Fairfax Behavioral Health & Memory Care Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure EBP were in place during wound care for 1 (#55) of 1 sampled resident reviewed for wound care.The Administrator reported one resident received routine wound care.Findings:On 07/17/25 at 9:30 a.m., ADON #1 was observed providing wound care to Res #55. ADON #1 was not observed to be wearing a gown. No signage was observed indicating Res #55 was on EBP.A facility policy titled Enhanced Barrier Precautions (EBP) Policy and Procedure, dated 11/01/23, read in part, [NAME] Behavioral Health & Memory Care Community shall implement Enhanced Barrier Precautions (EBP) for all residents known to be colonized or infected with MDROs [Multidrug-Resistant Organisms] and in accordance with CDC [Centers for Disease Control] guidance. This includes the use of personal protective equipment (PPE) for certain resident care activities even when residents are not in isolation or on contact precautions.An admission record, dated 04/08/25, showed Res #55 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 interview, the facility failed to provide a safe, clean, comfortable, homelike environment. The DON identified 49 residents resided in the facility. Findings: Observations of rooms on the 100 hall revealed the sinks did not have hot running water. On 10/16/24 at 2:00 p.m., Resident #4 stated they have not had hot water in their room for over a month. The resident stated they have arthritis in their hands and washing them in cold water causes pain. On 10/16/24 at 2:15 p.m., the maintenance supervisor stated the 100 hall has been without hot water due to a broken hot water tank. 10/16/24 at 2:44 p.m., the maintenance supervisor stated they had spoke with the administrator who told them they are to receive a government grant in March and that is when the hot water tank will be replaced. On 10/17/24 at 9:05 a.m., Resident #5 stated they have not had hot water in their room since they arrived on 09/05/24. On 10/17/24 at 9:06 a.m., Resident #6 stated they have not had hot water in their room for over a month. They stated it would be nice to have hot water for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure resident were free from abuse for one (#1) of three residents sampled for abuse. The DON reported 49 residents resided in the facility. Findings: An undated facility policy titled Abuse By a Resident To Other Residents, read in parts .abuse as used in this policy shall refer to all forms of abuse including, but not limited to physical, verbal, sexual and psychological . Resident #1 had diagnoses which included dementia with a BIMS of 5 Resident #2 had diagnoses which included dementia with a BIMS of 11. On 10/08/24 at 3:00 p.m., Resident #2 was observed by staff sitting beside Resident #1's bed with their left hand on Resident #1's pubic area. A nurse's note dated, 10/08/24 at 5:29 p.m., documented Residents #1 and #2 were immediately separated. A head to toe assessment was performed on Resident #1 with no signs or symptoms of trauma or injury. The physician, family and [NAME] Police Department were notified. On 10/15/24 at 2:30 p.m., the DON…

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, record review, and interview, the facility failed to ensure residents were free from abuse for one (#8) of four residents sampled for abuse. The director of nurses reported the census was 53. Findings: An undated facility policy, titled Abuse by a Resident to Other Residents, read in parts .Abuse as used in this policy shall refer to all forms of abuse including, but not limited to physical, verbal, sexual, and psychological . Resident #3 had diagnoses including diabetes mellitus and hypertension. Resident #8 had diagnoses including schizophrenia and convulsions. On 08/06/24 at 8:05 am, Res #3 was observed in the dining room propelling their wheelchair towards Res #8, who was seated in a wheelchair and stationary. Res #3 was shouting obscenities and threatening Res #8 with bodily harm. Res #3 was observed to bump their wheelchair into the leg of Res #8. The residents separated and Res #8 went out of the dining room to the nurse's desk. As Res #3 passed by Res #8 they were heard to yell more obscenities and threaten Res #8 again. A nurse note, dated 08/06/24 at…

