Atrium Nursing and Rehabilitation

Based on observation, staff interview, review of a facility census document, medical record review, review of water temperature logs, and facility policy review, the facility failed to ensure hot water temperatures were maintained in a safe manner. This affected 13 (#1, #2, #3, #4, #5, #6, #7, #10, #14, #15, #16, #17, and #18) of 19 residents that resided at the facility. The facility census was 19. Findings include: Observation of Maintenance Aide (MA) #244 taking the water temperatures on 06/22/25 at 10:19 A.M. revealed the hot water temperature in the 600 shower room was 136.4 degrees Fahrenheit (F), the hot water temperature in Resident #1 and Resident #10's room was 134.7 degrees F, the hot water temperature in Resident #2's room was 135.9 degrees F, the hot water temperature in Resident #3's room was 134.6 degrees F, the hot water temperature in Resident #4's room was 136.6 degrees F, the hot water temperature in Resident #5's room was 134.1 degrees F, the hot water temperature in Resident #6's room was 133.4 degrees F, the hot water temperature in Resident #7's room was 136.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of resident trust documentation, review of a resident census report, and medical record review, the facility failed to ensure residents whose care was funded by Medicaid had personal funds in excess of fifty dollars ($50.00) deposited and held in an interest bearing account. This affected one (#8) of four residents reviewed for resident funds accounts. The facility census was 19. Findings include: Review of Resident #8's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, psychotic disorder with delusions due to known physiological condition, anxiety disorder, major depressive disorder, and hypertension. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #8's resident funds authorization dated 12/04/23 revealed Resident #8's guardian authorized the facility to hold, safeguard,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, review of shower schedules, review of shower sheets, resident and staff interview, and review of the Resident Assessment Instrument manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one (#13) of five residents reviewed for accurate MDS assessments. The facility censes was 19. Findings included: Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hallucinations and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had intact cognition. Resident #13 required set up for eating, was dependent for toileting, and required moderate assistance for bed mobility. Resident #13 was not coded with any rejections of care during 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, staff interview, and review of a facility policy, the facility failed to ensure wound care on a resident's surgical wound was completed based on the physician's order. This affected one (#10) of one resident reviewed for surgical wounds. The facility census was 19. Findings include: Review of Resident #10's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, unspecified protein calorie malnutrition, chronic multifocal osteomyelitis, asthma, anxiety disorder, frostbite with tissue necrosis of the left foot, alcohol abuse, peripheral vascular disease, and gangrene. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and the resident required moderate assistance with showers. Resident #10 was independent with eating, rolling left and right, sitting to lying, and lying to sitting and required set up assistance 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 medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure application of prescribed foot care treatments were completed as ordered. This affected one (#18) of one residents reviewed for prescribed foot treatments. This facility census was 19. Findings included: Medical record review for Resident #18 revealed an admission of 01/18/24 with diagnoses including but not limited to paroxysmal atrial fibrillation, mild neurocognitive disorder without behaviors, cerebral infarction without residual residual, hypertension, late syphilis latent, and myocardial infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed the resident had an intact cognition. Resident #18 was coded with behaviors including rejection of care four to six days in the assessment period. Resident #18 was assessed to require supervision for eating, toileting, personal hygiene, bed mobility, and transfers. Resident #18 had no skin…

