Heritage Hills Living & Rehabilitation Center

Based on observation and interview, the facility failed to maintain the physical environment of the kitchen and ensure employees with facial hair wore a beard guard in the kitchen. The administrator identified 58 residents who resided in the facility. Findings: On 10/28/24 at 8:30 a.m., the kitchen was observed to have: a. a broken paper towel dispenser at the handwashing sink, b. missing trim on the exterior door, c. a broken cover on a fluorescent light fixture, d. build up of brown sticky substance on the walls around the grill area, and e. rusted air vents on the ceiling. On 10/28/24 at 12:15 p.m., a male employee with a partial beard was observed in the kitchen not wearing a beard guard. On 10/29/24 at 12:00 p.m., a male employee with a partial beard was observed in the kitchen not wearing a beard guard. On 10/30/24 at 8:41 a.m., the CDM stated they had made maintenance aware of the physical environment. They stated they would ensure staff wore beard guards when needed.

Based on record review and interview, the facility failed to implement a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. The administrator identified 58 residents who resided in the facility. Findings: CMS memo 17-30, revised date 06/09/17, documented CMS expects long term care facilities to have water management policies and procedures to reduce the risk of growth and the spread of Legionella and other opportunistic pathogens in the facility water system. No documentation of water management policies and procedures were found from record review. On 10/29/24 at 1:00 p.m., the maintenance supervisor was asked to provide documentation of water management policies and procedures. The maintenance supervisor stated they had never heard of a water management program to reduce the risk and growth of Legionella. They stated the facility did not need a water management program because they never had any standing water. On 10/29/24 at 1:22 p.m., the IP stated the facility did not have policies and…

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

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#30 and #41) of 15 sampled residents whose resident assessments were reviewed for accuracy. The administrator identified 58 residents who resided in the facility. 1. Res #30 had diagnoses which included depression, anxiety, mood disorder, and intermittent explosive disorder. An annual resident assessment, dated 08/31/24, documented a diagnosis of psychotic disorder. 2. Res #41 had diagnoses which included impulse disorder. A quarterly resident assessment, dated 11/24/21, documented a diagnosis of psychotic disorder. On 10/29/24 at 1:05 p.m., the IP reported no resident had a diagnosis of psychotic disorder in the facility. They were unsure as to why resident assessments would document the diagnosis of psychotic disorder. On 10/31/24 at 11:41 a.m., the MDS coordinator reported they started their position in December, and documented the diagnosis, psychotic disorder, on Res #30 and #41 because the diagnosis was documented on their previous resident assessments.

Based on observation, record review, and interview, the facility failed to change and label oxygen tubing according to physician orders for four (#17, 28, 31, and #50) of four sampled residents reviewed for respiratory treatments. The DON identified 13 residents who received oxygen therapy. Findings: A Respiratory Care/Oxygen Therapy policy, dated 09/07/22, read in part, .Change tubing weekly. Label tubing with date and initials . 1. Res #17 had diagnoses which included COPD and chronic respiratory failure with hypercapnia. An admission assessment, dated 01/17/22, documented the resident was cognitively intact and received oxygen therapy. A physician order, dated 09/27/22, documented to change oxygen tubing weekly on Thursdays. The order documented to date and initial the tubing. On 10/28/24 at 9:56 a.m., Res #17 was observed lying in bed. The resident was observed wearing oxygen delivered by nasal cannula at three liters per minute. The oxygen tubing was observed with a tape label dated 10/17/24. Res #17 stated the staff changed the tubing, but was not sure how often. 2. Res #28…

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 conduct a thorough investigation into an incident of abuse for two (#33 and #59) of three sampled residents reviewed for abuse. The administrator identified 58 residents who resided in the facility. Findings: An Investigation of Abuse, Neglect and Exploitation policy, undated, read in parts, .The facility prohibits mistreatment, neglect or abuse of residents. The resident has the right to be free from verbal, sexual, physical, or mental abuse .Physical abuse includes hitting, slapping, pinching, and kicking .In the event there is an allegation or incidents involving resident to resident abuse, the individuals involved in the abuse should be immediately separated by staff .Once safety is established, the Administrator and Director of Nursing should be notified immediately. Put the resident on 1:1 when needed and document .An investigation into what triggered the abuse shall be conducted by the DON with referrals made accordingly .The facility shall prevent the occurrence of abuse by reviewing past specific…