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

Based on observation and interview, the facility failed to ensure residents who require assistance with dressing were not left unclothed in their rooms and resident catheter bags were covered while in public spaces for one (#12) of two residents reviewed for dignity. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility's Policy and Procedure for Exercising of Rights policy, undated, read in part, The resident has a right to a dignified existence and the facility will protect and promote the rights of each resident. Resident #12 had diagnoses which included vascular dementia, acquired absence of right leg below the knee, and acquired absence of the left leg above the knee. On 06/03/24 at 2:19 p.m., upon entrance to Resident #12's room they were observed lying sideways on their bed nude from the waist down. They stated they could not reposition themselves or reach the call light to ask for assistance. They stated they they had returned from…

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 residents the opportunity to develop or refuse the creation of an advance directive or three (#15, 21 and #36) of five residents reviewed for advance directives. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility Policy and Procedure for Residents Rights Regardign (sic) Advance Directives for Health Care & Mental Health Treatment, undated, read in part, Every competent person has a right to determine whether he/she will receive life sustaining treatment , who will make the decisions concerning their health care if they cannot and provide their wishes concerning organ donation. 1. Resident #15 was admitted to the facility on [DATE]. 2. Resident #21 was admitted to the facility on [DATE]. 3. Resident #36 was admitted to the facility on [DATE]. On 06/04/24 at 12:57 p.m., LPN #1 stated the advance…

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 required interdisciplinary team members participated in the planning process of resident care plans for six (#5, 12, 16, 21, 26, and #36) of twelve residents reviewed for care plans. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The facility Policy and Procedure Regarding Resident Care Plan, undated, read in part, The comprehensive care plan will be developed by the IDT which will include the attending physician, registered nurse with the responsibility for the resident, nurse aide with responsibility for the resident, dietary staff representative, the resident and/or resident representative if possible, and any other healthcare professional as identified by the resident's needs or as requested by the resident. 1. Resident #5 was admitted on [DATE]. 2. Resident #12 was admitted on [DATE]. 3. Resident #16 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, record review, and interview, the facility failed to ensure: a. a resident was educated on the risks and benefits of using bedrails and obtained informed consent; b. bed frames and bed rails were inspected prior to the application of rails to the frame and use of bed rails by a resident; and c. alternatives to the use of bed rails were attempted prior to the use of bed rails for two (#12 and #36) of two sampled resident reviewed for bed rails. The DON reported eight residents had bed rails in use at the facility. Findings: When asked for the facility policy on the use of bed rails the DON offered the Policy and Procedure for the use of Alternative Measures to Restraints which was undated. The policy read in part, Positioning bars may be used by residents who request them as an aid to reposition in bed. Also, residents who are confused or disoriented to the point that they do not recognize the edge of the bed, but who would not attempt to climb over them, may use them to prevent falling from…

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 maintain registered nurses on duty eight hours each day seven days every week. Findings: A Policy Regarding Facility Staffing, undated, read in part, It shall be the policy of this facility to employ sufficient, adequately trained staff, to be on duty 24 hours a day, to meet the needs of the residents residing in the facility, as determined by the Administrator and/or Director of Nursing. A Payroll Based Journal (PBJ) report for the first quarter of 2024 (October 1, 2023 through December 31, 2023) documented registered nurse hours were not submitted for 11/04/23, 11/05/23, 11/18/23, 11/23/23, 12/02/23, 12/03/23, 12/16/23, and 12/17/23. A facility staffing schedule for November 2023, did not document registered nurses as having worked on 11/04/23, 11/05/23, and 11/18/23. A facility staffing schedule for December 2023, did not document registered nurses as having worked on 12/02/23, 12/03/23, 12/16/23, and 12/17/23. A Payroll Based Journal (PBJ) report for the second quarter of 2024 (January 1, 2024 through March 31, 2024)…

