Lincoln Knolls Health & Rehab LLC

Based on observation, record review, interview, and facility policy review, the facility failed to provide appropriate supervision and implement safe smoking interventions for all residents. This affected three residents (#6, #26, and #34) out of four reviewed for smoking. The facility census was 39. Findings include:1. Review of the medical record for Resident #6 revealed an admission date of 05/09/23 with diagnoses including muscle weakness, muscle wasting and atrophy, adjustment disorder with anxiety, and major depressive disorder. Review of the smoking care plan, revised 08/03/23, revealed Resident #6 was a smoker. Interventions included staff to inform resident of smoking policy and designated smoking times (initiated 05/10/23), staff were to keep cigarettes, lighter, and matches in a designated area (initiated 12/11/24), and resident was a supervised smoker (revised 06/30/25). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/23/26, revealed Resident #6 had moderate cognitive impairment. Review of the smoking evaluation dated 01/23/26 revealed Resident #6…

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 facility policy, the facility failed to ensure residents requiring dialysis treatments had reliable transportation to and from dialysis, maintain adequate communication with the dialysis providers, and complete pre and post dialysis assessments. This affected all three residents (#3, #11, and #20) identified by the facility as receiving dialysis treatments. The facility census was 39. Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 08/16/24 with diagnoses including end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the dialysis care plan dated 08/18/24 revealed Resident #3 needed dialysis related to end stage renal disease. Interventions included no blood pressures to be taken on arm with fistula (revised 02/10/25), complete pre and post dialysis assessments per facility policy (revised 06/30/25), check bruit and thrill of left arm fistula every shift (revised 06/30/25),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility failed to provide therapy services in a timely manner. This affected one resident (Resident #1) of one resident reviewed for therapy services. The census was 39.Findings include:Record review for Resident #1 revealed admission date 06/15/20 of with diagnosis including acute respiratory failure with hypoxia, unspecified abnormalities of gait and mobility, hereditary and idiopathic neuropathy, major depression, muscle weakness, and localized edema. Review annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 15 (no cognitive impairment), functional limitations: upper extremity as no impairment, lower extremity as impairment of both sides, roll in bed as partial/moderate assistance, lying to sitting on side of bed not attempted due to medical condition or safety concerns.Review of annual therapy screen completed on 01/08/26 revealed Resident #1 stated he would like to start getting out of bed and therapy will be determined after…