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 notify the OHCA of a new possible serious mental disorder diagnosis for two (#37 and #20) of six sampled residents reviewed for PASARR assessments. The administrator identified 58 residents who resided in the facility. Findings: 1. A Level I PASARR, dated 07/19/21, documented Res #37 did not have a serious mental illness. On 10/06/21, Res #37 received a new diagnoses of specified persistent mood disorder. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 10/30/24 at 12:10 p.m., the administrator stated OHCA must not have been contacted because the notification information was not documented at the bottom of the Level I PASSAR that was reviewed. 2. Resident #20 had diagnoses which included diabetes mellitus and adjustment disorder with depressed mood. A Level I PASARR screen, dated 11/29/22, documented no serious mental illness. On 01/06/23, the resident was diagnosed with delusional disorder. On 10/31/24 at 11:41 am, the administrator stated the OHCA should have 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.

Based on observation, record review, and interview, the facility failed to ensure: a. vaping of tobacco did not occur inside the facility, and smoking assessments were completed quarterly for one (#35) of two sampled residents reviewed for smoking; and b. oxygen tanks were stored properly for one (#12) of five sampled residents reviewed for oxygen. The DON identified 23 residents who smoked/vaped tobacco products and 13 residents who received oxygen therapy. Findings: A smoking policy, dated 01/09/22, documented smoking/vaping is only allowed in designated areas. The policy documented the courtyard is the only designated area for residents to smoke. 1. Res #35 had a diagnosis of nicotine dependence. A care plan, dated 09/10/20, documented the resident was an unsupervised smoker. The care plan documented the resident would follow facility policy related to smoking areas. An annual assessment, dated 08/12/23, documented the resident was cognitively intact. A quarterly smoking assessment, dated 11/07/23, documented the resident had a minimal problem of smoking in unauthorized areas and…

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

Based on record review, observation, and interview the facility failed to ensure a safe and homelike environment for the residents. The Resident Census and Conditions of Residents report documented 59 residents resided in the facility. Findings: On 10/10/23 at 1:00 p.m., an environmental tour of the facility was completed. On the west hall there were two locations with tape placed across the tiles. The tiles were observed to have been loose. A document provided by the maintenance supervisor documented 18 of 26 broken tiles had been replaced. On 10/11/23 at 9:22 a.m., the maintenance supervisor stated they were available 24 hours a day seven days a week. The supervisor stated they had replaced some tiles on the resident halls but the residents had rolled over them with their wheelchairs before the tile cement had dried and broke them.

Based on record review, observation, and interview the facility failed to ensure: a. the ice machine was locked to prevent possible cross contamination. b. dietary staff washed hands after handling dirty items and before touching clean items. c. hand washing was completed during wound care treatment. The administrator identified 59 residents who resided in the facility and two residents who received wound care treatments. Findings: 1. On 10/11/23 at 8:50 a.m., a resident was observed in the dining room raising the unlocked lid on the ice machine and scooped a cup of ice with their bare hands and placed the ice in a disposable cup. The scoop for the ice machine was was observed lying uncovered on top of the ice machine. On 10/11/23 at 8:56 a.m., the assistant dietary manager stated the ice machine should have been locked and the ice scoop should have been covered. On 10/11/23 at 11:35 a.m., a meal service was observed. An unidentified resident was observed to approach the kitchen door with a glass of ice tea and requested the glass to be emptied. Dietary aide #1 who was wearing…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: On 08/03/23 at 6:56 p.m., an initial tour of the kitchen was conducted. DA #1 was observed to enter the kitchen and was not observed to wash their hands. On 08/03/23 at 7:00 a.m., DA #1 was observed to take the silverware to the dining room and started passing the silverware to the residents in the dining room. The DA was then observed to return to the kitchen and retrieved coffee cups without washing their hands and returned to the dining room. The DA was then observed to return to the kitchen and was observed to touch the top of a trash can and was not observe to wash their hands. The DA was then observed to return to the dining room taking a coffee pot with them to pour coffee for the residents. On 08/03/23 at 7:10 a.m., the lid to the sugar bin was observed to have been broken. At that time the DM stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents' rights to privacy by providing a means of attaining full visual privacy during personal care and/or treatments for three (#1, 4, and #47) of 26 resident's whose rooms were observed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included vascular dementia, anxiety disorder, and carcinoma. A quarterly assessment, dated 05/13/23, documented the resident was severely impaired in cognition, had delusions, and was independent to requiring limited assistance with most ADLs. On 08/03/23 at 10:22 a.m., the resident was observed in their room sitting on a recliner. The resident was not able to be interviewed. The resident was observed to have a roommate who was out of the room at the time. The resident's room was observed to not have privacy curtains or tracts on the ceiling for privacy curtains. On 08/08/23 at 3:46 p.m., the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure the facility maintained a safe, clean, comfortable and homelike environment. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. On 08/03/23 at 7:23 a.m., the coffee bar area was observed to have saw dust on the counter, the floor, and ice machine. The ice machine dispenser tray was observed to be full of water and had visible brown substance between the two plastic layers of the ice dispenser. The ice drop was wiped with a clean white towel and had brown substance was observed on the towel after wiping the ice drop. The wall and floor by the ice machine was observed to have visible spillage of a dark substance on them. On 08/03/23 at 7:25 a.m., the administrator stated housekeeping was responsible for cleaning the ice dispenser at the coffee bar. On 08/03/23 at 7:31 a.m., the housekeeping supervisor stated they were to clean the area of the coffee bar and ice machine daily but…