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

Based on record review and interview, the facility failed to ensure medications were administered within the ordered time frame. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: A facility Time of Administration policy, undated, read in part, The following schedule will be implemented for administration of medications, unless physician orders indicated otherwise .TID First dose within 2 hours of rising, second dose no sooner than 5 hours, third dose no sooner than 5 hours. A Medication Admin Audit Report, dated 06/04/24, documented 23 of 48 residents who had medications ordered to be administered at 7:00 a.m., were administered those medications after 12:00 p.m. A Medication Admin Audit Report, dated 06/05/24, documented 13 of 49 residents who had medications ordered to be administered at 7:00 a.m., were administered those medications after 12:00 p.m. On 06/05/24 at 1:17 p.m., CMA #2 stated they had not finished passing morning medications as of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a written notice of discharge was provided to a resident and the ombudsman office was notified when a resident was discharged from the facility to a hospital for one (#12) of two resident reviewed for discharges and hospitalizations. The director of nurses stated six residents had discharged in the previous six months. Findings: The Policy and Procedure for Transfer and Discharge, undated, read in part, The facility will notify the resident, resident's representative if authorized, the person responsible for payment of the resident's care, or legal representative of the resident, of the tranfers or discharge. The reason for the transfer or discharge will be documented in the resident's medical record. Notice will be made as soon as possible before transfer or discharge when an emergency exists. Resident #12 was admitted to the facility on [DATE]. A review of Resident #12's MDS section of their electronic medical records found the resident 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.

Based on observation, record review, and interview, the facility failed to accurately assess and code a pressure wound in Section M of a MDS quarterly assessment for one (#12) of one resident reviewed for pressure wounds. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The Policy & Procedure for Assessment Review, undated, read in part, This facility will ensure that each resident's condition will be examined by the nursing facility at least once every three months, and if necessary, will change the resident's assessment to assure the continued accuracy of each resident's assessment. Resident #12 had diagnoses which included vascular dementia, acquired absence of right leg below the knee, and acquired absence of the left leg above the knee. A progress note, dated 05/13/24 at 7:56 p.m., documented Resident #12 had a new wound on the coccyx about 1 cm in length. A progress note, date 05/23/24 at 8:03 a.m., documented Resident #12's sacral wound 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, record review, and interview, the facility failed to ensure a significant change assessment was performed following the development of a new pressure ulcer and partial amputation of a resident's leg for one (#12) of twelve resident reviewed for Minimum Data Set assessments. A midnight census report, dated 06/02/24, documented 48 residents resided in the facility. The administrator stated that was the accurate census at the time the survey began. Findings: The Policy & Procedure for MDS Frequency & Completion, undated, read in part, If a significant change in the resident's condition does occur, an assessment must be done within 14 days of when the change in condition was identified. Resident #12 had diagnoses which included vascular dementia, acquired absence of right leg below the knee, and acquired absence of the left leg above the knee. A progress note, dated 05/13/24 at 7:56 p.m., documented Resident #12 had a wound on their coccyx. A hospital Discharge summary, dated [DATE], documented…

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 have policy and procedures for obtaining and using feedback from staff, residents, and resident representatives. Findings: A review of the facility QAPI and QAA records did not find documentation of a program to obtain feedback from facility staff, residents, and resident representatives. On 06/07/24 at 12:05 p.m., the Administrator stated although the facility did have a grievance process for residents it did not have a feedback program or policy and procedures for a feedback program.