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 provide assistance to Resident #11 to maintain the Medicaid benefits for which he was eligible. This affected one resident (#11) out of two reviewed for Medicaid coverage. The facility census was 39. Findings include: Review of the medical record for Resident #11 revealed an admission date of 10/29/19 with diagnoses including end stage renal disease, dependence on renal dialysis, type two diabetes mellitus, cerebral infarction, peripheral vascular disease, dementia, and congestive heart failure. Review of the payer source information for Resident #11 revealed the primary payer was listed as Medicaid. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/04/25, revealed Resident #11 had no cognitive impairment. Review of the progress note dated 01/12/26 at 10:18 A.M. revealed Resident #11's transportation to dialysis was cancelled and dialysis treatment was missed as a result. Review of the Medicaid Benefits and Assignment Plan for Resident #11 revealed his Medicaid benefits ended on 01/31/26. 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interviews and facility policy review, the facility failed to ensure a safe transfer via mechanical lift (Hoyer) for Resident #45. This affected one (Resident #45) of three residents reviewed for falls/Hoyer transfers. The facility census was 44.Findings include:Review of the closed medical record for Resident #45 revealed an admission date of 12/07/22 with diagnoses including type two diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), anxiety disorder, failure to thrive, morbid obesity, and chronic kidney disease (CKD). Review of the physician's order dated 01/15/25 revealed an order for a Hoyer lift for transfers. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was cognitively intact, was dependent on others for mobility and required extensive assistance/dependence with activities 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 observation and interview the facility failed to maintain an outside sidewalk to allow for safe passage of residents. This had the potential to affect all residents residing in the facility. The facility census was 49. Findings include: Interview on 07/08/24 at 8:55 A.M. with Residents #24, #27, and #32 while they were out on the patio smoking confirmed they get their wheelchairs stuck in the large cracks in the sidewalks all the time. They also confirmed that the large divots on the sides of the sidewalk had wheelchair marks from where they rolled off the sidewalk and got stuck. Observation during the interview revealed the sidewalk to the smoking area had four cracks in sidewalks measuring six inches wide and two to three inches deep. There were numerous divots on the grass area next to the sidewalks measuring four to twelve inches deep with wheelchair marks where they got stuck. Interview and observation on 07/08/24 at 2:00 P.M. with the Director of Nursing (DON) confirmed the large cracks in the sidewalk leading to the smoking patio. He also confirmed the areas next 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, 2019 Food Code - Chapter 3717-1-03 Reference Guide review, and facility policy review the facility did not ensure food was served at a palatable temperature. This had the potential to affect 44 residents who received food from nutrition services. The facility identified one resident (#35) that received nothing by mouth. The facility census was 45. Findings include: Observation was conducted on 03/20/24 at 11:28 A.M. of the tray line temperatures at meal service. The food temperatures were taken with a calibrated digital thermometer as follows: beef pepper patty 169.4 degrees Fahrenheit (F), mashed potatoes 168 degrees F, roasted zucchini 184 degrees F, milk 39 degrees F. The tray line's start time was11:30 A.M. The system being used to retain hot food temperatures was a plate warmer and thermal dome cover. The test tray was placed on the 100/200 hall cart at 12:05 P.M. where staff would pass on the 100 unit then the 200 unit. At 12:11 P.M. a test tray was passed to Dietary Manager #725 who proceeded to take the food temperature with the same 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 observations, interviews, and facility policy review the facility failed to ensure food was stored in a sanitary manner. This had the potential to affect 44 residents receiving meals from the kitchen. The facility identified one resident (#35) who received nothing by mouth. The census was 45. Findings include: Observation on 03/18/24 at 6:53 P.M. the kitchen dry storage revealed two open undated Potato Pearls containers with no use by date. These findings were verified by the Dietary Manager (DM) #725 at the time of the observation. Observation on 03/20/24 at 1:00 P.M. revealed the resident's refrigerator on the 200-unit had a white plastic bag with three take out containers. The plastic bag did not have a resident name or date. A paper bag with an employee's name on it with perishable food inside the bag was undated, and a gallon of ice cream in the freezer with no resident name or date. This was verified by DM #725 at the time of the observation. Interview with the Administrator on 03/20/23 at 1:12 P.M. revealed the unit-200 refrigerator should not have any food in it.…

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 did not ensure all medication carts in the facility were maintained to secure all drugs in their proper packaging. This had potential to affect all 38 residents residing in the facility who received medications from three of three medication carts. The facility census was 45. Findings include: Observation of medication carts completed on 03/20/24 at 2:30 P.M. revealed there were a total of 11 loose medications observed. There were five loose medications observed in the 100-hall medication cart, as well as five loose medications observed in the 300-hall medication cart, and one loose medication observed in the 400-hall medication cart. The facility had a total of four medication carts. Interview on 03/20/24 at 2:45 P.M. with Licensed Practical Nurse (LPN) #724 revealed she confirmed there were five loose medications observed in the 100-hall medication cart, as well as five loose medications observed in the 300-hall medication cart. Interview on 03/20/24 at 3:00 P.M. with LPN #721 revealed she confirmed there was one loose medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide care and treatment according to physician orders. This affected one resident (#36) of one resident reviewed for insulin and two residents (#31 and #35) of two residents reviewed for nutrition. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including colitis, hemiplegia, severe protein calorie malnutrition, acute kidney injury, type two diabetes, muscle wasting, anxiety. and peripheral vascular disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 had moderately impaired cognition. Resident #36 needed extensive assistance for bed mobility and transfers. Supervision was required while eating. Review of the plan of care dated 02/06/24 revealed Resident #36 was noncompliant with wound care as ordered. Interventions included resident education in regard to wound care and treatment, risk of noncompliance…

