Salem West Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 64 residents who resided in the facility. Findings include: Review of facility document titled Position Description for position of Executive Director revealed the Administrator had signed the job description on 05/02/23. The description revealed the purpose of this position was to provide leadership to all staff to assure that care standards were met and the highest degree of quality resident care was provided at all times. The position description indicated the executive director must function as both a team member, team leader, and supervisor to ensure that work was accomplished and quality of care was delivered and had the authority, responsibility, and accountability for the…

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

Based on review of the facility assessment and staff interview, the facility failed to ensure a complete and accurate facility assessment was developed with active involvement of the required participants. This had the potential to affect all 64 residents residing in the facility. Findings include: Review of the Facility Assessment (FA), dated 04/03/25, revealed the following concerns: There were no persons named to identify required participants involved in completing the FA, as that section was left blank. The date the assessment was reviewed with the Quality Assurance Performance Improvement (QAPI) committee was blank indicating it had not been reviewed by QAPI. On page four, line four the facility resources needed to provide competent care for residents had several blank spaces intended for identification of laboratory services, x-ray services, food services, laundry services, nursing agency, electronic medical records, staff scheduling, and other contracted services. On page six, the certified bed capacity was incorrectly listed as 90 certified beds. On page 23, there 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 observation, interview, record review, review of the facility policies, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to maintain infection control practices by not adhering to proper hand hygiene during care for two residents (#21 and #22). This afffected two residents (#21 and #22) of five residents reviewed for assistance with activity of daily living. Also, the facility failed to ensure a flow diagram and a written description to describe the facility's water system was included in the facility water management program (WMP) in order to minimize the growth and transmission of the bacterium Legionella. This had the potential to affect all residents residing at the facility. The facility census was 64. 1.Record review for Resident #21 revealed an admission date of 12/04/23 with diagnoses including obesity, muscle weakness and the need for assistance with personal care. An observation was conducted on 04/23/25 at 11:06 A.M. of Certified Nursing Assistant (CNA) #524 and #574 completing incontinence care for Resident #21.…

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

Based on observation, record review, interview and review of facility policy, the facility failed to ensure call lights were within reach for Resident #50, #56 and #60, and failed to ensure Resident #20 was reasonably accommodated to meet his shower preference. This affected four residents (#20, #50, #56 and #60) of 22 residents reviewed for accomodation of needs/preferences. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. revealed Resident #56 was resting in bed with his call light draped on a light fixture above his bed not within reach. The observation was confirmed by Licensed Practical Nurse (LPN) #515 who stated call lights should be within reach of residents at all times. Resident #56 was not interviewable. Observation on 04/21/25 at 8:25 A.M. revealed Resident #56 was sleeping in bed and his call light was on the floor behind his bed. The observation was confirmed with LPN #503 and she stated call lights should be within reach of residents at all times. 2. Observation on 04/23/25 at 10:36 A.M. revealed Resident #60 was asleep in bed 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 observation and interview the facility failed to ensure a clean environment was maintained for Resident #56 and Resident #267 and failed to maintain comfortable water temperatures and at the required water temperature for Resident #11, #15, #19, #27, #33, #34, #52 and #54. This affected 10 residents (#11, #15, #19, #27, #33, #34, #52, #54, #56 and #54) with the potential to affect an additional 13 residents (#7, #14, #22, #23, #28, #31, #37, #42, #43, #45 #46, #60 and #114) residing on the 100 hall. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. of Resident #56's room revealed Resident #56 was resting in bed and was noninterviewable due to drowsiness at the time of the observation. In Resident #56's bathroom the toilet was observed to have a large amount of black/green colored liquid stool on the toilet seat and in the toilet bowl. The observation was confirmed by Licensed Practical Nurse (LPN) #515. 2. Observation on 04/16/25 at 8:41 A.M. of Resident #267's bathroom revealed the toilet had dried stool on the toilet seat and inside 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 medical record review, interviews, review of care plan schedules, and review of facility policy, the facility failed to develop a comprehensive care plan as required for Resident #264, failed to ensure there was documented proof in the medical record that care plan meetings with required participants were being held for Residents #20 and #21, and failed to ensure fall interventions were timely updated in the care plan for Resident #38. This affected four residents (#20, #21, #38, #264) out of 22 residents reviewed for care plans. The facility census was 64. Findings include: 1. Review of the closed medical record for Resident #264 revealed an admission date of 02/26/25 and a discharge date of 03/20/25. Diagnoses included ulcerative colitis, mild protein- calorie malnutrition, anorexia, pneumonia, dysphagia, cognitive communication deficit, atherosclerotic heart disease, bipolar disease, anxiety disorder, personality disorder, Alzheimer's disease, and major depressive disorder. Review of Resident #264's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #114 received staff assistance for showering, and failed to ensure timely incontinence care was provided for Resident #21, #23 and #42. This affected four residents (#114, #21, #23 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #114 had an admission date of 03/26/25 with diagnoses including multiple sclerosis, epilepsy, and paralytic syndrome. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #114 was dependent for showering and bathing. Review of Resident #114's care plan, date initiated 03/26/25, revealed Resident #114 had an ADL self-care performance deficient related to multiple sclerosis, schizophrenia and partial quadriplegia. Interventions included assistance of two or more helpers with bathing/showering due to total dependence on staff. An…

