 01/01/24 to 03/13/25 for COVID-19 vaccinations revealed there was no evidence of any COVID-19 vaccinations being completed from 01/01/24 to 03/13/25. In addition, record review revealed there was no documented evidence of consent/declination, screenings, or education regarding COVID-19 vaccinations for any facility residents during this time period. Interview on 03/13/25 at 7:30 A.M. with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the personnel files, review of the facility assessment and interviews, the facility failed to ensure Certified Nursing Assistants (CNA) #305 and #329 received annual performance reviews. This affected two CNAs of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility. Findings include: Review of the personnel file for CNA #305 revealed a hire date of 06/03/21. There was no documented evidence that CNA #305 had an annual performance review. Review of the personnel file for CNA #329 revealed a hire date of 06/03/21. There was no documented evidence that CNA #329 had an annual performance review. Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNAs #305 and #329 did not have an annual performance reviews in their personnel files. Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training 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 record review, interview and facility policy review, the facility failed to ensure advance directive orders were consistent across electronic and paper medical records. This affected five residents (#7, #15, #20, #25 and #34) out of 24 resident records reviewed. The facility census was 54. Findings include: 1. Review of Resident #7's medical record revealed an admission date of [DATE] and diagnoses including schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes. Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA) (indicating no life-sustaining interventions would be attempted in the event of cardiac or respiratory arrest). Review of Resident #7's paper medical record revealed he had an advance directive of full code, indicating life-sustaining interventions, including cardiopulmonary resuscitation (CPR) would be attempted in the event of cardiac or respiratory arrest). Interview on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments for residents were complete and accurate. This affected four (Residents #22, #24, #37 and #43) of 28 residents reviewed for the accuracy and completion of assessments. The facility census was 54. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure. Review of the quarterly MDS 3.0 assessment dated [DATE] for Resident #22 revealed section C for cognitive patterns was not completed. Question C100 was answered yes to interview for mental status. However, questions C200, C300, C400, C500, C600, C700, C800, C900, C1000 and C1310 were all answered with either not assessed or dashes. Section J revealed question J200 was answered yes to attempt to interview the resident for pain. However, J300, J410, J520, J530 and J600 were answered not assessed or had dashes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 4. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety and depression. Review of Resident #25's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). No care plan was available addressing Resident #25's advance directives. Interview on 03/12/25 at 9:11 A.M. with Social Service Designee (SSD) #355 revealed the MDS nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #25 did not have a care plan developed addressing his advance directive and should have. 5. Review of Resident #34's medical record revealed an admission date of 08/21/23 and diagnoses including vascular dementia with psychotic disturbance, paranoid personality disorder, violent behavior, osteoarthritis and depression. Review of Resident #34's EMR revealed he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure showers were provided as scheduled and per the resident preference for dependent residents. This affected four (Residents #23, #37, #43 and #48) of four dependent residents reviewed for activities of daily living. The facility census was 54. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 08/21/24 with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression and chronic pain syndrome. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] for Resident #37 revealed he had intact cognition and did not refuse care. He was dependent on staff for toileting, showers, dressing and transfers. Review of the shower schedule for the facility, undated, revealed Resident #37 was scheduled for showers on Wednesdays and Saturdays from 7:00 A.M. to 7:00 P.M. for the date range of 01/01/25 through 02/25/25. On 02/26/25 his shower schedule was changed and were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #18 and Resident #204 to prevent falls. The facility also failed to ensure cigarette butts were properly disposed of after smoking. This affected two residents (#18 and #204) of three residents reviewed for falls/accidents and 19 residents (Residents #1, #2, #3, #9, #11, #12, #14, #16, #23, #25, #27, #29, #38, #39, #42, #43, #44, #48 and #203) identified by the facility as residents who smoke. The facility census was 54. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair. Review of the st risk for falls related to deconditioning, balance problems, incontinence, intermittent aggressive behaviors, impaired safety awareness 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 record review, interview and review of the facility policy, the facility failed to act upon pharmacy reviews in a timely manner. This affected five (Residents #5, #7, #18, #24 and #37) of five residents reviewed for unnecessary medications. Facility census was 54. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 07/26/17 and diagnoses including heart failure, schizophrenia, anxiety, constipation, type two diabetes, depression and unspecified psychosis. Review of Resident #5's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she received insulin, antipsychotic's, antianxiety medications, antidepressants, anticoagulants, diuretics and opioids. Review of Resident #5's discontinued orders revealed an order dated 07/21/24 for hydroxyzine pamoate oral capsule 25 milligrams (mg) give by mouth every six hours as needed (PRN) for itching. The order was discontinued on 02/04/25. Continued review of Resident #5's discontinued orders revealed an order…

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

Based on record review, observations and interviews, the facility failed to ensure medical records were complete and accurate. This affected four (Residents #11, #18, #22 and #43) of 28 records reviewed. The facility census was 54. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 01/25/17 with diagnoses including dementia with behavioral disturbance and Coronavirus Disease 2019 (COVID-19). Review of the physician's orders for Resident #11 revealed an order dated 12/27/24 to maintain contact and droplet precautions every shift. Review of the Treatment Administration Record (TAR) for March 2025 for Resident #11 revealed nursing staff were still signing that Resident #11 was on contact and droplet precautions for COVID-19. Observation and interview on 03/10/25 at 11:46 A.M. with Certified Nursing Assistant (CNA) #305 verified Resident #11 was on enhanced barrier precautions related to having a wound. She stated staff wore gowns and gloves when providing care. Interview on 03/18/24 at 10:09 A.M. with the Director of Nursing (DON) 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.