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 provided medication administration time verification document, staff interview, and review of a facility policy, the facility failed to ensure medications were administered within prescribed timeframes. This affected one (#7) of one resident reviewed for pain medication administration. The facility census was 19. Findings include: Review of the medical record for Resident #7 revealed an admission date of 12/28/18 with diagnoses of quadriplegia, morbid (severe) obesity due to excess calories, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, required supervision assistance with eating, required partial assistance with oral hygiene, required substantial assistance with bed mobility, and was dependent on staff assistance with toileting hygiene, bathing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner. This affected one (#9) of five residents reviewed for unnecessary medications. The facility census was 19. Findings include: Review of Resident #9's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting the right non-dominant side, cerebral infarction, insomnia, schizoaffective disorder bipolar type, generalized anxiety disorder, conversion disorder with seizures or convulsions, bipolar disorder, and Behcet's disease. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #9's physician order dated 12/16/24 revealed the resident was ordered the narcotic pain medication tramadol 50 milligrams (mg) every eight hours as needed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, hospice staff interviews, hospice contract review, and facility policy review, the facility failed to ensure collaboration with hospice providers for resident care. This affected two (#1 and #13) of two residents reviewed for hospice care. The facility census was 19. Findings include: 1. Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hypertension, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had an intact cognition. Resident #13 required set up for eating, was dependent for toileting, required moderate assistance for bed mobility, and transfers were not applicable. Resident #13 was coded as receiving hospice services during the look back period.…

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

Based on record review, staff interview, review of the Legionella Environmental Risk Assessment, review of the Water Management Plan, review of the Legionella Control measures and Monitoring, review of water temperature logs, review of weekly monitoring logs, review of the online resources from the Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to follow their Water Management Plan and Legionella Risk Assessment. This had the potential to affect all 18 residents who resided in the facility. The facility census was 18. Findings include: Review of the Water Management Plan-Legionella, dated 11/2021, revealed the facility would establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system by having proactive endeavors to establish and maintain a healthy, infection free environment for the residents, staff and visitors. The facility would develop, implement and maintain an infection prevention and control program in order to prevent, recognize, and control 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, staff interview, and review of facility policy, the facility failed to provide a clean and homelike environment. This had the potential to affect all 18 residents residing on the secured behavioral unit. The facility census was 18. Findings included: Observation of the common areas of the secured behavioral unit on 02/03/25 at 10:15 A.M., revealed a fur like material and dirt hanging off of the large heat register/vents affixed to the walls. The floors throughout the unit were soiled and appeared dirty. Observation of the secured behavioral unit on 02/05/25 at 8:22 A.M. with the Registered Nurse (RN) #127, revealed an unlocked, unoccupied resident room with multiple stacks of supplies that ran the entire length of the room and numerous boxes were stacked to the ceiling. There were multiple trash bags of unopened incontinence briefs, trash and various debris scattered throughout the floor, and large metal rails leaned up against the walls. Interview with RN #127 at same time, verified the condition of the room. RN #127 stated the unoccupied, resident's room 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 staff interviews and record review, the facility failed to convey resident funds within 30 days of residents being discharged from the facility. This affected three Residents (#87, #88 and #89) out of the five residents reviewed for conveyance of personal funds. The facility census was 18. Findings include: 1) Review of the medical record for Resident #87 revealed the resident was admitted to the facility on [DATE]. Diagnoses included gout, congestive heart failure, generalized anxiety disorder, paranoid schizophrenia, major depressive disorder, muscle weakness, and hypothyroidism. Resident #87 discharged from the facility on 08/30/24. Review of a Resident Funds Authorization, for Resident #87 dated 03/20/23, revealed the authorization was signed by Resident #87's responsible party. The authorization was also witnessed by a non-employee. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #87 was cognitively intact. Review of a progress note for Resident #87 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 record review, and staff interview, the facility failed to ensure residents' advanced directives were updated and accurate in the medical record. This affected one Resident (#30) out of the two residents reviewed for advanced directives. The facility census was 18. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, hemiplegia, bipolar disorder, gastro-esophageal reflux disease (GERD), bipolar disorder, essential primary hypertension, hyperlipidemia, anxiety disorder, hypothyroidism, diabetes mellitus (DM), insomnia, schizoaffective disorder, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Review of a physician order dated 11/19/24 for Resident #30, revealed the resident was ordered to be Do Not Resuscitate Comfort Care (DNR-CC). Review of an DNR-CC paper form dated 11/19/24 and signed by the physician, revealed Resident #30 was marked as a DNR-CC. 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 observations, staff interviews, record review, and review of facility policy, the facility failed to provide a comfortable, safe, and homelike environment. This affected three Residents (#25, #30 and #29) of three residents reviewed for environment. The facility census was 18. Findings include: 1) Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, anemia, schizoaffective disorder bipolar type, homicidal ideations, auditory hallucinations, psychotic disorder with delusions due to a known physiological condition, hyperlipidemia, hypertension and mood disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #25 dated 10/26/24, revealed Resident #25 was cognitively intact, and required supervision for activities of daily living (ADLs). Observation of Resident #25's bathroom on 02/03/25 at 9:51 A.M., revealed Resident #25's bathroom had an approximately one foot in length by one foot in width…