Based on observation, record review, and interview, the facility failed to maintain a functioning call light system for one (#47) of 12 sampled residents reviewed for a functioning call light system. The Administrator identified 48 residents resided in the facility. Findings: The Resident Call System policy, undated, read in part, .In the event of a call light malfunction, the facility will provide alternative methods of alerting staff of needs, ie: bell, buzzer, light. Facility staff will then immediately notify maintenance via verbal communication of call light malfunction for further intervention . Resident #47 had diagnoses which included vascular dementia, atherosclerotic heat disease, bipolar disorder. Resident #47's care plan, revised 04/21/24, documented to keep call light within reach and mark call light with bright tape. On 06/03/24 at 1:01 p.m., Resident #47's call light was out of reach of the resident. The call light was attached to privacy curtain. Resident #47 was sitting in her wheelchair. Resident #47 was unable to state if the call light was working properly. 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 observation, record review, and interview the facility failed to ensure: a. foods were labeled and dated, and disposed of according to policy, and b. kitchen equipment, sinks and refrigerators were cleaned and free from food debris and grime. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: An undated, Food Storage, Preparation and Distribution policy, read in parts, .Leftovers food items will be labeled, dated and stored under refrigeration .non-potentially hazardous leftovers will be used or disposed of within 48 hours .Leftover foods will be stored in covered containers or wrapped securely. Each item will be clearly labeled and dated before being stored . An undated, Sanitation and Infection Control policy, read in parts, .The following is a suggested cleaning schedule for kitchen and dining areas .All Appliances After each use .Sinks After each meal . On 05/09/23 at 8:30 a.m., the following was observed in the kitchen: a. the hand-washing sink was observed to have brown stains and grime in the sink, b. a…

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

Based on observation and interview, the facility failed to ensure there was a system in place to monitor for Legionella and other waterborne diseases. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: An undated Water Management Program policy, read in part, .The facility can control the growth and spread of water-borne pathogens through a water management program . On 05/11/23 at 8:30 a.m., the medication storage room was observed. The double sink was observed to be used, the water was observed to back up from the other side of the drain. LPN #1 was asked how long had the sink not been draining. They stated, since the maintenance man had quit. They were asked how long was that. They stated about one to two weeks ago. On 05/11/23 at 10:35 a.m., the Administrator was asked if there was a system in place to monitor for Legionella or other waterborne diseases. They stated, No. They were asked if they were working on a system. They stated, we are hiring a new maintenance man, and they are familiar with all the requirements.

Based on observation, record review and interview, the facility failed to ensure wound care was performed as ordered by the physician for one (#59) of three sampled residents reviewed for wound care. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six and three residents had wounds. Findings: Resident #59 had diagnoses which included muscle weakness, bilateral below the knee amputations, depression, and type two diabetes mellitus. A Nurses Progress Note, dated 05/07/23 at 2:57 a.m., read in parts, Resident put thumb through the side of [their] cup of noodles and the liquids caused an area on the outside of [their] right thigh approximately 1.5 cm x 3.9 cm. Obtained an order from PCP for Silvadene. Clean area with NS pat dry apply and cover with non-stick Telfa pad BID . A Treatment Administration Record, dated 05/07/23 through 05/08/23, documented the treatments had been completed. On 05/09/23 the resident refused the treatment. On 05/09/23 at 3:10 p.m., LPN #1 was asked what date was documented on Resident #58's dressing. They…

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

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours, seven days a week for October 2022, November 2022, December 2022, January 2023, February, 2023, March 2023, and May 2023. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: The Schedule Sheet, dated October 2022, did not contain documentation of RN coverage for 10/8, 10/15, 10/16, 10/21, 10/22, 10/25, 10/26, or 10/30/22. The Schedule Sheet, dated November 2022, did not contain documentation of RN coverage for 11/13, 11/18, or 11/20/22. The Schedule Sheet, dated December 2022, did not contain documentation of RN coverage for 12/1 or 12/21/22. The Schedule Sheet, dated January 2023, did not contain documentation of RN coverage for 01/21, 01/27, 01/28, or 01/29/23. The Schedule Sheet, dated February 2023, did not contain documentation of RN coverage for 02/12, 02/19, or 02/24/23. The Schedule Sheet, dated March 2023, did not contain documentation of RN coverage for 03/16, 03/24, or 03/25/23. The Schedule Sheet,…