Based on interview, record review, review of infection control logs, and review of facility policy, the facility failed to ensure implementation of appropriate antibiotic stewardship measures. This affected one Resident (#9) of three reviewed for urinary tract infections and 15 residents (#2, #9, #19, #23, #24, #25, #29, #32, #33, #35, #37, #42, #43, #50, and #55) of 15 residents reviewed in the infection control log. The facility census was 54. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/12/24 and diagnoses including bell's palsy, systemic lupus erythematosus, congestive heart failure, hypertension, dementia, metabolic encephalopathy, malignant neoplasm of bronchus and lung, and chronic kidney disease. Review of the nurses note dated 01/11/25 revealed Resident #9 was agitated and adamant she was going home. Resident #9's son came to the facility to try to calm her down and he reported that Resident #9 was exhibiting symptoms of a urinary tract infection (UTI) as she had in the past. Hospice and the residents physician were…

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

Based on interview and record review, the facility failed to ensure resident authorized the facility to manage their personal funds and the authorization was witnessed by a third party. This affected two (Residents #30 and #207) of six residents reviewed for personal funds. The facility census was 54. Findings include: 1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with diagnoses including heart disease, anxiety and dementia. He was discharged on 02/15/25. Review of the Resident Fund Management Service (RFMS), undated, for Resident #30 revealed handwriting at the top of the form stating Human Resources Director (HR) #343 had opened the account. She had explained to the resident and over the course of a month he would not sign and stated he needed to read the form over. Review of the RFMS trial balance list dated 03/10/25 revealed Resident #30 had a balance of $2,000.29. Interview on 03/18/25 at 8:43 A.M. with HR #343 verified Resident #30 passed away on 02/15/25. She stated he had a guardian for financial decisions. She stated she had…

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

Based on interview, record review, and facility policy review, the facility failed to ensure resident personal funds were disbursed to the resident's estate within 30 days. This affected two (Residents #30 and #207) of two residents reviewed for personal funds after death. The facility census was 54. Findings include: 1. Review of the closed medical record for Resident #30 revealed an admission date of 07/23/24 with diagnoses including heart disease, anxiety and dementia. He passed away on 02/15/25. Review of the Resident Fund Management Service (RFMS) trial balance list dated 03/10/25 revealed Resident #30 had a balance of $2,000.29. Interview on 03/18/25 at 8:43 A.M. with Human Resource Director (HR) #343 verified Resident #30 passed away on 02/15/25. She stated he had a guardian for financial decisions who she had attempted to contact. She was unaware of the required time frame to disperse the funds to his estate. 2. Review of the closed medical record for Resident #207 revealed an admission date of 03/19/20 with diagnoses including dementia and depression. Resident #207 passed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were able to use the phone when requested and in private. This affected one (Resident #206) of one resident reviewed for facility phone usage. The facility census was 54. Findings include: Review of the medical record for Resident #206 revealed an admission date of 02/27/25 with diagnoses including bipolar disorder (mental health condition that causes mood swings), anxiety and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #206 had adequate hearing, clear speech, understood others and was able to be understood. He had impaired cognition. It was noted under section F for preferences for routines and activities that it was very important for him to use a phone in private. Interview on 03/18/25 at 7:40 A.M. with Licensed Practical Nurse (LPN) #325 revealed residents had access to a phone but would have to use the corded phone at the nurse's station. The phone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to prevent resident-to-resident physical abuse. This affected one resident (#23) out of five residents reviewed for abuse. Facility census was 54. Findings include: Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day look-back period. Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical aggression, verbal aggression and emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a self-reported incident (SRI), review of the facility policy, record review and interview, the facility failed to timely report allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse. Facility census was 54. Findings include: 1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day lookback period. Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a self-reported incident, review of the facility policy, record review and interview, the facility failed to thoroughly investigate allegations of misappropriation and injury of unknown origin. This affected two residents (#18 and #23) out of five residents reviewed for abuse Facility census was 54. Findings include: 1. Review of Resident #23's medical record revealed an admission date of 06/27/24 and diagnoses including lumbago, low back pain, general anxiety disorder and post-traumatic stress disorder. Resident #23 was her own responsible party. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a brief interview for mental status (BIMS) score of 14, indicating she was cognitively intact and displayed other behaviors one to three days of the seven-day lookback period. Review of Resident #23's plan of care dated 09/18/24 and revised 12/19/24 revealed Resident #23 had delusions, behavior problems and could attempt to manipulate with physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 nursing assessments were completed on admission for residents. This affected one (Resident #48) of 28 residents reviewed for nursing assessments. Findings include: Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of the brain), hallucinations and alcohol use with withdrawal. Review of Resident #48's electronic medical record and paper chart revealed there were no nursing admission assessments done when he arrived at the facility. Interview on 03/19/25 at 11:45 A.M. with the Chief Operating Officer (COO) #300 verified Resident #48 did not have a nursing assessment performed on admission to the facility on [DATE]. The facility was unable to provide a policy related to nursing assessments and timing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a baseline care plan for Resident #48. This affected one (Resident #48) out of 19 residents reviewed for baseline care plans. The facility census was 54. Findings include: Review of the medical record for Resident #48 revealed an admission date of 01/31/25 with diagnoses including multiple fractures of ribs, encephalopathy (condition that affects function of your brain), hallucinations and alcohol use with withdrawal. Review of Resident #48's electronic medical record and paper chart revealed there was no baseline care plan completed after admission. Interview on 03/19/25 at 11:45 A.M. with Chief Operating Officer (COO) #300 verified Resident #48 did not have a baseline care plan completed since admission on [DATE]. Review of the facility policy titled, Baseline Plan of Care, dated 05/01/22, revealed the interdisciplinary team, resident, resident's representative and physician would develop and implement a baseline care plan upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the facility policy, the facility failed to timely update care plans to address changes in residents' advance directives. This affected three residents (#7, #15 and #20) out of 26 residents reviewed for care planning. Facility census was 54. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 05/07/15 and diagnoses including schizoaffective disorder, hypertension, insomnia, muscle weakness and diabetes. Review of Resident #7's electronic medical record (EMR) revealed he had an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA). A plan of care revised 07/05/22 revealed Resident #7 had an advance directive of full code. Review of Resident #7's paper medical record revealed he had an advance directive of full code. Interview on 03/12/25 at 9:13 A.M. with Social Service Designee (SSD) #355 revealed the Minimum Data Set (MDS) nurse put in the care plans, but any staff could update resident care plans. SSD #355 confirmed Resident #7's care plan was not revised to reflect his current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure showers were completed for independent residents. This affected three (Residents #15, #22 and #203) of three residents reviewed who were independent with activities of daily living (ADL). The facility census was 54. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 11/05/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had clear speech, understood staff and staff understood him. There was no cognitive assessment performed on this MDS. Resident #22 was noted to be independent for showers and dressing. Review of the care plan dated 11/12/24 for Resident #22 revealed he needed assistance with his activities of daily living (ADLs). However, his care plan was incomplete and did not state the level of care he required for assistance with showers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an anchoring device for Resident #204's indwelling urinary catheter was implemented to prevent catheter-related complications. This affected one resident (Resident #204) of one resident reviewed for indwelling urinary catheters. The facility census was 54. Findings include: Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia. Review of Resident #204's physician's orders for March 2025 revealed there were no orders for an anchoring device for his urinary catheter. Review of Resident #204's baseline care plan dated 03/03/25 revealed he had a catheter care plan. Interventions included providing a leg strap for the catheter (for anchoring of the catheter). Observation on 03/10/25 at 2:26 P.M. revealed Resident #204 was on a mat on the floor beside his bed. His urinary catheter tubing was stretched tight and the drainage bag was under the mat. At 2:39 P.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility contract, review of the facility policy and interview, the facility failed to complete pre and post dialysis assessments as required and to collaborate care with the outside dialysis center. Also, the facility failed to ensure there was a valid contract between the facility and the outside dialysis center to ensure coordination of all care and services pertaining to dialysis treatment for Resident #25. This affected one resident (#25) of one resident reviewed for dialysis. The facility identified no other residents as receiving dialysis. The facility census was 54. Findings include: 1. Review of Resident #25's medical record revealed an admission date of 09/16/24 and diagnoses including traumatic brain injury, insomnia, protein-calorie malnutrition, vascular dementia with other behavioral disturbance, anxiety, depression and dependence on renal dialysis. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 was cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure staff were providing necessary behavioral health care for residents to attain and maintain their highest physical, mental and psychosocial well-being. This affected one (Resident #204) of six residents reviewed for behaviors. The facility census was 54. Findings include: Review of the medical record for Resident #204 revealed an admission date of 03/03/25 with diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease and dementia. Review of the nursing admission assessment dated [DATE] for Resident #204 revealed he was alert to person only and had agitation. Review of the care plan dated 03/03/25 for Resident #204 revealed he was dependent on staff for meeting his emotional, intellectual, physical and social needs. Interventions included for staff to invite him to scheduled activities, encourage him to participate and introduce him to others with similar background and interests. He also had…