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, staff interviews, and review of facility policy, the facility failed to ensure residents, and their representatives were offered and received care conferences or the ability to participate in care planning. This affected two Residents (#18 and #19) out of the two residents reviewed for participation in care planning and care conferences. The facility census was 18. Findings include: 1) Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included psychotic disorder with delusions due to known physiological condition, major depressive disorder, generalized anxiety disorder, schizoaffective disorder and insomnia. Review of medical record from 08/22/24 to 02/04/25 revealed there was no documentation that Resident #18 or her guardian were offered or received a care conference. Review of the annual Minimum Data Set (MDS) assessment dated [DATE]. revealed Resident #18 was cognitively intact and required supervision for Activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to obtain signed refusal forms for vaccinations and failed to obtain any information related to prior immunizations and vaccinations for newly admitted residents. This affected two Residents (#08, and #13) out of five Residents reviewed for immunizations and vaccinations. The facility census was 18. Findings Include: 1) Review of the medical record for Resident #08 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, schizophrenia, hyperlipidemia, diabetes mellitus (DM), gastro-esophageal reflux disease (GERD), and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 01/09/25, revealed Resident #08 had impaired cognition. Review of Resident #08's vaccination record, revealed the resident was documented as refusing an influenza vaccine on 11/07/24, the respiratory syncytial virus (RSV) vaccination on 03/07/24 and the pneumococcal bacteria vaccination 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.

Based on record review and staff interview, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of the staffing schedules revealed there was no RN scheduled on the following dates: 07/07/24, 07/11/24, 07/15/24, 07/16/24, 07/20/24, 07/21/24, 07/25/24, 07/26/24, 07/29/24, 07/31/24, 08/03/24, and 08/04/24. Interview on 08/08/24 at 3:56 P.M., the Director of Nursing (DON) confirmed the facility did not have an RN working for eight consecutive hours on the following dates: 07/07/24, 07/11/24, 07/15/24, 07/16/24, 07/20/24, 07/21/24, 07/25/24, 07/26/24, 07/29/24, 07/31/24, 08/03/24, and 08/04/24.

Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 41 residents who resided in the facility. Findings include: 1) Observation on 08/08/24 at 10:48 A.M., revealed a fly swatter on a cart next to the oven. Interview at the same time, District Dietary Manager (DDM) #400 verified the fly swatter was on the cart next to the oven. Observation on 08/08/24 at 12:07 P.M. revealed three flies continuously flying above and around the steam table. Interview on 08/08/24 at 12:08 P.M., [NAME] #405 verified the flies were present and stated flies were always in kitchen. 2) Observation on 08/08/24 at 10:49 A.M., revealed a puddle of water, measuring approximately one foot by four feet below the three-compartment sink. Dietary Manager (DM) #410 took a mop and cleaned up the water from the floor. Interview on 08/08/24 at 10:51 A.M., [NAME] #405 verified the puddle below the three -compartment sink and stated every time he washed dishes, the sink leaked. [NAME] #405…