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

Based on observation, interview, record review and review of facility policy, the facility failed to ensure therapeutic activities as scheduled were being provided to residents on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10. #18, #29, #30,#48, #55, #50, #56, #58, #59, #61) who resided on the secured unit. In addition, the facility failed to ensure Resident #20 was provided one-to-one activities of interest, and Resident #50 was provided routine therapeutic activities for socialization. This affected two residents (#20 and #50) of three residents reviewed for activities. The facility census was 64. Findings include: 1. Review of the April 2025 activity calendar posted on the wall in the hallway of the secure unit revealed activities scheduled on the unit for 04/16/25 included chair yoga at 9:00 A.M., chronicles /brain games at 9:30 A.M., games with friends at 10:00 A.M., guess your weight at 10:30 A.M., cards with friends at 1:30 P.M., sit and chat at 2:30 P.M., socialize and snack at 3:00 P.M., and TED talk at 5:30 P.M. Observation on 04/16/25 at…

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

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 smoking materials were in a secured area when not in use for Resident #26 and Resident #41, failed to ensure fall interventions were implemented after a fall for Resident #38, and failed to ensure water was at a safe temperature for Resident #36 and #267. This affected five residents (#26, #41, #38, #36, and #267) of seven residents reviewed for accidents/hazards. The facility census was 64. Findings include: 1. Review of Resident #26's medical records revealed an admission date of 12/02/24. Diagnoses included tobacco use. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and was independent with ambulation. Review of the care plan dated 03/20/25 revealed Resident #26 used nicotine products. Interventions included educate resident on designated smoking area and provide safe smoking devices if required. Review of the smoking assessment dated [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.

Based on medical record reviews, interviews, review of signed arbitration agreements, and review of facility policy, the facility failed to ensure the arbitration agreements were explained in a way the residents understood prior to the residents signing the agreement. This affected five residents (#20, #21, #26, #51 and #214) out of five residents reviewed for arbitration agreements and had the potential to affect all 26 residents (#1, #11, #15, #16, #17, #20, #21, #26,#32, #34, #38, #39, #41, #42, #43, #44, #48, #50, #51, #52, #53, #54,#55,#57,#58, #214) the facility identified as having signed an arbitration agreement. The facility census was 64. Findings include: 1. Review of the medical record for Resident #214 revealed an admission date of 03/25/25. Diagnoses included type two diabetes, obstructive sleep apnea, respiratory failure, morbid obesity, generalized anxiety disorder, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Resident #214 was her own resident representative. Review of Resident #214's admission Minimum Data Set (MDS) 3.0 assessment,…