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

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy and administered as ordered. This affected one (Resident #23) of 28 residents reviewed for medication administration. The facility census was 54. Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/27/24 with diagnoses including asthma, anxiety and chronic pain. Review of the physician's orders for Resident #23 revealed she had an order for Fluticasone Propionate Nasal 50 micrograms (mcg) one time a day for allergy symptoms dated 09/18/24, Hydroxyzine HCl 10 milligrams (mg) three times a day for anxiety dated 12/31/24, Cran-B-OTC Oral Liquid 30 milliliters (mL) one time a day for supplement dated 01/21/25 and Tizanidine 2 milligrams (mg) three times a day for pain dated 02/20/25. Review of the Medication Administration Record (MAR) for Resident #23 for January 2025 revealed Cran-B-OTC was not administered on 01/22/25 and 01/28/25 at 9:00 A.M. Hydroxyzine HCl 10 mg was not administered on 01/02/25 at 10:00 P.M. and at 6:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were monitored for the use of psychotropic medications. This affected three residents (#5, #18, and #37) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder. Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar (an antipsychotic medication). Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam (a medication used for anxiety). Review of physician's order dated 07/17/24 revealed order for 150 mg Clozaril (an antipsychotic medication). Review of Abnormal Involuntary Movement Scale (AIMS) assessment dated [DATE] revealed Resident #18 was not observed to have any…

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

Based on interview, record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one resident (#18) of 28 residents reviewed for medications. The facility census was 54. Findings include: Review of the medical record for Resident #18 revealed an admission date of 05/30/18 and diagnoses including Parkinson's disease, oropharyngeal phase dysphagia, schizophrenia, depression, dementia with severe behavioral disturbance, anxiety disorder, and depressive type schizoaffective disorder. Review of physician's order dated 04/22/23 revealed order for six milligrams (mg) Vraylar one time per day. The medication was scheduled for 9:00 A.M. Review of physician's order dated 12/19/23 revealed order for 0.5 mg Lorazepam two times per day. The medication was scheduled for 9:00 A.M. and 9:00 P.M. Review of physician's order dated 03/20/24 revealed order to ensure Carbidopa-Levodopa was administered one hour prior to a meal to assist with swallowing and to hold meal tray until at least 60 minutes have passed since medication administration.…

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

Based on record review, review of the facility's self-reported incidents (SRI) #250112 and #250126, staff interview, and review of the facility's abuse policy, the facility failed to submit their SRI investigation findings within five working days. This affected three residents (#5, #21, and #37) of five reviewed for abuse. The facility census was 44. Findings include: Review of the medical record for Resident #5 revealed an admission date of 06/27/24 with diagnoses of fibromyalgia, post traumatic stress disorder, anxiety disorder, and major depressive disorder. Review of the medical record for Resident #21 revealed an admission date of 01/05/24 with diagnoses of dementia with agitation, depression, moderate intellectual disability, and anxiety disorder. Review of the medical record for Resident #37 revealed an admission date of 10/30/20 and readmission date of 03/06/24. Diagnoses included vascular dementia with psychotic disturbance, major depressive disorder, anxiety disorder, alcohol abuse in remission, cocaine use in remission, and other psychoactive substance use in remission.…