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 facility's mold testing results, physician interview, review of Quality Assurance and Performance Improvement (QAPI) documentation, and staff interview, the facility failed to inform Medical Director (MD) #500 of high levels of mold discovered in the facility. This had the potential to affect all the residents of the facility. The census was 41. Findings include: Review of an Environmental and Residential Microbial Inspection Report dated 05/13/24, revealed the facility was inspected for mold on 05/08/24 by a mold testing speciality company. The areas tested for mold revealed the following areas: a) room [ROOM NUMBER] (unoccupied). b) 200 Hall shower room. c) 300 hallway. d) Therapy room. e) A common area. f) The main dining room. The mold readings in these areas were compared to readings from outside the facility. The results in the tested areas revealed higher levels of mold than outside of the facility and mold remediation was required to be completed. Review of QAPI meeting documents dated…

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

Based on observation, staff interview, review of facility audits, and review of operation manuals, the facility failed to ensure essential equipment was maintained in a safe and properly functioning manner. This had the potential to affect all residents in the facility. The facility census was 41. Findings include: 1) Observation on 08/08/24 at 10:36 A.M., revealed an ice machine at the entrance to the 200 hall, had a wet blanket laying under it with a puddle of water, which extended beyond the area of the blanket. Water was observed dripping onto the floor from the bottom of the machine. Interview at the same time, State Tested Nursing Assistant (STNA) #308 verified the wet blanket over the puddle of water. STNA #308 picked up the wet blanket and walked away from the area. Observation on 08/08/24 at 12:33 P.M., revealed another puddle of water had formed below the ice machine. Interview at the same time with Licensed Practical Nurse (LPN) #317, verified the presence of the puddle of water below the ice machine. LPN #317 verified the ice machine was leaking from the bottom. 2)…

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, mold testing company interview, staff interview, and review of the facility's mold testing results, the facility failed to abate and remediate the presence of mold in the facility and the facility failed to ensure residents were provided with a clean, safe, homelike environment. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of an Environmental and Residential Microbial Inspection Report dated 05/13/24, revealed the facility was inspected for mold on 05/08/24 by a specialty mold testing company. The areas tested in the facility for mold were room [ROOM NUMBER], the shower room on the 200-hall, the 300-hallway, the therapy room, a common area, and the main dining room. The mold readings in these areas were compared to mold readings from outside the facility. The results in the tested areas revealed higher levels of mold than outside of the facility and mold remediation was required. The following remediation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, resident and staff interviews, review of the facility policy, the facility failed to provide a clean and safe environment for residents. This affected 12 (#28, #69, #32, #33, #35, #36, #17, #02, #03, #05, #06 and #07) residents out of 12 residents reviewed. The facility census was 71. Findings include: Record review for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis, hypothyroidism, chronic obstructive pulmonary disease (COPD), diabetes mellitus, anxiety disorder, morbid obesity, post-traumatic stress disorder (PTSD), and chronic respiratory failure. Resident #28 was cognitively intact. Record review for Resident #69 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction (stroke), anxiety disorder, depression, hyperlipidemia, essential primary hypertension, obesity, and bipolar disorder. Resident #69 was cognitively intact. Record review for Resident #32 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, observations and resident and staff interviews, the facility failed to provide a safe environment for residents. This affected three (#39, #40, and #41) out of four residents sampled for the physical environment and the potential to affect all independently ambulatory residents 100 hallway (#04, #05, #06, #07, #08, #11, #12, and #13). The census was 72. Findings include: 1. Observations on 03/11/24 at 1:46 P.M. revealed a wooden pallet leaning against the wall and hand railing in the 100 hall. A deflated bed air mattress was sitting on the floor beside the pallet. Observation and interview with the Director of Nursing (DON) on 03/11/24 at 2:42 P.M. confirmed the wooden pallet and deflated bed air mattress in the 100 hall. The DON stated it was unacceptable and would be a hazard to ambulatory residents. Review of facility provided documentation revealed 100 hall Residents (#04, #05, #06, #07, #08, #11, #12, and #13) were independent with ambulation. 2. Review of Resident #39's medical record revealed an admission date of 10/31/22. Diagnoses listed included…