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 2. Res #20 had diagnoses which included multiple fractures due to a MVA. A quarterly assessment, dated 05/22/23, a significant change assessment, dated 02/20/23, and a quarterly assessment dated [DATE], had the following diagnoses listed as active diagnoses: left humerus fracture, left skull/facial bones fracture, laceration of lip, left radial styloid process fracture, and left clavicle fracture. On 08/08/23 at 1:02 p.m., the MDS coordinator reported they needed to remove the multiple fractures and laceration of lip diagnoses and stated the diagnoses were old and were no longer active diagnoses for Res #20. 3. Res #40 was admitted with diagnoses which included anxiety, schizophrenia, and PTSD. A physician order, dated 09/25/21, read in part, Invega Sustenna 156mg/ml 1 vial IM on the 25th of each month. On 02/16/23, the consultant pharmacist recommended a GDR for Ivega. Res #40's physician refused to attempt a GDR and documented the rationale as schizophrenia. A quarterly resident assessment, dated 04/08/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident with a new possible serious mental disorder was referred to OHCA for two (#26 and #56) of seven sampled residents whose PASRR screenings were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided at the facility. Findings: 1. Res #26 was admitted on [DATE] and had diagnoses which included impulse disorders, dementia with behavioral disturbance, adjustment disorder with depressed mood, and insomnia The resident's PASRR I, dated 12/01/23, documented the resident had a history of mental retardation or a related condition. There was no documentation the resident was referred to the OHCA. The resident's EHR documented a new diagnosis of delusional disorder on 01/06/23. On 08/07/23 at 7:54 a.m., the administrator stated the PASRR form was filled out incorrectly. The administrator stated the resident did not have a MR diagnosis. They were asked if the facility notified the state of the new possible…

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 care plans were updated to meet the residents' needs for five (#3, 26, 40, 46, and #59) of 26 sampled residents whose care plans were reviewed. The facility failed to: a. update the care plan related to falls for Res #40, 26, and #59. b. update the care plan to include diuretic medications and updates for psychotropic medication use for Res #3. c. update the care plan to include new diabetes interventions for #46. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: An undated facility policy entitled, Policy: Falls - Prevention and Risk Reduction Policy:, read in part, 1. The MDS Coordinator will: .d. Update interventions on the falls care plan with any new occurrence of falls . 1. Res #59 had diagnoses which included pain, clostridium difficile, gastrointestinal hemorrhage, and pancytopenia. An admission assessment, dated 06/04/23, documented the resident was severely impaired in cognition, required limited to extensive assistance with most…