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

Based on observation, interview, record review and review of the facility policy the facility failed to ensure a safe environment, and equipment was functioning and available for preparation of resident food. This had the potential to affect all residents served food from the kitchen. The facility census was 40. Findings include: Observation on 07/02/24 at 11:00 A.M. of the facility kitchen revealed staff were very busy, moving about the kitchen hurriedly and were preparing the lunch meal. Interview on 07/02/24 at 11:00 A.M. of Cook/Dietary Aide #266 revealed the kitchen staff were behind preparing the lunch meal because they had a mandatory meeting today and the meeting had just finished. Cook/Dietary Aide #266 stated the lunch meal would be about a half hour behind because of the meeting. Observation on 07/02/24 at 11:05 A.M. of the kitchen with Cook/Dietary Aide #266 revealed a Steamer sitting on the counter that was not being used. Cook/Dietary Aide #266 stated the Steamer did not work and had not worked for quite a while. Further observation of the kitchen floor revealed tiles…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of camera footage, interview, record review and review of facility policy the facility failed to ensure Resident #21 was treated with dignity and respect. This affected one resident (Resident #21) out of three residents reviewed for dignity. The facility census was 40. Findings include: Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia. Review of Resident #21's care plan initiated 06/11/18 included Resident #21 had bowel and bladder incontinence, was fixated on bladder urge, and was followed by urology. Resident #21 had a history of neurogenic bladder and took diuretics as needed. Resident #21 sometimes voiced the need for toileting after she was incontinent. Staff placed Resident #21 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility self-reported incident (SRI) review, and review of facility policy the facility failed to ensure Resident #21's Injury of Unknown Origin was reported to the State Agency. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40. Findings include: Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia. Review of Resident #21's care plan dated 10/14/19 included Resident #21 had an ADL (Activity of Daily Living) self-care performance deficit related to severe cognitive impairment secondary to dementia, physical limitations, chronic and debilitating health conditions. Resident #21 was nearly dependent for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure a thorough investigation of Resident #21's Injury of Unknown Origin on her bilateral arms. This affected one resident (Resident #21) out of three residents reviewed for abuse. The facility census was 40. Findings include: Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia. Review of Resident #21's care plan dated 10/14/19 included Resident #21 had an ADL (Activity of Daily Living) self-care performance deficit related to severe cognitive impairment secondary to dementia, physical limitations, chronic and debilitating health conditions. Resident #21 was nearly dependent for all ADL's. Resident #21 would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #18 and #21's incontinence care was completed timely, and followed appropriate standards of care. This affected two residents (Resident's #18 and #21) out of three residents reviewed for incontinence care. The facility census was 40. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 10/27/22 and diagnoses included unspecified dementia, unspecified severity with agitation, psychotic disorder with delusions due to known physiological condition, and Alzheimer's Disease. Review of Resident #18's care plan dated 11/03/22 included Resident #18 had an ADL (activity of daily living) self-care performance deficit related to Alzheimer's Disease, dementia. Resident #18 would maintain his current level of function in ADL's through the review date of 06/03/24. Interventions included Resident #18 required assistance with incontinence care when incontinent. Resident #18…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to complete Resident #20's Speech Therapy evaluation was ordered to ensure safe eating and adequate nutrition. This affected one resident (Resident #20) out of three residents reviewed for nutrition. The facility census was 40. Findings include: Review of Resident #20's medical record revealed an admission date of 09/11/18 and diagnoses included Alzheimer's Disease, dementia without behavioral, psychotic disturbance, mood disturbance and anxiety, atherosclerotic heart disease, and major depressive disorder. Resident #20 resided in the secured unit for dementia. Review of Resident #20's care plan revised 01/02/22 included Resident #20 had an ADL (Activity of Daily Living) self-care performance deficit related to Alzheimer's Disease, dementia and other diagnoses. Resident #20 would maintain her current level of function with ADL's and mobility through the review date. Interventions include Resident #20 was independent, supervised, cued with eating.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and review of the facility policy the facility failed to ensure Resident #21 was free from significant medication error and medications were administered per physician orders. This affected one resident (Resident #21) out of three residents reviewed for medications administered per physician orders. The facility census was 40. Findings include: Review of Resident #21's medical record revealed an admission date of 05/30/18 and diagnoses included Parkinson's Disease without dyskinesia, without mention of fluctuations, chronic obstructive pulmonary disease, follicular lymphoma, unspecified, lymph nodes of head, face, and neck, dementia, severe, with other behavioral disturbance and schizophrenia. Review of Resident #21's care plan initiated 06/11/18 included Resident #21 received psychoactive medications (antipsychotic, anxiolytic) to treat mental illness. Resident #21 would receive the lowest possible dosage of the prescribed psychotropic drugs to ensure maximum functional ability…

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

Based on observations and interview the facility failed to ensure food was stored in a manner to prevent food borne illness and failed to maintain a sanitary kitchen. This had the potential to affect all residents except Resident #34 who did not receive nutrition by mouth. Facility census was 38. Findings include: Observations of the kitchen on 05/28/24 at 8:10 A.M. revealed thawed raw boneless/skinless chicken breast in a bag lying in a bin in the refrigerator; the Ziplock bag holding the chicken breast was dated 05/19/24 and the juices from the chicken had leaked out filling the bottom of the bin. There was a bag of cooked barbeque chicken in a Ziplock bag that was dated 05/19/24 to 05/26/24, a carton of whole eggbeaters dated 05/06/24, two opened containers of beef base dated 11/27/23 and 01/05/24, and a carton of imitation vanilla was capped with aluminum foil dated 02/24. A large garbage can next to the stove was covered with a dirty lid. The microwave had dried food debris on the inside, there was loose miscellaneous debris covering the top the dishwasher, and the air vents 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 observations and interview the facility failed to dispose of garbage and refuse appropriately. This had the potential to affect all 38 residents residing in the facility. Findings include: Observations on 05/20/24 at 7:56 A.M. of the main dumpster area revealed trash was contained within the walls of the dumpster except for two used latex gloves. Further observation revealed a large garbage can located against the wall just outside the back door to the kitchen. The garbage can had no lid and was full of food, a wash basin, and miscellaneous items. A smaller can without a lid was observed against the wall next to the larger can, which contained food, Styrofoam plates and other miscellaneous items. Continued observations of the area surrounding the facility revealed empty wooden pallets lying against the wall of the facility, broken boards form the pallets lying on the ground with paper and miscellaneous debris, five broken wheelchairs, broken bed side trays, two pieces of plywood leaning against the facility, a bag of soiled incontinence supplies lying in a bin that was not…

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

Based on observation, resident interview, and staff interview, the facility failed to ensure residents were provided dignified dining experience when meals were not provided on non-disposable plates. This affected 13 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #37, #60, #90 and #92) who were served all meals on Styrofoam plates due to the facility not having a sufficient number of plates. The facility census was 40. Findings include: Interview on 02/20/24 at 11:47 A.M., with Dietary Manager #282 revealed he started working at the facility in June 2023. Dietary Manager #282 revealed he did not have enough plates for all the residents when he started working at the facility. Dietary Manager #282 revealed there were 27 plates and 40 residents. Dietary Manager #282 revealed he brought it to the Administrator's attention in December 2023 and has been waiting for approval to purchase more plates since then. Dietary Manager #282 revealed all the residents in memory care were served on Styrofoam plates and two additional residents outside of memory care would also have to be…