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 facility policy, the facility failed to ensure restorative nursing services were accurately documented in the medical record. This affected one resident (#37) of one resident reviewed for mobility. The facility census was 45. Findings include: Review of the medical record for Resident #37 revealed an admission date of 06/14/23 with diagnoses including injury to the cervical spinal cord, paralytic syndrome, chronic pain syndrome, polyneuropathy, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Review of the care plan dated 02/29/24 revealed Resident #37 had a risk for limited mobility related to decreased range of motion, pain, weakness, and paraplegia. Intervention included therapy as ordered. Review of the physician orders dated 09/01/23 indicated an order for splinting for contractures of the hands: patient to wear left hand splint on in evening and off 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 observation, interview, record review, and facility policy review the facility failed to ensure proper hand hygiene and glove use were followed during wound care for Resident #35. This affected one resident (#35) of two residents reviewed for wound care. The facility census was 45. Findings include: Review of the medical record for Resident #35 revealed an admission date of 08/21/23. Medical diagnoses included acute and chronic respiratory failure with hypoxia, multiple sclerosis, type two diabetes mellitus, unspecified sever protein calorie malnutrition, peripheral vascular disease, unspecified dementia without behavioral disturbance, and contracture of right and left hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was severely cognitively impaired, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Resident #35 had one unhealed stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle.…

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 record review, the facility failed to provide adequate supervision and a safe environment to prevent elopement for Resident #1. This affected one (#1) of three residents reviewed for elopement. The facility census was 48. Findings include: Review of the closed medical record for Resident #1 revealed an admission date of 01/05/23 with diagnoses including Huntington's disease, encephalopathy, dysphagia, acute respiratory failure, major depressive disorder, altered mental status, alcohol use with withdrawal delirium, muscle weakness, restlessness and agitation. Review of the elopement risk screen, dated 07/05/23, revealed Resident #1 was not at risk for elopement. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 07/15/23, revealed Resident #1 had a severe cognitive impairment. He displayed no wandering behaviors during the seven day look back period. He was independent for transfers and required supervision for walking and locomotion. Review of the psychiatric note dated 05/16/23 revealed Resident #1 was alert and oriented to person,…

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 serve meals in a timely manner affecting 47 residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Findings include: Record review was conducted of the facility document titled Meal Times, undated, which was hanging in the main dining room, kitchen and given to the surveyor by Dietary Manager (DM) #508 as the current meal times. The document indicated breakfast service was 8:10 A.M. in the main dining room, 8:20 A.M. to the 300/400 units and 8:30 A.M. to the 100/200 units. Lunch service was 12:10 P.M. in the main dining room, 12:20 P.M. to the 300/400 units, and 12:30 P.M. to the 100/200 units. Dinner service was 4:10 P.M. in the main dining room, 4:20 P.M. to the 300/400 units and 4:30 P.M. to the 100/200 units. Record review of the of the facility document titled Concern Log for the months of September 2021 and October 2021 revealed there had been concerns expressed with breakfast being served late to the residents. Observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review the failed to ensure the disposal of expired medication and supplements. This had the potential to affect all residents in the facility. The facility census was 48. Findings include: Observation of the medication room with Licensed Practical Nurse (LPN) #403, on [DATE] at 1:00 P.M. revealed four boxes of iron supplements with an imprinted use by date of 01/22; one box of Reagent Urinalysis Strips with an expiration date of [DATE] and one bottle of Cherry Sore Throat Spray with an expiration date of 11/21. Interview with LPN #403 at the time of the observation verified the medication was expired and should have been thrown away. Review of the facility's policy Storage of Medication, dated [DATE], indicated the facility shall not use discontinued, outdated, expired, or deteriorated medications/nutritional supplements. All such medications shall be returned to the dispensing pharmacy or destroyed. Nutritional supplements will be discarded. Nurses shall check…