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, staff interview, and review of facility policy, the facility failed to have an effective pest control program. This affected four (#05, #06, #07, and #08) out of four residents reviewed for pest control. The census was 72. Findings include: Review of Resident #05's medical record revealed an admission date of 04/19/23. Diagnoses listed included major depressive disorder, paranoid schizophrenia, bipolar disorder, and psychotic substance abuse disorder. Review of Resident #06's medical record revealed an admission date of 01/20/23. Diagnoses listed included disorganized schizophrenia, metabolic encephalopathy, and alcohol abuse. Review of Resident #07's medical record revealed an admission date of 07/20/20. Diagnoses listed included schizoaffective disorder, dementia, muscle wasting and atrophy, hypertension, anxiety disorder, and epilepsy. Review of Resident #08's medical record revealed an admission date of 01/25/23. Diagnoses listed included Parkinson's disease, schizophrenia, dementia, anxiety disorder, and hypertension. Observation on 03/11/24…

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 staff interview, the facility failed to provide a comfortable, safe, and homelike environment by ensuring the residents had hot water. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72. Finding include: Review of the plumbing contractor proposal dated 01/18/24 revealed the facility was quoted $15,243.00 to replace a water heater. Review of a second plumbing contractor proposal dated 01/24/24 revealed the facility was quoted $12,500.00 to replace a water heater. Review of facility's water temperature documentation dated 02/15/24 revealed the water temperature on the secured unit ranged from 75 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's water temperature documentation dated 02/28/24 revealed the water temperature on the secured unit ranged from 80 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's…

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

Based on observations, resident and staff interviews and review of facility policy, the facility failed to maintain essential equipment to provide hot water to the residents. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72. Finding include: Review of the plumbing contractor proposal dated 01/18/24 revealed the facility was quoted $15,243 to replace a water heater. Review of a second plumbing contractor proposal dated 01/24/24 revealed the facility was quoted $12,500 to replace a water heater. Review of facility's water temperature documentation log dated 02/15/24 revealed the water temperature on the secured unit ranged from 75 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's water temperature documentation log dated 02/28/24 revealed the water temperature on the secured unit ranged from 80 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's…

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

Based on observation, record review and staff interview, the facility failed to ensure an egress door's push bar was maintained and working properly on the secured behavioral unit. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72. Findings include: Observation of the secured unit's interior egress right side door on 03/04/24 at 7:47 A.M. revealed the door had a sign which indicated Push until alarm sounds - Door can be opened in 15 seconds. The door did not have a push bar to exit the unit to the main common area of the facility, but the door was noted to have two gold pieces attached to the right door where the push bar had previously been attached to the door. Further observation of secured unit revealed State Tested Nurse Aide (STNA) #801 was pulling the metal lip open on the left door to exit the unit instead of pressing on the right door that had the missing push bar.…

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

Based on observation and staff interview, the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect 28 Residents (#2, #4, #5, #7, #8, #9, #10, #11, #12, #13. #14, #15, #16, #17, #18, #19, #20, #21, #23, #24, #25, #26, #28, #29, #32, #33, #34, and #35) who were able to access a common/dining area. The census was 59. Findings include: Entrance conference interview with the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #150 on 12/13/23 at 1:45 P.M. revealed the facility's central heating was not operating adequately. Portable electric space heaters were being used in some resident areas. Observation during tour the facility with the Administrator, DON, and Maintenance Supervisor (MS) #100 on 12/13/23 from 1:55 P.M. to 2:10 P.M. revealed two portable electric space heaters being used in the common/dining area located between resident halls. Observation and interview with MS #100 on 12/13/23 at 2:58 P.M. revealed one portable electric space heater in the common/dining…