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

Based on observation, record review, resident interview, staff interview, and review of the policy, the facility failed to provide a phone for residents to use that would be located in a private area to allow for private conversations. This affected one (#37) and had the potential to affect all residents except (Resident #34, #6, #10, #60, #25, #9, #23, and #11) who did not use the facility phones. The facility census was 40. Findings include: Review of Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included obstructive uropathy and depression. Review of the quarterly minimum data set (MDS) assessment revealed Resident #37 was cognitively intact. Observation on 02/20/24 at 4:17 P.M., revealed Resident #37 was standing in front of the nurses station talking on the phone. Observation revealed residents and staff near the area. Resident #37's conversation could be heard clearly by anyone near the area. Interview on 02/20/24 at 4:24 P.M., with Resident #37 revealed he was talking with a family member. Resident #37 revealed this was the only phone he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, record review, and review of the policy, the facility failed to provide a clean, comfortable homelike environment for residents. This affected four (#1, #2, #8, and #26) of 22 resident rooms observed. The facility census was 40. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, psychosis, morbid severe obesity, polyosteoarthritis, and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 was moderately cognitively impaired. Resident #8 required substantial maximum assistants with toileting and lower body dressing. Resident #8 was occasionally incontinent of urine. Review of the care plan for Resident #8 dated 02/15/24 revealed Resident #8 experiences frequent bladder incontinence and is at risk for episodes of bowel incontinence related to activity intolerance,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, activity calendar review, resident interview and staff interview, the facility failed to prove structured meaningful group activities for residents residing in the Memory Care Unit. This affected three (#7, #17, and #92) and had the potential to affect all 11 residents (#6, #7, #13, #17, #18, #20, #24, #28, #34, #90 and #92) residing in the Memory Care Unit. The facility census was 40. Findings include: 1. Review for Resident #17's medical record revealed an admission date of 01/19/24. Diagnoses included malignant neoplasm of the brain and diabetes mellitus. Resident #17 resided in the Memory Care (MC) Unit. Review of the admission minimum data set (MDS) assessment revealed Resident #17 was severely cognitively impaired. Resident #17 required set up or clean up assistants with activities of daily living. Residents were independent with transfers and ambulation. Review of the Activity Calendar posted in the Memory Care Unit for 02/21/24 revealed 10:00 A.M. Bingo; 11:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of policy, the facility failed to ensure fall prevention interventions were in place and ensure a resident was provided a smoking apron intervention to prevent burns. This affected six (#3, #9, #14, #27, #32, and #34) of seven residents reviewed for incidents and accidents. The facility census was 40. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following cerebral infarction, and acquired absence of left leg below the knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 was moderately cognitively impaired. Resident #32 used a wheelchair for mobility. Resident #32 required substantial/maximum assistants with transfers and wheelchair mobility. Review of the care plan for Resident #32 dated 12/28/23, revealed Resident #32 was at risk for falls related to gait/balance problems, impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure medications were stored in a secure manner. This affected one (#7) and had the potential to affect 10 (#6, #13, #17, #18, #20, #24, #28, #34, #90 and #92) additional residents residing in the Memory Care Unit. The facility census was 40. Findings include: 1. Review of Resident #7 revealed an admission date of 06/22/15. Diagnoses included unspecified dementia moderate with psychotic disturbance, restlessness and agitation, delirium, noncompliance with other medical treatment, and wandering. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 had no impairment to upper or lower extremities and was independent with ambulation. Review of the care plan for Resident #7 dated 01/12/24 revealed Resident #7 had a behavior problem of refusing medication. Interventions included anticipating and meeting the resident's needs. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, record review and review of the policies, the facility failed to maintain infection control practices of hand washing and during oxygen therapy. This affected four (#2, #6, #16 and #17) of six residents reviewed for infection control. The facility census was 40. Findings include: 1. Review of Resident #17's medical record revealed an admission date of 01/19/24. Diagnosis included diabetes mellitus. Record review of the admission Minimum Data Set (MDS) revealed Resident #17 was severely cognitively impaired. Record review of the physician order dated 01/09/24. for Resident #17 revealed an order for accu checks (blood sugar checks) before meals and at bedtime for diabetes. Observation on 02/20/24 at 10:18 A.M., of Licensed Practical Nurse (LPN) #225 assess Resident #17's blood sugar using a glucometer revealed LPN #225 removed the glucometer from the medication cart drawer. LPN #225 took the glucometer in Resident #17's room, sat the glucometer directly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy, the facility failed to timely notify a resident's Guardian, after a fall. This affected one (#1) of three residents reviewed for notification to the responsible party after a fall. The facility census was 20. Findings include: Review of Resident #1's medical record revealed an admission date of 05/07/15. Diagnosis included unspecified dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Review of the resident profile revealed Resident #1 had a Guardian of Person. The Guardian of Person was the primary contact person and Resident #1's legal Guardian. Review of the progress note dated 01/23/24 at 11:00 A.M., completed by Licensed Practical Nurse (LPN) #259 revealed, This nurse was alerted by activities that this resident had fell. This nurse went to the lounge where this resident was found sitting on his behind. This nurse assessed the patient. Resident stated, I tripped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident council minutes, review of staff schedules, review of Self-Reported Incidents (SRI), staff interview and review of the policy, the facility failed to report an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40. Findings include: 1. Review for Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, morbid severe obesity and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. Resident #8 required assistants with activities of daily living. 2. Review for Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of resident council minutes, staff interview and review of the policy, the facility failed to investigate an allegation of staff being rough to one resident (#8) and personal items being stolen from one resident (#32). This affected two (#8 and #32) of six residents reviewed for Abuse, Neglect and Misappropriation. The facility census was 40. Findings include: 1. Review for Resident #8's medical record revealed an admission date of 07/26/17. Diagnoses included chronic obstructive pulmonary disease, myopia, morbid severe obesity and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. Resident #8 required assistants with activities of daily living. 2. Review for Resident #32's medical record revealed an admission date of 01/27/23. Diagnoses included cerebral infarction, memory deficit following cerebral infarction, and acquired absence of left leg below the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility did not provide or offer resident showers or baths as care planned. This affected one (#9) of three residents reviewed for showers/bathing. The facility census was 20. Findings include: Observation on 02/20/22 at 1:40 P.M., revealed Resident #9 was sitting up in her wheelchair. Resident #9 was not answering questions. Resident #9's hair was disheveled and had a body odor. Record review for Resident #9 revealed an admission date of 03/30/21. Diagnoses included muscle weakness, aphasia following cerebral infarction, muscle weakness and need for assistants with personal care. Resident #9 received Hospice services effective 01/26/24. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was unable to complete the interview. Resident #9 required substantial/maximum assist with bathing. Review of the care plan dated 12/28/23 revealed Resident #9 had a self-care performance deficit and required extensive/total…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, and policy review, the facility failed to implement a physician order timely for treatment to a wound for a resident and complete wound treatments as ordered. This affected two (#9 and #16) of five residents reviewed for wound treatments. The facility census was 40. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 03/30/21. Diagnoses included blister to the right thigh, muscle weakness, age related nuclear cataract bilateral, contracture of the left hand, need for assistants with personal care, and nicotine dependence, cigarettes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was unable to complete the interview. Resident #9 required assistants with activities of daily living. Review of the progress note dated 11/21/23 at 12:59 A.M., completed by Certified Nurse Practitioner CNP #290 revealed Chief Complaint/Reason for this visit was the facility requested visit for wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide nutritional supplements per physician orders. This affected one (#9) of three residents reviewed for supplements. The facility census was 40. Findings include: Review of Resident #9's medical record revealed an admission date of 03/30/21. Diagnoses included aphasia, dysphagia, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) for Resident #9 revealed the resident was unable to complete the cognitive status interview. Resident had weight loss not on prescribed weight loss regimen. Review of the care plan dated 12/28/23 revealed Resident #9 had a nutritional problem related to disease process per nutritional assessment with a history of difficulty with chewing and swallowing. Interventions included providing supplements per order and provide and serve diet as ordered. Review of the physician orders for February 2024 included Resident #9 was to receive a mechanical soft diet with thin liquids and a magic cup two times a day. Observation on 02/20/24 at 4:30 P.M.,…