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

Based on record review, observation, and interviews the facility did not ensure the Dietary Manager had the appropriate competencies and skill set to effectively run the dietary department to meet the needs of all residents residing in the facility. This had the potential to affect 47 residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Findings include: Record review was conducted of the personnel file for Dietary Manager (DM) #508 whose date of hire was listed as 01/20/22. There was no evidence DM #508 was a certified dietary manager or held an associate degree or higher degree in food service management or hospitality management. Observation was conducted on 02/14/22 at 6:54 A.M. of cases of raisin bread and juice cups sitting directly on the floor near the walk-in cooler. DM #508 revealed the cases were delivered on 02/11/22 and she had not yet been able to put the foods away. When asked if those foods were highly perishable, she said she was not 100 percent sure if they needed to be thrown away or not.…

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

Based on record review, observation, and interviews the facility did not ensure the dietary staff could demonstrate competency in all aspects of food production, service, and kitchen sanitation. This had the potential to affect all residents receiving meals from the kitchen except for one (Resident #7) who did not eat by mouth. The facility census was 48. Findings include: Record review was conducted of the personnel files for Dietary Manager (DM) #508, [NAME] #507, [NAME] #512, [NAME] #516 and Dietary Aide (DA) #511, DA #513 and DA #517. There was no evidence the employees had initial or annual competency checks related to their job specific duties in kitchen. Observation was conducted on 02/14/22 at 6:54 A.M. of the general kitchen environment. [NAME] #512 was present in the kitchen and identified herself as the person in charge until the dietary manager arrived to work. When the surveyor asked her to explain how she monitored the dish machine to ensure it was functioning properly, [NAME] #512 said she did not do dishes because she was the cook so the surveyor would have to ask 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 record review, observation, and interview the facility failed to ensure food was prepared, stored, and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen except for Resident #7 who did not eat by mouth. The census was 48. Findings include: Observation on 02/14/22 at 7:05 A.M. in the kitchen dry storage room revealed one open, undated carrot cake mix with a use by date of 11/11/21, four 16-ounce containers of medium barley with a use by 12/17/21, an open, undated five-pound bag of blueberry muffin mix with a use by date of 10/26/21, and an open undated gallon Ziploc bag with four tortilla shells. Sitting directly on the floor were two cases of 48, four-ounce 100% orange juice and one case vegetable oil. The entire perimeter of the dry storage room floor where the floor met the wall was heavily covered in crumbs and a buildup of dirt. Outside the dry storage room by the walk-in cooler sat a case of raisin bread on top two cases of 48, four-ounce juice cups. These findings were confirmed at the time 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 record review, observations, and interviews the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 48 residents residing in the facility. The facility census was 48. Findings include: The following concerns were identified throughout the duration of the annual survey: 1. The breakfast and/or lunch meal service was running between 37 to 45 minutes late at breakfast and/or lunch on 02/14/22 and 02/15/22. On 02/15/22 at 8:51 A.M. Dietary Manager (DM) #508 informed the surveyor she had to hand write tray tickets for 47 residents (Resident #7 did not eat by mouth) since she started her job there almost a week prior because the former dietary manager had taken the computer with the tray ticket program on it. She said the Administrator was aware of it. Interview was conducted on 02/15/22 at 3:28 P.M. with the Administrator who verified she was aware the former dietary manager took the computer with her, and a replacement had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews the facility did not ensure an effective system was in place to honor resident meal choices and provide therapeutic diets as ordered by the physician. This affected seven (Resident's #10, #19, #25, #26, #33, #246 and #345) of 16 residents reviewed for food. The facility census was 48. Findings include: 1. Record review was conducted of the four-week cycle menu titled Fall/Winter 2021-2022. The menu listed only one meal at breakfast, lunch, and dinner with no second-choice options on the menu. Resident interviews were conducted on 02/14/22 from 9:40 A.M. to 4:48 P.M. with Resident's #19, #25, #26, #33 and #246 who reported they did not get a choice in what meal was served to them and no one came around to their rooms to ask them if they wanted something besides what was on the menu. Observation on 02/15/22 at 8:51 A.M. of the breakfast tray line in the kitchen revealed [NAME] #516 verified she cooked one entree with no alternate choices. The