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

Based on observation, interview, and review of facility policy, the facility failed to ensure all residents at all times on the secured unit were able to communicate their needs using a call system that would relay an audible sound directly to a staff member or to a centralized staff work area on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10, #18, #29,#30, #49, #50, #55, #56, #57, #58, and #61) living on the secured unit. The facility census was 64. Findings include: Observations during an environmental tour on 04/15/25 between 2:02 P.M. and 4:24 P.M. with Director of Plant Maintenance (DPM) #516 revealed when a call light was pressed in Residents #8 and #58's room on the secure unit, the light outside the room lit up but there was no audible sound coming from the call system unit at the nurse's station. Licensed Practical Nurse (LPN) #503 ,who was sitting at the nurse's station where the call system unit was sitting on the counter, confirmed the light outside the room had come on but she heard no audible sound coming from the call system unit. LPN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and review of facility policy, the facility failed to provide a dignified dining experience for all residents. This affected one resident (#23) of five residents reviewed for food/nutrition. The facility census was 64. Findings include: Review of the medical record for Resident #23 revealed an admission date of 11/20/19 with diagnoses including muscle weakness, contracture of muscle of multiple sites, and transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/07/25, revealed Resident #23 had severely impaired cognition for daily decision making and was dependent on staff for eating assistance. Review of the activities of daily living (ADLs) care plan, revised 11/20/24, revealed Resident #23 had an ADL self-care performance deficit related to chronic obstructive pulmonary disease, contractures, weakness, cognitive deficit, and functional deficit. Interventions included total dependence on staff for eating with the helper doing all the effort and the resident doing none of the effort. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review and review of facility policy, the facility failed to ensure privacy with mail correspondence for Resident #41. This affected one resident (#41) of one resident reviewed for privacy with mail. The facility census was 64. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], and was his own responsible party. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Interview with Resident #41 on 04/17/25 at 9:26 A.M. revealed staff opened his mail on several occasions without his permission. The Activity Director #555 who was also present during this interview, confirmed that staff opened resident #41's mail if it looked like insurance or a bill. Interview with the Social Services Designee (SSD) #558 on 04/17/25 at 11:19 A.M. revealed she and the Business Office Manager (BOM) #534 went through 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 interview, the facility failed to ensure the do not resuscitate (DNR) authorization form was completed in its entirety for Resident #51. This affected one resident (#51) of 22 residents reviewed for advanced directives. The facility census was 64. Findings include: Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, acute kidney failure, and major depressive disorder. Review of the uploaded documents in Resident #51's electronic health record revealed a do not resuscitate (DNR) authorization form signed and dated 03/22/24. The patient name, patient address, patient birthdate, and patient gender fields were all blank. The signature of the resident or representative was unable to be deciphered. There was no clear indication on the authorization as to whom the authorization was intended for. On 04/21/25 at 8:58 A.M., an interview with the Administrator verified there was no identifying information on the DNR authorization form and stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Notice of Medicare Non-Coverage was acknowledged by the resident representative for residents with cognitive impairment. This affected two residents (#29 and #57) of five residents reviewed for beneficiary notices. The facility census was 64. Findings include: 1. Review of Resident #29's medical records revealed an admission date of 09/24/24 with diagnosis including dementia. Resident #29 resided on the secured unit, and a niece was listed as Resident #29's representative. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had impaired cognition. Review of Resident #29's Notice of Medicare Non-Coverage revealed a date of non coverage of 10/11/24. Under the additional information section on the document was a hand written note dated 10/09/24 authored by Social Services Designee (SSD) #558 indicating a call was placed to Resident #29's niece and a message was left regarding last of day of coverage of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to ensure admission paperwork was signed as required. This affected one resident (#214) of five residents reviewed for admission. The facility census was 64. Findings include: Review of the medical record for Resident #214 revealed an admission date of 03/25/25 with diagnoses including type two diabetes mellitus, obstructive sleep apnea, respiratory failure with hypoxia, anxiety disorder, and hypertension. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/25, indicated Resident #214 admitted on [DATE] and had no cognitive impairment. Review of the admissions packet provided by the Administrator on 04/22/25 for Resident #214 revealed the admissions agreement, responsible party/resident representative agreement, agreement to arbitrate disputes, assignment of benefits, Medicare secondary payer determination, photograph consent, authorization to share medical information, vendor consultation consent,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and review of facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the residents' status. This affected three residents (Residents #20, #21, and #38 ) out of 22 residents reviewed for accurate MDS assessments. The facility census was 64. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, depression, and pseudobulbar affect. Review of Resident #38's quarterly MDS 3.0 assessment, dated 03/14/25, revealed Resident #38 was moderately impaired cognitively, had inattention behavior which was continuously present and did not fluctuate, was dependent on staff for transfers, did not walk, was dependent on staff to wheel her manual wheelchair, and had no falls since the prior MDS assessment, which was a quarterly assessment dated [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 develop a comprehensive care plan to identify triggers and effective interventions related to a diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #42. This affected one resident (#42) of 22 residents reviewed for care plans. The facility census was 64. Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with a diagnosis of PTSD, anxiety, unspecified psychosis and depression. Resident #42's wife was listed as the resident representative and Power of Attorney (POA) for Resident #42. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS also revealed Resident #42 demonstrated verbal and physical behavior symptoms directed at others one to three days per week. Review of the care plan for Resident #42, with a date initiated of 06/19/23 and 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 observation, record review and interview the facility failed to ensure indwelling urinary catheters were emptied in a timely manner to prevent back flow of urine for Resident #16. This affected one resident (#16) of three residents observed for catheters. The facility identified nine residents (#16, #51, #5, #2, #19, #45, #32, #53 and #31) as having indwelling urinary cathetars. The facility census was 64. Findings include: Review of Resident #16's medical records revealed an admission date of 04/10/24. Diagnoses included need for personal care assistance and open wound of the lower back and pelvis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition. Resident #16 required maximum assistance with toileting and had an indwelling catheter for urination and was incontinent of bowel. Review of the care plan dated 02/28/25 revealed Resident #16 had a urinary catheter. Interventions included provide catheter care every shift and as needed. Review of…