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

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error when medications were not administered per the physicians order. This affected one (#37) of three residents reviewed for medication administration. The facility census was 40. Findings include: Review for Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included unspecified psychosis and dementia. Review of the progress note dated 12/29/23 at 12:52 P.M., completed by Licensed Practical Nurse (LPN) #201 included the nurse was notified by the physician that Resident #37 was hard to arouse and diaphoretic. The physician ordered a stat (immediate) laboratory test (labs). Review of the physician orders revealed on 12/29/23 an order for Resident #37 was received for STAT Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential (Diff) and a Urinalysis (UA) culture and sensitivity (C&S). Review of the progress note for Resident #37 dated 01/01/24 at 6:10 P.M., completed by Registered Nurse (RN) #292, revealed 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, staff interview, and review of the policy, the facility failed to notify the physician/Certified Nurse Practitioner (CNP) timely of a high potassium level (lab value) for one resident. This affected one (#37) of three residents reviewed for physician notification of lab results. The facility census was 40. Findings include: Review for Resident #37's medical record revealed an admission date of 08/21/23. Diagnoses included unspecified psychosis and dementia. Review of the progress note dated 12/29/23 at 12:52 P.M., completed by Licensed Practical Nurse (LPN) #201 included the nurse was notified by the physician that Resident #37 was hard to arouse and diaphoretic. The physician ordered a stat (immediate) laboratory test (labs). Review of the physician orders revealed on 12/29/23 an order for Resident #37 was received for STAT Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC) with differential (Diff) and a Urinalysis (UA) culture and sensitivity (C&S). Record review of the progress note dated 12/29/23 at 8:50 P.M. completed by LPN #274, Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy, the facility failed to consistently document three residents controlled drug administration on their Medication Administration Record (MAR). This affected three (#1, #2 and #3) of four residents reviewed for accuracy of documentation on the medication administration record. The facility census was 40. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 05/07/15. Diagnoses included lumbago with sciatica, low back pain and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired. Record review of the physician orders for February 2024 revealed resident had an order to receive oxycodone hcl tablet five mg by mouth every six hours as needed for pain. Record review of the Controlled Drug Record compared to Resident #1's Medication Administration Record (MAR) for February 2024 revealed Resident #1 received oxycodone hcl tablet five mg by mouth on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment in resident rooms. This affected seven of twelve rooms on the locked unit, the residents who used the East hallway, and had the potential to affect all 39 residents currently residing in the facility. Findings include: During the initial tour was conducted on 09/18/23 from 10:18 A.M. to 12:20 P.M. the following was observed. • room [ROOM NUMBER] had a sticky floor. • room [ROOM NUMBER] floors needed cleaning, they had spills and sticky areas. • room [ROOM NUMBER] had sticky floors. • room [ROOM NUMBER] had no paper towels. The floor and paper and crumbs. • room [ROOM NUMBER] had no soap in the in the soap dispenser. • room [ROOM NUMBER] had no soap in the in the soap dispenser. • room [ROOM NUMBER] the paper towel dispenser was not working and there was a spill on the floor. The above observations were verified by State Tested Nurse Aide (STNA) #301 at the time of the observations. Interviews on 09/18/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the failed to maintain Resident #7's padded electric wheelchair in a clean and sanitary condition. This affected one resident (#7) of 39 residents reviewed for environment. Findings include: Review of Resident #7's medical record revealed an admission date of 08/28/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, heart failure, major depressive disorder, and vascular dementia. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had severe cognitive impairment. Resident #7 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Resident #7 was always incontinent of urine and bowel. Review of Resident #7's care plan revised 04/07/23 included Resident #7 had an ADL (activity of daily living) self-care performance deficit related to diagnoses. Resident #7 would maintain his current level of function in self-care performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to ensure proper mouth care was provided for Resident #43. This affected one resident (#43) out of three residents reviewed for assistance with activities of daily living. The facility census was 39. Findings include: Review of the medical record for Resident #43 revealed and admission date of [DATE] with diagnoses including unspecified dementia severe with psychotic disturbance, paranoid schizophrenia, and chronic obstructive pulmonary disease. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 required extensive assistance of two or more staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. Review of the physician orders for Resident #43 revealed an order dated [DATE] to admit to hospice services. Further review of physician orders for Resident #43 revealed no orders for mouth care. Review of Plan of Care tasks 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 observation, record review, facility policy review and interview, the facility failed to ensure routine ongoing skin assessments were completed to timely identify and/or prevent pressure ulcer development. This affected three residents (#7, #20 and #43) of four residents reviewed for skin assessments/pressure ulcer care and treatment. Findings include: 1. Review of Resident #7's medical record revealed an admission date of 08/28/18 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, heart failure, major depressive disorder, and vascular dementia. Review of Resident #7's physician orders dated 07/31/20 revealed weekly skin checks by licensed nurse, every day shift, every Tuesday for weekly skin check. Review of Resident #7's medical record including assessments dated 12/19/21 through 09/21/23 revealed on 12/19/21 Resident #7's Braden Scale for Predicting Pressure Ulcer Risk noted he was high risk for developing a pressure ulcer, injury.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation was accurate for two residents (#20, and #41) out of four resident records reviewed for accurate documentation. The facility census was 39. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 06/30/23 with diagnoses including cellulitis of right and left lower limb, and chronic diastolic congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 required extensive assistance of two or more staff members for bed mobility and dressing. Resident #20 required total dependance of two or more staff members for transfers, toilet use, and personal hygiene. Review of physician orders for Resident #20 revealed an order dated 09/13/23 for left lower thigh posterior, medial area, to cleanse with normal saline, pat dry, pack wound with alginate silver, and cover with absorbent dressing to be completed one time a day and as…