entree she cooked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control recommendations for Healthcare Personnel (HCP), the facility failed to follow acceptable infection control practices, including the proper use of personal protective equipment (PPE) to prevent the potential spread of COVID-19. This had the potential to affect all 48 residents residing in the facility. Findings include: Observation on 02/14/22 at 6:23 A.M. revealed State Tested Nurse Aide (STNA) #534 coming out of room [ROOM NUMBER] not wearing proper PPE (no eye protection or N95 respirator mask). STNA #534 verified she was not wearing proper PPE as she only had a surgical mask on. She stated she had been in-serviced on COVID-19 and there was an adequate supply of PPE including eye protection and N95 respirator masks. Observation on 02/14/22 at 6:24 A.M. revealed STNA #532 coming out of room [ROOM NUMBER] not wearing proper PPE (no eye protection). STNA #532 verified she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews the facility failed to ensure Resident's #246 and #250 were provided a dignified dining experience. This affected two (Resident's #246 and #250) of two residents reviewed for dignity. The facility census was 48. Findings include: 1. Review of the medical record revealed Resident #246 was admitted on [DATE] with diagnoses including diabetes mellitus, hypertension, and depression. Interview on 02/14/22 at 9:40 A.M. with Resident #246 revealed he was still waiting on his breakfast tray. He stated his roommate's breakfast tray had been delivered. Resident #246 stated he had asked State Tested Nurse Aide (STNA) #503 three times for his breakfast but had not received it. Interview with STNA #503 on 02/14/22 at 9:42 A.M. verified Resident #246's breakfast tray was not on the cart with the other trays, and she asked the kitchen for his breakfast three times and still had not received his tray. Review of facility mealtimes posted in the 100 Unit hallway 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 and interview the primary care physician/medical director failed to write, sign, and date progress notes at each visit. This affected three (Resident's #19, #39 and #245) of three residents reviewed for physician services as part of the extended survey. The facility census was 48. Findings include: Medical record reviews were conducted for Resident's #19, #39 and #245 and found to be without progress notes from Primary Care Physician/Medical Director (PCP/MD) #552 after 08/24/21. Interview on 02/23/22 at 10:05 A.M. with the Director of Nursing (DON) verified PCP/MD #552, had the resident's progress notes from his visits with the resident. The DON verified the progress notes were not in the resident's medical record. She said this had been ongoing for a while. Interview on 02/24/22 at 9:06 A.M. with PCP/MD #552 verified he did not produce progress notes while at the facility making rounds on his residents. Instead, he would just jot a few notes down then go home and write out a dated and signed progress note. He verified he had his notes at home, and they 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 and interviews the facility did not ensure food was served at palatable temperatures. This affected three (Resident's #10, #25 and #33) of nine residents reviewed for food. The facility census was 48. Findings include: Interview was conducted on 02/14/22 at 2:24 P.M. with Resident #25 who stated he did not want to eat the food from the facility anymore because he either did not get what he asked for or it just was not good food. Interview was conducted on 02/14/22 at 4:48 P.M. with Resident #33 who stated a lot of times the food was cold by the time it was served to her in her room. Interview was conducted on 02/15/22 at 9:40 A.M. with Resident #10 who said hot foods are not always hot by the time he gets his room tray. Observation was conducted on 02/17/22 at 12:08 P.M. of the tray line food temperatures and meal service. The food temperatures were taken with a calibrate digital thermometer as followed: BBQ chicken 169 degrees Fahrenheit (F) , sweet potato 203 degrees F, cauliflower 191 degrees F. The tray line started at 12:12 P.M. The system being used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure physician progress notes were made available in the medical record for Resident's #19, #39 and #245. This affected three of three residents reviewed as part of the extended survey. The facility census was 48. Findings include: 1. Record review was conducted for Resident #39 who was admitted to the facility on [DATE] with diagnoses including major depression, chronic pain, contractures, paraplegia, anemia, and heart disease. There were no primary care physician progress notes or visits dated after 08/24/21 in the resident's medical record. Interview with the Director on Nursing (DON) on 02/23/22 at 2:12 P.M. revealed she had been having problems getting the progress notes from Primary Care Physician/Medical Director (PCP/MD) #552 because PCP/MD #552 had the notes with him instead of leaving the notes at the facility or in the medical record. 2. Review of the medical record revealed Resident #19 was admitted on [DATE] with diagnoses including…

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.