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

Based on record review, interview, and review of facility policy, the facility failed to ensure weekly weights were being obtained as ordered by the physician to monitor nutrition status for Resident #38 and #42. This affected two residents (#38 and #42) out of four residents reviewed for nutrition. The facility census was 64. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, cognitive communication deficit, depression, and severe protein calorie malnutrition. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/25, revealed the resident was moderately impaired cognitively, exhibited continuous inattention behavior; required partial/moderate assistance for eating; had a significant weight loss which was not prescribed; and was on a therapeutic diet. Review of a weight change progress note dated 03/19/25 at 2:54 P.M. revealed Resident #38's 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 observation, interview and record review the facility failed to ensure Resident #26 received proper and physician ordered care of a feeding tube site to prevent potential for skin irritation and infection. This affected one resident (#26) of two residents reviewed for feeding tubes. The facility census was 64. Findings include: Review of Resident #26's medical records revealed an admission date of 12/02/24. Diagnoses included surgical interventions of the digestive system. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the care plan dated 03/20/25 revealed Resident #26 required the use of a feeding tube. Interventions included check placement of feeding tube and monitor tube feedings. Review of physician orders for April 2025 revealed an order dated 12/02/24 to cleanse Resident #26's feeding tube site with normal saline and apply drain gauze at bed time. Observation on 04/21/25 at 12:02 P.M. revealed Resident #26's tube feeding site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, record reviews, and review of facility policy, the facility failed to ensure oxygen tubing was changed weekly. This affected three residents (#5, #20, and #21) out of three residents reviewed for respiratory care. The facility identified eleven residents (#5, #9, #17, #19, #20, #21, #23, #25, #27, #31, and #43) as having a physician order for oxygen. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 12/04/23. Diagnoses included chronic obstructive pulmonary disease (COPD), obesity, and a history of pulmonary embolism. Review of Resident #21's physician orders revealed orders dated 12/05/23 for oxygen at two liters per minute at bedtime for decreased pulse ox (a device used to measure blood oxygen and pulse) and to change oxygen tubing every week and PRN (as needed). Review of Resident #21's care plan, initiated on 03/15/24, revealed the resident had COPD with shortness of breath while lying flat. Interventions included elevate head of bed as needed to prevent shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors. This affected two residents (#35 and #37) of five residents reviewed for medication administration. The facility census was 64. Findings include: 1. Review of Resident #35's medical records revealed an admission date of [DATE]. Diagnoses included dementia and depression Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the care plan dated [DATE] revealed Resident #35 had behaviors that included verbal disagreements with her roommate regarding the television. Interventions included administer medications as ordered. Resident #35 used anti-depressant medications. Interventions included provide medications per physician orders. Review of Resident #35's current physician orders for [DATE] revealed an order to administer Ativan (anti-anxiety medication) one milligram (mg) at bedtime. Review of the progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure lab work had been completed timely and according to physician order. This affected one resident (#15) of two residents reviewed for laboratory services. The facility census was 64. Findings include: Review of Resident #15's medical records revealed an admission date 08/15/23. Diagnoses included dementia, muscle weakness and need for personal care assistance. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. Review of a progress note dated 04/17/25 timed 3:24 P.M. authored by Licensed Practical Nurse (LPN) #566 revealed new orders were received to obtain a urinalysis and blood work. Review of physician orders dated 04/17/25 revealed orders for blood work and urinalysis. Review of the document titled Biomedical Laboratories dated 04/21/25 revealed Resident #15's blood specimen was collected on 04/21/25 and all results for the blood tests were pending. There was no collection for urinalysis.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of the facility diet spread sheet, and review of facility policy, the facility failed to ensure Resident #42 received foods consistent with a dysphagia advanced diet to meet individual needs. This affected one resident (#42) out of four residents reviewed for nutrition. The facility identified six residents (#14, #27, #30, #42,#43, and #266) ordered a dysphagia advanced diet. The facility census was 64. Findings include: Review of the medical record for Resident #42 revealed an admission date of 06/16/23 with diagnoses including Parkinson's disease, dementia, and Alzheimer's disease. Review of Resident #42's physician orders revealed an order dated 01/13/25 for Regular diet, Dys (dysphagia) Adv (advanced) texture, Thin liquids consistency, Fortified hot cereal QD (every day) w/(with) breakfast, Fortified mashed potatoes BID (twice a day) w/ lunch and dinner. Review of Resident #42'S annual Minimum Data Set (MDS), dated [DATE], revealed Resident #42 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the self-reported incident (SRI) tracking number 250524, facility SRI investigation, medical record review, interviews, and facility policy review, the facility failed to prevent staff-to-resident physical abuse for Resident #34. This affected one resident (#34) of three residents reviewed for abuse. The facility census was 56. Findings include: Review of the medical record for Resident #34 revealed an admission date of 07/15/24 with diagnoses including type two diabetes mellitus, unspecified dementia with agitation, hypothyroidism, benign prostatic hyperplasia, ulcerative colitis, presence of an automatic implanted cardiac defibrillator, rheumatoid arthritis, weakness, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/07/24 revealed Resident #34 had severely impaired cognition and was dependent for eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure pharmacy services provided for timely ordering, dispensing, acquiring, and administering of medications to meet the needs of each resident. This affected two residents (Resident #45 and Former Resident #58) out of four residents who were reviewed for medication administration. The facility census was 56. Findings include: 1. Review of the closed medical record for Former Resident (FR) #58 revealed an admission date of 03/25/24 and a discharge date of 07/18/24. admission diagnoses included spondylolysis of the lumbar region, radiculopathy of the lumbar region, dizziness, anxiety, major depression, fibromyalgia, dermatophytosis, post-traumatic stress disorder (PTSD), dissociative and conversion disorder, disorders of the bladder, and postural orthostatic tachycardia syndrome. Review of the care plan dated 03/25/24 revealed FR #58 was at risk for impaired psycho-social well-being related to…