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 physician was notified of a foul odor of a surgical wound in a timely manner for one (#21) of five residents sampled for non-pressure skin issues and failed to notify a physician of out of parameters FSBS readings for one (#46) of five residents reviewed for medications. The Resident Census and Conditions of Residents form documented 60 residents resided at the facility. Findings: Res #21 had diagnoses which included anoxic brain damage, disruption of wound, and subsequent encounter of mechanical complication of internal right hip prosthesis. A quarterly MDS assessment, dated 05/03/23, documented the resident was severely cognitively impaired, required extensive assistance with ADL, had a surgical wound, and surgical wound care. The care plan, last revised 06/07/23, documented an abscess to right hip area approximately 6.0 x 4.0 cm. The care plan documented the physician was notified and a new order for Bactrim BID for 5 days and wound care with with Betadine/NS and apply Silvadene was obtained.…

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 pressure ulcers were assessed routinely for two (#4 and #19) of three sampled residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented two residents had pressure ulcers. Findings: 1. Res #19 was admitted to the facility on [DATE] with diagnoses which included COPD, emphysema, idiopathic pulmonary fibrosis, peripheral vascular disease, An admission assessment, dated 06/20/23, documented the resident's cognition was moderately impaired, required extensive assistance with ADLs, and had no pressure ulcers. A nurse note, dated 07/20/23, documented an 1.0 cm in diameter open area to the resident's right outer ankle with erythema present to surrounding tissue. The note documented the physician was notified and order received for heel protectors while in bed and to cleanse BID with NS, Betadine, apply thin layer of TAO, and cover. This was the only assessment documentation found for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received the supervision and assistance to prevent falls for three (#26, 40, and #59) of three sampled residents reviewed for falls and for two (#30 and #39) of two sampled residents reviewed for smoking hazards. The DON identified 27 resident who had falls in 2023 and the Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: An undated facility policy entitled, Policy: Falls - Prevention and Risk Reduction Policy:, read in part, 1. The MDS Coordinator will: .d. Update interventions on the falls care plan with any new occurrence of falls . A Smoking Policy, dated of 06/23/16, read in part .4. The MDS coordinator will: a. Write and maintain a smoking care plan for the resident that includes interventions to maintain residents safety and hygiene. b. Complete a smoking screen with every scheduled resident assessment and any significant change of condition. 1. Res #59 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, record review, and interview, the facility failed to ensure to adequately monitor residents for behaviors and adverse side effects for four (#1, 3, 26, and #28) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 48 residents who lived in the facility received psychotropic medications. Findings: 1. Res #1 had diagnoses which included vascular dementia, generalized anxiety disorder, major depressive disorder, impulse disorder, bi-polar disorder, and psychotic disorder with delusions. A physician order, dated 04/08/20, documented the facility was to administer 15 mg of buspirone (a medication used to treat anxiety) twice daily. A physician order, dated 11/24/20, documented the facility was to administer 100 mg of sertraline (a medication used to treat depression) daily. A care plan, dated 10/26/22, documented to monitor for adverse reactions to medications, increased sedation, changes in level of consciousness, fatigue, restlessness, increased anxiety, over-sedation, headache, nausea. 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, record review, and interview, the facility failed to ensure residents were free from significant medication errors for one (#3) of five residents sampled for medications. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: Res #3 had diagnoses which included diabetes mellitus with hyperglycemia. A physician order, dated 02/22/23, documented the facility was to administer Novolog U-100 insulin twice daily for a FSBS greater than 200. A quarterly assessment, dated 07/14/23, documented the resident was moderately impaired in cognition, required limited to extensive assistance with most ADLs, and received insulin for seven days of the seven day assessment period. The resident's MAR for July was reviewed and documented the facility administered insulin 10 times when the resident's FSBS results were less than 200. On 08/07/23 at 12:52 p.m., LPN #1 reviewed the resident's MAR and stated from the documentation it appeared the resident's dose of Novolog was given when the resident's FSBS reading was not over…

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 residents were informed in advance of the risks and benefits of treatment for two (#3 and #26) of five residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. Res #26 had diagnoses which included delusional disorders, impulse disorders, adjustment disorder with depressed mood, and dementia with behavioral disturbance. A care plan, dated 11/30/22, documented the resident had a diagnosis of dementia with behaviors and was at risk for complications. An admission assessment, dated 12/10/22, documented the resident was moderately impaired in cognition and was independent to requiring supervision with ADLs. The assessment documented the resident received antipsychotic and antidepressant medications daily during the assessment period. A physician order, dated 02/20/23, documented the facility was to administer 1 mg of risperidone (an antipsychotic medication) twice daily for a diagnosis of delusional…