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 interviews, and review of a plumbing company repair estimate, the facility failed to ensure a clean and sanitary kitchen due to a substance backing up through a drain in a kitchen closet. This had the potential to affect all the residents in the facility except one resident (#70) who did not receive food from the kitchen. The facility census was 59. Findings included: Observation on 01/02/24 at 12:15 P.M. of the facility kitchen revealed a closet located in the kitchen which contained roasters, baking pans, and other dishes on shelves. The observation revealed 75% of the closet floor was coated in a tarnish-orange substance that was about one-inch thick in width. The substance was noted to have large clumps of debris and a foul odor. Interview on 01/02/24 at 12:16 P.M. with Dietary Manager #175 stated she had been with the facility since October 2023 and the substance in the closet had been coming up through a drain weekly since she started at the facility. Dietary Manager #175 stated the kitchen staff would clean up the substance with towels as time…

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

Based on medical record review, staff and resident interviews, and interview with receptionist at wound clinic, the facility failed to ensure resident was seen by the wound clinic physician as scheduled. This affected one resident (#34) out of the three residents reviewed for wound care. The facility census was 59. Findings included: Review of the medical record for Resident # 34 revealed an admission date of 02/27/23 with medical diagnoses of insomnia, post-traumatic stress disorder (PTSD), diabetes mellitus (DM) with foot ulcer, hypertension, and anxiety. Review of the medical record for Resident #34 revealed a quarterly Minimum Data Set (MDS) 3.0, dated 10/07/23, which indicated Resident #34 was cognitively intact and required set-up assistance with eating and toilet hygiene and was independent with bed mobility and transfers. The MDS indicated Resident #34 had a diabetic foot ulcer with dressing changes noted. Review of the medical record for Resident #34 revealed a physician order, dated 08/29/23, to refer to wound clinic related to non-healing chronic diabetic foot ulcer.…

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 clinical record review, staff interviews, observations, and policy review, the facility failed to provide adequate supervision to prevent a resident's elopement and failed to timely identify the root cause of the resident's elopement. This affected one (Resident #1) of three residents reviewed for elopement. The facility identified 29 residents residing on the secured unit. The facility census was 63. Findings include: Clinical record review for Resident #1 revealed an admission date of 09/14/23 with diagnoses including schizophrenia, bipolar disorder, non-insulin diabetes mellitus, and obesity. Resident #1 was responsible for himself and had a brother listed as a contact person. Resident #1 resided on the secured unit during his stay from 09/14/23 to 10/11/23. Review of an elopement assessment dated [DATE] revealed Resident #1 was not an elopement risk. Review of the care plan initiated 09/15/23 revealed Resident #1 refused bathing, hygiene, blood sugar monitoring, and medications at times. He 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 observation and staff interviews, the facility failed to ensure the phone system was working properly. This had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings include: Observation on 10/02/23 revealed when calling the facility, an automated message answered and gave the option to press one for admissions, two for nursing, three for the Administrator, and zero for immediate assistance. At 2:04 P.M. option one was chosen, with no answer and they automated message stated extension 110 was unavailable and the mailbox was full. A second call was placed at 2:06 P.M. the automated message answered and option two was chosen, the message stated extension 110 was unavailable and the mailbox was full. A third call was placed at 2:21 P.M. and the automated message answered and option zero was chosen, the message stated extension 110 was unavailable and the mailbox was full. At 2:23 P.M. the automated message answered and option three was chosen, the message stated extension 110 was unavailable and the mailbox was full. At 2:24…

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 staff interview and review of personnel files, the facility failed to ensure dietary staff were trained and competent to perform the job duties prior to beginning employment. This had the potential to affect all 68 residents residing in the facility. Facility census was 68. Findings include: Interview on 10/03/23 at 9:12 A.M. with Kitchen Staff #37 revealed the first time he worked at the facility was on 09/22/23 he had his Tuberculosis (TB) testing and background checks prior to working. Kitchen Staff #37 confirmed when he worked on 09/22/23 he did not fully complete the facility orientation to work in the kitchen. The facility confirmed all 68 residents receive their meals from the kitchen. Interview on 10/03/23 at 11:13 A.M. with Human Resources (HR) #42 revealed Kitchen Staff #37 was hired on 09/07/23 and went through the entire process of TB testing, background check, physical and then we never heard from the staff member. HR #42 stated the facility thought Kitchen Staff #37 decided not to take the dietary position he was hired for, and then on 09/22/23 he just showed…