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

Based on observation, interview, medical record review, review of facility policy, and Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum summary, reference number QSO-24-08-NH review the facility failed to ensure proper infection control procedures were implemented and followed for Resident #13. This affected one resident (#13) of three residents reviewed for incontinence care. The facility census was 56. Findings include: Review of the medical record for Resident #13 revealed an admission date of 08/17/24 with diagnoses including left femur fracture, Alzheimer's disease, metabolic encephalopathy, cognitive communication deficit, severe protein-calorie malnutrition, history of falling, acute respiratory failure, dysphagia, and attention to gastrostomy. Review of the Functional Abilities and Goals - Admission assessment completed 08/19/24 revealed Resident #13 was dependent on others for daily self-care. Review of the admission nurses progress note dated 08/17/24 revealed Resident #13 was incontinent of bowel and bladder and received nutrition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to ensure all staff were wearing the appropriate Personal Protective Equipment (PPE) to help prevent the spread of COVID-19 in the facility. This had the potential to affect 32 residents who were not COVID-19 positive (#2, #4, #7, #8, #9, #14, #15, #17, #19, #20, #21, #26, #28, #29, #30, #32, #34, #35, #36, #37, #40, #41, #42, #45, #46, #48, #50, #52, #54, #55, #57,and #58) and residing in the facility at the time of the survey. The facility census was 53. Findings include: Record review of facility line list revealed there were 21 residents (#1, #5, #6, #10, #12, #18, #22, #23, #24, #25, #31, #33, #38, #39, #43, #44, #47, #49, #51, #53 and #56) currently residing in the facility and two employees who tested positive for COVID-19 from 04/05/24 to 04/08/24. Observations made on 04/09/24 upon arrival to the facility at 9:30 A.M. revealed the facility was in a current outbreak of COVID-19 with 23 residents in droplet isolation due to testing positive of COVID-19. The Administrator, receptionist and multiple other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and interviews the facility did not ensure palatable food was served to all the residents eating meals from the kitchen. This had the potential to affect all residents in the facility, with the exception of Residents #4, #17 and #37 the facility identified as consuming nothing by mouth. The facility census was 58. Finding include: Interviews conducted intermittently on 10/31/22 between 9:18 A.M. and 3:33 P.M. with Residents #16, #22, #24, #27, #31, #35, #38, #43, #44, #51, #52 and #53 revealed multiple, pervasive complaints of cold, poor tasting food. Observation was conducted on 10/31/22 beginning at 10:30 A.M. of [NAME] #855 preparing the lunch meal which consisted of breaded fish on bun, marinated chicken thighs, seasoned green beans, potato wedges, rice pilaf and dinner rolls. [NAME] #855 pureed the fish for residents requiring pureed diets and during the pureeing process, added juice from the green beans to the pureed fish. She verified she used green bean juice to add moisture to the pureed fish. Cook #855 was observed to start lunch meal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the infection control log/antibiotic stewardship program and interview the facility failed to implement a comprehensive antibiotic stewardship program. This affected three residents (#14, #57, and #222) of three residents reviewed for infections and had the potential to affect all 72 residents residing in the building. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 09/04/19 with diagnoses including epilepsy, unsteadiness on feet and schizophrenia. Review of the infection surveillance log revealed that while at the hospital on [DATE] the resident was started on an antibiotic, Bactrim for a urinary tract infection (UTI). The section on the log indicating what organism the culture grew was left blank on the form. Review of the December 2019 Medication Administration Record (MAR) revealed Bactrim DS 800-160 milligrams (mg) was given every 12 hours for 10 days for a UTI. Interview on 02/13/20 at 1:09 P.M. with Registered Nurse (RN)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice Form (SNF ABN) Form CMS-10055 was provided to Resident #14 and #71 as required. This affected two residents (#14 and #71) of three residents reviewed for liability notices. The facility census was 72. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. On 10/06/2019 Resident #14 was placed under skilled traditional Medicare part A services. The facility issued a Notice of Medicare Non-Coverage form (NOMNC) for a last skilled Medicare day of 12/16/2019. Review of the facility provided forms revealed a SNF ABN form was not provided at the time the NOMNC was issued. 2. Resident #71 was admitted to the facility on [DATE]. On 10/16/2019 Resident #71 was placed under skilled traditional Medicare part A services. The facility issued a Notice of Medicare Non-Coverage form (NOMNC) for a last skilled Medicare day of 11/04/2019. Review of the facility provided forms revealed…