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

Based on interview and record review the facility failed to honor a resident's choice of leaving the facility without staff for one (#9) of one sampled residents reviewed for choices. The Resident Census and Conditions of Residents report, documented 60 residents resided in the facility. Findings: The facility's, Therapeutic Leave Policy, dated 05/01/22, read in part, All residents have the right to take leave with family, friends, with consent or agreement of POA/Guardian, unless the resident is self-determined .Resident(s) may attend church services of choice, with transportation of by church van or POV Res #9 admitted to the facility and had diagnoses which included psychoactive substance abuse with other psychoactive substance-induced disorder, PTSD, and personal history of other mental and behavioral disorders. A quarterly assessment, dated 06/27/23, documented the resident was intact with cognition and was independent with ADLs. The assessment documented the resident had no behaviors. A care plan, dated 05/05/22, documented the resident's plan was to return home when their…

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 complete a quarterly assessment for one (#40) of 18 sampled residents whose clinical records were reviewed for resident assessments. The Resident Census and Conditions of Residents form documented a census of 60 residents. Findings: Res #40's last quarterly assessment was completed on 04/08/23. A quarterly assessment was due on 07/08/23 but was not completed. On 08/08/23 at 1:00 p.m., the MDS Coordinator reported Res #40 should have had a quarterly assessment completed on 07/08/23 and did not.

Based on record review and interview, the facility failed to ensure an RN coordinated and signed the resident assessment for one (#46) of 18 sampled residents whose resident assessments were reviewed. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: An annual assessment for Res #46, dated 03/30/23, was not signed by the RN in one of the two required sections and had been signed by the MDS coordinator LPN in a section which required an RN to review and sign. On 08/08/23 at 2:11 p.m., the MDS Coordinator reported the RN was supposed to sign in two required sections but had only signed one section. The MDS Coordinator reported they signed in the RN section in error.

Based on record review and interview, the facility failed to ensure OHCA was contacted when a resident with a PASRR level I assessment with a diagnosis of a serious mental illness for three (#3, 26, and #56) of six sampled residents reviewed for PASRR assessments. The Resident Census and Conditions of Residents form documented 44 residents had documented psychiatric diagnoses. Findings: 1. Res #3 admitted to the facility and had diagnoses which included vascular dementia, delusional disorder, and major depressive disorder. A PASRR I, dated 03/16/21, documented the resident had a diagnosis of a serious mental illness. A quarterly assessment, dated 07/14/23, documented the resident was moderately impaired with cognition and required limited assistance with most ADLs. The assessment documented the resident had not had behaviors during the look back period. The assessment documented the resident had received an antipsychotic and an antidepressant seven days in the seven day assessment period. On 08/07/23 at 2:58 p.m., the MDS coordinator stated the resident did not have a PASRR II. 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 develop a care plan related to edema and diuretic use for one (#11) of one resident sampled for edema. The Resident Census and Conditions of Residents form documented 60 residents resided at the facility. Findings: Res #1 had diagnoses which included peripheral vascular disease, edema, and history of non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin. An annual assessment, dated 02/09/23, documented the resident received diuretic medication. A quarterly assessment, dated 05/12/23, documented the resident was cognitively intact and received diuretic medication. A physician order, dated 07/08/23, documented an increase of furosemide (a diuretic medication) to 20 mg twice daily. On 08/03/23 at 12:11 p.m., the resident was observed with edema in their feet and legs. Both legs were observed with patches of pink skin. The resident stated they had had sores on her legs from the edema but was better now because of the treatment the physician ordered. On 08/07/23 at 11:53…

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 discharge summary documented the required components for one (#61) of two sampled residents whose discharge summaries were reviewed. The DON identified eight residents who were discharged in 2023. Findings: Res #61 was admitted on [DATE] and discharged to family on 06/27/23. The Discharge summary, dated [DATE], documented frequent therapeutic passes with daughter for the recapitulation of Res #61's stay. On 08/08/23 at 10:30 a.m., the DON reported the discharge summary did not adequately reflect a recapitulation of Res #61's nine year stay in the facility.