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 staff interviews, the facility failed to ensure recipes were followed. This had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings include: Interview on 10/03/23 at 8:32 A.M. with Kitchen Staff #31 revealed for breakfast she prepared an egg, sausage and cheese casserole. Kitchen Staff #31 stated she could not find the egg and sausage strata recipe, nor the serving size or scoop size, as she pointed to four large binders on the counter, so she Googled the recipe. Kitchen Staff #31 added the recipe called for bread, and since they were already serving wheat toast, she altered the recipe to keep the bread out. Interview and observation on 10/03/23 at 1:17 P.M. with Dietary Manager (DM) #32 revealed after some effort she was able to find the egg and strata recipe in the large binder she brought along. DM #32 verified the proper recipe and proper utensil was not used for serving. DM #32 shared her company would provide production sheets with recipes adjusted for required servings. The egg and strata sheet 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 observation and staff interviews, the facility failed to ensure a physical environment was maintained in a safe and sanitary manner regarding the presence of a black substance on the wall in the laundry room. This had the potential to affect all 68 residents residing in the facility. Additionally, the facility also failed to ensure a homelike environment was maintained regarding a sticky substance on the floors and a towel around a toilet to catch urine. This affected three residents (#18, #19 and #20) out of three residents sampled for comfortable living environment. Facility census was 68. Findings include: 1. Interview on 10/02/23 at 1:48 P.M. with Laundry Staff #36 verified awareness of mold in the laundry area. At 2:08 P.M. observation of the laundry area revealed an approximate four foot by six-foot area behind the washing machines of multiple, scattered, splotchy blackened areas. Laundry Staff #36 revealed the area had been repaired in the past and added the workers did not do a very good job. Interview and observation on 10/04/23 at 11:12 A.M. with Maintenance Staff…

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, resident and staff interviews, the facility failed to maintain air conditioning equipment to keep resident rooms at a comfortable temperature. This affected one (#17) out of three residents sampled for comfortable room temperatures. Facility census was 68. Findings include: Interview and observation on 10/04/23 at 10:29 A.M. with Resident #17 revealed the wall unit air conditioner in the room was not on and there was a small (approximately three feet by 1.5 feet) portable air conditioning unit in front of it. A four-foot oscillating fan was beside the bed across from Resident #17 and her room mate who were sitting in their wheelchairs. The room was noticeably warmer than the hall and other resident rooms. Resident #17 shared the wall unit air conditioner had been broken all summer, and she had purchased the fan to help keep her cool. Resident #17 acknowledged she found it hard to sleep some nights because of the heat. Observation on 10/04/23 at 10:34 A.M. revealed Maintenance Staff #38 checked the temperature of Resident #17's room with a digital thermometer…

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 and resident interviews, the facility failed to ensure resident call lights were working correctly. This affected three (#17, #21 and #22) out of three residents residents sampled for functioning call lights. Facility census was 68. Findings included: Interview and observation on 10/03/23 at 8:18 A.M. with Resident #22 revealed his call light did not work. Resident #22 pressed the call button and no light was observed on the call box, and the light on top of the room door did not light. Resident #22 was unsure how long it had been broken. Interview on 10/03/23 at 9:26 A.M. with Maintenance Staff #38 revealed he was aware of several call lights that were not working, and the facility had contacted an outside company to provide the repairs. Interview on 10/03/23 at 10:42 A.M. with the Maintenance Manager #57 revealed he was aware several call lights were not working. Maintenance Manager #57 explained the facility was an old building, with an old system and an outside company had been contacted for repairs. Maintenance Manager #57 stated the rooms affected…