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

Based on record review, observation and interviews, the facility did not ensure Resident #23 was treated with respect and dignity. This affected one resident (#23) of three residents reviewed for resident rights. The facility census was 44. Findings include: Review of Resident #23's medical record revealed an admission date of 05/30/18 with diagnoses including Parkinson's disease, schizophrenia, major depressive disorder, hearing loss, dementia severe with other behavioral disturbance, dependence on wheelchair, anxiety disorder, urgency of urination, agitation, and schizoaffective disorder. Resident #23 had a legal guardian. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/14/23, revealed the resident had severe impairment in cognition, no rejection of care, was always incontinent and required two-person extensive assistance with transfers. Review of Resident #23's plan of care, date initiated 06/01/18 and revised on 06/15/23, revealed Resident #23 had intermittent behaviors including cursing, name calling/racial slurs, refusing care, throwing items, breaks furniture,…

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

Based on review of facility staffing schedules and staff interviews, the facility failed to maintain 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 44 residents currently residing in the facility. Findings include: Review of the nursing staff information and staff schedule for 11/5/22 revealed no RNs were present and working in the facility. Interview on 11/17/22 at 11:10 A.M. with Business Office Manager (BOM) #255 confirmed there was not an RN in the building on 11/5/22, the Director of Nursing (DON) #223 was scheduled on call. Interview on 11/17/22 at 11:22 A.M. with the Director of Nursing (DON) #223 confirmed she was on call but did not work in the facility on 11/5/22 and there was not an RN working.

Based on observation, interview and record review, the facility failed to serve food in the proper portions to meet the nutritional needs of all residents in the facility ordered regular and therapeutic diets. This affected all 44 residents receiving meals from the kitchen, as no residents were identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Review of the facility's diet list revealed all residents received a variety of diet types including carbohydrate controlled diet (a therapeutic diet used to help control blood sugar levels in residents with diabetes), no added salt (NAS) diet, mechanically altered diet and regular diets with no restrictions. Review of the posted lunch menu for 11/15/22 revealed the meal being served to the residents included beef pot pie, broccoli, choice of bread and apricot crisp. Review of Resident Council meeting minutes for 04/27/22 revealed concerns with diet orders not being followed and the minutes for 10/19/22 revealed a concern with meal tickets not being followed and residents receiving the wrong…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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. This had the potential to affect 44 residents receiving meals from the kitchen. No residents were identified as nothing by mouth (NPO). The facility census was 44. Finding include: Observation on 11/15/22 at 11:25 A.M. of the lunch tray line revealed all hot food items on the steam table had temperatures over 165 degrees Fahrenheit (F) including beef and broccoli. There was no heat retention system being used in the kitchen to keep the food warm once it left the steam table besides thermal domes to cover the plates and enclosed meal delivery carts. The meal delivery cart carrying a test tray left the kitchen at 12:11 P.M. and arrived on the unit at 12:12 P.M. The test tray was the last tray served off the cart to Dietary Manager (DM) #275 who proceeded to take temperatures of the beef and broccoli on the test tray. The beef and broccoli did not reach 100 degrees Fahrenheit (F) as verified by DM #275 during the observation. DM #275 stated the food should be…

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

Based on observations, interview and record review, the facility failed to ensure the food was prepared, stored and served in a clean and sanitary manner. This had the potential to affect all 44 residents in the facility receiving meals from the kitchen, as there were no residents identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Observations during the initial tour of the kitchen on 11/14/22 from 8:15 A.M. to 8:30 A.M. revealed the walk-in freezer had a heavy ice build on the floor and reaching onto the bottom of the wire shelf and onto boxes of grilled chicken breasts, two cases of ground beef and one case of breaded fish sticks. Food splatter was on the wall behind the stove and wall near dishmachine. The microwave had dried food residue on the inside of the microwave. These observations were verified by Dietary Manager (DM) #275 at time of observation and DM #275 stated the dietary department had been short staffed recently as an explanation of the findings. Review of the facility policies and procedures dated 1/22/09 with 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 record review, observation and staff and resident interviews, the facility failed to act promptly upon grievances voiced during Resident Council meetings concerning issues of resident care and life in the facility. This affected four residents (Resident #3, #10, #11, and #29) of six residents who attended the resident council meeting and voiced concerns. The facility census was 44. Findings included: Review of the Resident Council meeting minutes dated 11/17/21, 12/15/21, 01/19/22, 02/16/22, 03/23/22, 04/27/22, 05/25/22, 06/22/22, 07/20/22, 08/29/22, 09/21/22, and 10/19/22 revealed the residents voiced concerns about hot food not being hot, not receiving evening snacks, therapeutic diets not being followed, inconsistent meal delivery times, no weekend activities and showers not being provided as preferred. There was no documented evidence the facility acted promptly on these concerns. Interviews were conducted on 11/15/22 at 10:00 A.M. with Residents #3, #10, #11 and #29 at the Resident Council meeting. Resident #3 stated when she raised concerns at the meeting those…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #299) of one resident reviewed for funds conveyance. The facility census was 44. Findings Include: Resident #299 was admitted to the facility on [DATE]. Resident #299 expired at the facility on [DATE] with diagnoses to include but not limited to hemiplegia and hemiparesis right side, dysphagia, diabetes mellitus, depression, and cerebral infarction. Review of the business records for Resident #299 revealed $974.48 were dispersed to the State Recovery of the United States on [DATE]. Interview on [DATE] at 9:46 A.M. with Human Resource Manager/Business Office Manager (HR/BOM) #255 revealed the corporate office sends her the check and then she sends it out right away. HR/BOM #255 verified that Resident #299's funds were conveyed outside of required timeframes (30 days).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #39) of one resident reviewed for advanced directives. The facility census was 44. Findings Include: Resident #39 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, schizophrenia, bipolar and systemic lupus erythematosus. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was moderate cognitively impairment and was independent for activities of daily living. Review of the physicians' orders for Resident #39 revealed an order dated [DATE] for do not resuscitate comfort care (DNRCC) a code status signifying cardiopulmonary resuscitative measures (CPR) was not to be conducted in case of cardiac or respiratory arrest. Review of the care plan dated [DATE] revealed the resident was a do not resuscitate comfort care- arrest (DNRCC-A) code status signifying medical…