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 side effect monitoring was completed for: 1. anti-anxiety medication for one (#1); 2. anti-depressant medications for three (#1, 3, and #4); and 3. anti-psychotic medication for one (#1) of five sampled residents reviewed for unnecessary medications. The Residents Census and Conditions of Residents report, dated 05/09/23, documented the census was six, six residents received psychoactive medications, one resident received an antipsychotic medication, two residents received an anti-anxiety medication, and six residents received an anti-depressant medication. Findings: An undated, PROCEDURES FOR MONITORING MEDICATION EFFICACY AND POTENTIAL SIDE EFFECTS policy, read in parts, .Individual monitoring of a specific drug regimen will be based on the physician's therapeutic goals .desired effect .Monitoring for potential side effects will be accomplished through data collection such as AIMS evaluation, non-movement side effects documentation, behavior…

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

Based on observation, record review and interview the facility failed to ensure the medication error rate was not greater than 5% for two (#4 and #59) of three sampled residents observed during medication administration. The medication error rate was 6.45%. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: An undated Policy & Procedure On Medication Errors, read in part, .It shall be the policy of this facility to insure that medications error rates are not greater than 5% and residents will be free of any significant medication errors . An undated Medication Card Identification and Administration System, read in parts .Remove the appropriate medication dosage, placing it in the souffle cup . 1. Resident #4 had diagnoses which included high blood pressure and depression. A Physician Order, dated 04/25/23, documented to administer Duloxetine 30 mg one capsule by mouth one time a day for depression. On 05/10/23 at 8:35 a.m., LPN #1 was observed to remove a card of Duloxetine from the medication cart, then return it 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 and interview, the facility failed to ensure Tuberculin solution multi dose vials, were labeled when the seal was punctured and disposed of after 30 days. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: On 05/11/23 at 8:30 a.m., the medication storage room was observed. There were two vials of Tuberculin Purified Protein Derivative solution that were in the medication refrigerator. One of the vials had been used and had no date on the box or the vial. The other vial had a date (03/28/23) written on the box. LPN #1 was asked how long TB solution was good for after the seal was punctured. They stated they were unsure, but everything should be dated when opened. They were asked who the TB solution was used for. They stated the tests are used on the residents and the staff. On 05/11/23 at 8:45 a.m., the DON was asked how long the TB medication is good for once the seal is broken. They stated they were unsure and would have to ask. On 5/11/23 at 12:01 p.m., the DON stated, We don't have an actual…

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 submit accurate data regarding direct care staffing information to CMS on October 2022, November 2022, and April 2023. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: The PBJ Staffing Data Report, for Quarter 1, 2023 (October 1 - December 31), documented the facility failed to have Licensed Nursing Coverage 24 hours a day for 10/01, 10/02, 10/08, 10/09, 10/13, 10/16, 11/23, and 11/24/22. The Data Report of Nursing Home Information, dated April 2023, documented the following: 1. On 04/29/23, the census was three. The direct staff for day shift was 15.50 hours, evening shift hours was 15.75 hours, and night shift was 15.75 hours. 2. On 04/30/23, the census was three. The day shift was 15.50 hours. The facility should have had 16 hours each shift for direct care staffing. On 05/11/23 at 11:05 a.m., the DON was asked if the facility had issues with licensed coverage for 24 hours/day. The DON stated they had been there for a year and in charge of the nursing…

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 written information for the bed hold policy for one (#5) of two residents reviewed for discharge. The Resident's Census and Conditions of Residents report, dated 05/09/23, documented the census was six. Findings: Resident #5 had diagnoses which included chronic kidney disease, type two diabetes mellitus, and hallucinations. A Discharge Assessment, dated 04/07/23, documented the resident had an unplanned discharge to an acute hospital. On 05/10/23 at 3:52 p.m., the MDS coordinator was asked if they provide the resident or resident representative with a copy of the bed hold policy when the resident was discharged to the hospital. They stated, No. There was no documentation Resident #5 had been provided a bed hold policy at the time of discharge.