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

Based on personnel file review, review of the job description, and staff interview, the facility failed to ensure the Dietary Manager met the qualifications to be a dietary manager. This had the potential to affect 72 of 72 residents who receive meals from the kitchen. The facility census was 72. Findings include: Review of the personnel file for Dietary Manager (DM) #282 revealed he was promoted from [NAME] to Dietary Manager on 07/05/23. There was no documentation in DM #282's employee file that indicated he met one of the qualifications to be a dietary manager. Interview on 08/24/23 at 10:55 A.M., with DM #282 confirmed he did not have the certification required for the Dietary Manager position. Interview on 08/23/23 at 2:26 P.M., with the Registered Dietician (RD) #300 confirmed she was a contracted employee who was scheduled to work one day per week at the facility. Interview on 08/24/23 at 4:29 P.M. with the Administrator confirmed she was not aware that DM #282 did not have certification for the Dietary Manager position. Review of the facility undated job description titled…

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

Based on observations, menu review, record review of Registered Dietitian (RD) reports, policy review, RD interview and staff interview, the facility failed to follow the facility menus to ensure the residents received nutritional meals to meet their needs as approved by the RD. This had the potential to affect 72 of 72 residents who received food from the kitchen. The facility census was 72. Findings include: Review of the Food Preparation, Meal Service and Dining Observation dated 07/31/23 revealed Registered Dietitian (RD) #300 noted menus, recipes, and spreadsheets were not available for therapeutic diets. Review of the Dietitian Quality Assurance Report dated 07/31/23, revealed RD #300 reported concerns with menus, dietary recommendations, and modified diets. Comments included the kitchen did not have access to menus or knowledge of options for therapeutic diets (i.e., carbohydrate controlled, renal, reduced sodium, etc.). Review of the facility's RD approved menu dated 08/23/23 revealed the facility lunch meal revealed the following was to be served: 3/4 cup of Korean barbeque…

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 of menus, resident interviews, staff interviews, resident council minute review, policy review, the facility failed to ensure food was served at an appetizing and safe temperature and acceptable palatability. This had the potential to affect 72 of 72 residents who received meals in the facility. The facility census was 72. Findings include: Review of the facility's Resident Council Meeting Notes, dated 05/03/23, revealed there were multiple concerns regarding food temperatures and hot food items delivered cold. On 06/26/23, the notes revealed the food was being sent out cold and on 08/01/23, the residents requested better food options, a request for fried chicken, and more salads. Observation on 08/23/23 of the tray line for the lunch meal from 12:25 P.M. to 12:50 P.M., revealed Dietary [NAME] (DC) #254 served one grilled cheese, broccoli, and cauliflower medley, coleslaw, and an oatmeal cookie. DC #254 stated he was unable to take the temperatures of the food items for the lunch meal because he does not have a working food thermometer. Interview…

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, policy review, public health department inspector interview and staff interview, the facility failed to prepare and store food to prevent food born illness and maintain a clean and sanitary kitchen area. This had the potential to affect 72 of 72 residents who receive meals from the facility. The facility census was 72. Findings include: Observations on 08/23/23 from 10:00 A.M. to 11:00 A.M., during tour of the kitchen, with Dietary Aide (DA) #250 and DA #251, revealed the standing refrigerator (refrigerator #01) contained a large clear container with an unknown type of meat salad (i.e., chicken, tuna) with no label or date. DA #250 confirmed the large container of unknown meat salad was not labeled or dated. Review of the second refrigerator (refrigerator #02) revealed a thermometer on the outside of the refrigerator reading over 60 degrees Fahrenheit and did not contain a second thermometer on the outside of the refrigerator. DA #250 stated the public health advised the facility to throw out all the milk because the refrigerator #02 was not working 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.