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

Based on medical record review, staff and family representative interview, and review of the facility policy, the facility failed to ensure a resident's family was notified following a change in status. This affected one (Resident #33) of three residents reviewed for notification of change in condition. The facility census was 44. Findings include: Review of the medical record for Resident #33 revealed an admission date of 11/07/17. Diagnoses included unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, chronic kidney disease stage three, hypertensive chronic kidney disease, type two diabetes mellitus, history of traumatic brain injury, schizoaffective disorder bipolar type, and chronic viral hepatitis C. Review of the 08/31/22 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #33 revealed a brief interview of mental status score of two which indicated severe cognitive impairment. Resident #33 was noted to be totally dependent upon one staff for toileting and bathing, required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents received showers as scheduled and per their preference. This affected three (Residents #2, #3, and #19) of three residents reviewed for showers. The facility had a census of 44 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, and bed confinement. Review of Resident #2's Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and required limited assistance of one staff member for hygiene. Bathing did not occur on this assessment. Review of Resident #2's care plan, dated 01/10/19, revealed he had self-care performance deficit related to morbid obesity, weakness and degenerative disc disease of the lower spine. Interventions included staff to provide extensive assistance for showering and bathing. Review of the shower log for Resident #2 revealed he 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 medical record review, resident and staff interviews, review of job description, review of facility activity calendars, and policy review the facility failed to ensure activities to meet resident preferences and interests were offered on Saturdays. This affected two residents (Residents #10 and #29) of six residents reviewed for activities. The facility census was 44. Findings include: 1. Review of medical record for Resident #10 revealed an admission date of 06/13/18. Diagnoses included schizophrenia, hypertensive heart disease with heart failure, depression, type II diabetes mellitus with neuropathy, and morbid obesity. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Activities of daily living (ADLs) revealed Resident #10 required extensive assist of one staff for bed mobility, transfer, transfer on and off the unit and toileting. Resident #10 required extensive assist of two staff for dressing and personal hygiene. Interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and policy review the facility failed to change an enteral tube feeding after 24 hours. This affected one resident (Resident #248) of two residents reviewed for tube feedings. The facility census was 44. Findings include: Review of medical record for Resident #248 revealed an admission date of 07/30/21. Diagnoses included severe dementia with agitation. chronic obstructive pulmonary disease, unspecified psychosis, pressure ulcer of left heel stage III, and unspecified severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #248 was severely mentally impaired, required extensive assist for bed mobility, transfer, dressing and eating. Resident #248 was totally dependent upon staff for toileting, personal hygiene and bathing. Review of physician order dated 11/10/22 for Resident #248 revealed an order for an enteral feeding of Osmolite 1.2 at a rate of 60 milliliters per hour 24 hours a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected two (Resident #2 and #4) of two residents reviewed for respiratory care. The facility had a census of 44 residents. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement and anxiety. Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition and utilized oxygen. Review of Resident #2's care plan dated 01/10/19 revealed he had respiratory impairment related to chronic obstructive pulmonary disease and experienced shortness of breath while lying flat. He was noted to use oxygen frequently. Interventions included to administer medications as ordered. Review of the physician's order dated 11/07/19 revealed Resident #2's nasal cannula and oxygen tubing was to be replaced,…

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

Based on record review and interview, the facility failed to ensure Resident #2's pain medication was administered as ordered. This affected one (Resident #2) of three residents reviewed for timely reordering of pain medications. The facility had a census of 44 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement. Review of the physician's orders for Resident #2, revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19. Review of the October 2022 Medication Administration Record, revealed Resident #2's Methadone was not administered at 9:00 A.M. and 9:00 P.M. on 10/24/22 and 10/29/22. Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/24/22 and 10/29/22. Interview on 11/14/22 at 9:04 A.M. with Resident #2 revealed there were times he did not receive his pain medications because 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 interviews, the facility failed to ensure all narcotic medication accounting logs were maintained. This affected one (Resident #2) of three residents reviewed for documentation and accounting of narcotic medications. The facility had a census of 44 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic pain and bed confinement. Review of the physician's orders for Resident #2 revealed an order for Methadone HCL tablet 10 milligrams (mg) (medication for pain), give 30 mg every 12 hours for pain dated 12/30/19. Review of the October 2022 Medication Administration Record, revealed Resident #2 was administered Methadone 30 mg at 9:00 A.M. and 9:00 P.M. on 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and 10/28/22. Review of the Controlled Drug Records log for Resident #2, revealed there were no entries for narcotics given for the Methadone 10 mg tablets for the dates of 10/14/22, 10/15/22, 10/16/22, 10/17/22, 10/25/22, 10/26/22, 10/27/22 and…

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

Based on observations, interviews and record review, the facility failed to ensure medications were properly stored and secured. This affected one (Resident #2) of one resident reviewed for improperly stored medications. The facility had a census of 44 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 01/02/19 with diagnoses including chronic obstructive pulmonary disease, chronic pain, bed confinement, anxiety and non-compliance with medications and treatment regimens. Review of the care plan dated 01/10/19 revealed Resident #2 had respiratory impairment related to chronic obstructive pulmonary disease with interventions including to administer medications per order. It was not care planned the resident could have medications at bedside and self administer. Review of the physician's orders for Resident #2 revealed an order for Advair Diskus Aeorosol Powder Breath Activated 250-50 micrograms (mcg) (medication for chronic obstructive pulmonary disease), one inhalation, orally every 12 hours for shortness of breath dated 06/26/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve food at the proper consistency to Resident #35. This affected one resident (Resident #35) of 44 residents receiving meals from the kitchen. No residents were identified by the facility as nothing by mouth (NPO). The facility census was 44. Findings include: Record review revealed Resident #35 was admitted on [DATE] and readmitted on [DATE] to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease, vascular dementia with mood disturbance, dysphagia following cerebral infarction and aphasia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was severely cognitively impaired and required extensive assistance of one staff for eating. Review of the plan of care for Resident #35 dated 04/05/21 with a revision date of 10/14/22 revealed Resident #35 had a nutritional problem related to diagnoses and a history of difficulty chewing/swallowing.…

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