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

Based on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASSAR) were accurate to contain diagnosis of serious mental disorders. This affected three resident (#10, #21 and #29) of five residents reviewed for PASSAR. Findings include: 1. Review of Resident #29's medical record revealed an admission dated of 06/09/17. Review of the diagnoses included a 02/01/17 major depressive disorder with severe psychotic symptoms, 04/12/18 diagnosis of unspecified psychosis not due to a substance or known physiological condition and 07/01/18 generalized anxiety disorder. A PASSAR dated 04/17/13 had a determination of no indication of serious mental illness. The PASSAR was coded yes for depression and faxed to the facility 06/09/17. Record review revealed no updated PASSAR that included the diagnosis of psychosis and anxiety. Interview on 02/11/20 at 03:47 P.M. with Social Service #10 verified there was not a PASSAR completed for the resident including the diagnoses of psychosis and anxiety. 2. Review of Resident #21's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure residents who were dependent on staff for personal care received adequate and timely nail care. This affected three residents (#3, #43, and #172) of five residents reviewed for actives of daily living. The facility census was 72. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, muscle weakness, and unspecified convulsion. Review of Resident #3's care plan dated 11/26/19 revealed the resident had a self care deficit related to personal care, the facility was to maintain proper hygiene and staff were to provide total assistance with care. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment, dated 1/27/20 revealed the resident required total dependence on staff for personal hygiene. Observation on 02/11/20 at 2:10 P.M. of Resident #3 revealed he had very long fingernails and he was unable to cut them himself. Interview on 02/11/20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to ensure Resident #14 received adequate and as ordered care for treatment related to a fracture. This affected one resident (#14) of one resident reviewed for injuries of unknown origin. Findings include: Review of Resident #14's medical record revealed an admission date of 09/04/19 with diagnoses including, epilepsy, unsteadiness on feet and schizophrenia. Review of a 12/26/19 hospital note revealed the resident suffered a fracture to his middle phalanx of the right digit. Review of Resident #14's December 2019 physician's order revealed an order, dated 12/31/19 that stated may buddy tape fingers if resident wont keep splint in place. Review of the resident's February 2020 Medication Administration Record revealed splint to right hand for fracture. The record also revealed may buddy tape fingers if the resident wont keep splint in place. The record revealed documentation of the devices being in place each shift from 02/01/20 to 02/12/20. Observations on 02/12/20 at 2:52 P.M., 02/13/20 at 8:44 A.M. and 02/13/20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to ensure a splinting device was provided as planned for Resident #29 who had a left wrist/hand/finger contracture. This affected one resident (#29) of three residents reviewed for positioning. Findings include: Review of Resident #29's medical record revealed an admission date of 06/09/17 with diagnoses including major depressive disorder with severe psychotic symptoms, hemiplegia affecting left non dominant side and polyneuropathy. Review of a 08/30/17 Occupational Therapy Discharge note revealed a Left Wrist, Hand, Finger Orthosis (WHFO) was to be used for the resident at night in bed. Review of the 01/01/20 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, had verbal behaviors one to three days a week, was totally dependent on two staff for bed mobility, required extensive assist from two staff for transfers, and extensive assistance from two staff for personal hygiene. The MDS assessment revealed the resident had upper and lower extremity…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and interview the facility failed to ensure nebulizer treatments were maintained under sanitary conditions and oxygen humidification was provided for Resident #43. This affected one resident (#43) of four residents reviewed for respiratory care. Findings include: Review of Resident #43's medical record revealed an admission date of 10/11/19 with diagnoses including type 2 diabetes, atherosclerotic heart disease, escherichia coli, altered respiratory failure, acute kidney failure and osteomyelitis. Review of the 12/09/19 oxygen therapy plan of care revealed the resident required oxygen related to congestive heart failure, ineffective gas exchange and respiratory illness. Review of the physician's orders revealed an order dated 12/10/19 for DuoNeb Solution 0.5-2.5 milligrams/in 3 milliliter (MG/ML) (Ipratropium-Albuterol) one International Unit Dose (IUD) inhale orally via nebulizer every four hours related to acute respiratory failure with hypoxia and 12/17/19 order for oxygen at three liters per minute (LPM) continuous every shift. Review of the…

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

Based on observation, record review and interview the facility failed to ensure Resident #26 received routine dental care. This affected one resident (#26) of two residents reviewed for dental care. Findings include: Review of Resident #26's revealed an admission date of 06/13/17 with diagnoses including anxiety disorder, hypertension, weakness, bipolar disorder, post traumatic stress disorder and hyperlipidemia. The resident signed the dental consent 06/13/17 he wanted he wanted to receive dental services. A new dental provider form was signed 09/16/19 for a new company. Review of the annual 03/22/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident had obvious or likely cavity or broken natural teeth. Review of the 12/13/19 quarterly MDS 3.0 assessment revealed the resident was independent for daily decision making and required supervision set up for personal hygiene. Observation on 02/11/20 at 08:35 A.M. revealed Resident #26 was in bed. Observation of the resident's mouth revealed the resident had white built up around the gum line. Interview on 02/11/20 at 08:57 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.