Based on observation, record review, and interview, the facility failed to follow their policy for medications regimen reviews for one (#1) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 48 residents who resided in the facility received psychotropic medications. Findings: A facility policy titled Consultant Pharmacist Reports, dated 2006 and revised in January 2018, read in part: .D. In performing medication regimen reviews, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards, .G. Recommendations are acted upon and documented by the facility staff and/or the prescriber . Res #1 had diagnoses which included vascular dementia, generalized anxiety disorder, impulse disorder, major recurrent depressive disorder which was severe with psychotic symptoms, bipolar disorder, and psychotic disorder with delusions. A physician order, dated 04/08/20, documented the facility was to administer 15 mg of buspirone (a medication used to treat…

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 residents receiving medications were adequately monitored for side effects for two (#3 and #26) of five residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 60 residents resided in the facility. Findings: 1. Res #26 had diagnosis which included atherosclerosis of native arteries of extremities with intermittent claudication, atherosclerosis of native arteries of extremities with gangrene of the left leg, atherosclerosis of native arteries of left leg with ulceration of other part of foot, chronic total occlusion of artery of the extremities, hypertensive heart disease with heart failure, and chronic systolic (congestive) heart failure. An admission assessment, dated 12/10/22, documented the resident was moderately impaired in cognition, was independent to requiring supervision with most ADLs, and received an anticoagulant medication daily during the assessment period. A physician order, dated 05/12/23, documented the facility was 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 controlled medications in the medication room refrigerator were stored in a permanently affixed compartment. The DON identified one resident who received controlled medications from the refrigerator. Findings: On 08/08/23 at 10:43 a.m., during observations of the medication room, a small black refrigerator, with a lock on the door, contained a metal lock box that was not permanently affixed to the inside of the refrigerator. There was one unopened bottle of Lorazepam (a medication for anxiety) 2mg/ml inside the metal lock box. On 08/08/23 at 10:45 a.m., CMA #1 reported being aware the metal lock box containing controlled medication should have been permanently affixed to the inside of the refrigerator. On 08/09/23 at 2:00 p.m., the DON reported being unaware the lock box for controlled medications was not permanently affixed and reported it should have been affixed to the inside of the refrigerator.

Based on observation, record review, and interview, the facility failed to ensure standard precautions to be followed to prevent spread of infections during wound care for one (#30) three residents review for wound care. The Resident Census and Conditions of Residents form documented two residents had pressure ulcers. Findings: Res #30 had diagnoses which included open wound of unspecified buttock. A quarterly assessment, dated 05/24/23, documented the resident was intact in cognition and was independent to requiring supervision with ADLs. The assessment documented the resident did not have skin issues. A care plan, dated 07/11/23, documented the resident had an open area to the left intergluteal cleft measuring 6 cm x 2 cm. The care plan documented slough was present to the wound bed and the surrounding tissue felt spongy. The care plan documented the wound had moderate amount of purulent drainage observed. The care plan documented the wound care physician was to assess and provide wound treatment. The care plan documented the staff were to check the site and change the dressings…

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.

2. Res #4 had diagnoses which included unspecified open wound of unspecified buttock, anorexia, and chronic pain. A base line care plan, dated 04/21/23, documented staff were to turn and reposition the resident every two hours, to provide incontinent care every two hours, and to assist the resident with transfers utilizing a mechanical lift. An admission assessment, dated 05/10/23, documented the resident was intact in cognition, required extensive to total assistance with ADLs, and was always incontinent of bowel and bladder. On 08/03/23 at 7:30 a.m., the resident was observed sitting in a recliner. The resident was observed to have been covered with a blanket and had a cap on. The resident's shoulders were observed to have been bare and a transfer sling was observed under the resident. At that time, the resident stated when the staff did incontinent care the last time they placed them in the recliner. The resident stated this was several hours ago and they told them at the time they wanted to go back to bed. The resident stated trying to sleep on the recliner was like trying 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 record review and interview, the facility failed to provide an advance directive acknowledgment for 10 (#12, 13, 14, 30, 33, 38, 54, 55, 56, and #160) of 10 residents sampled for advance directives. The Resident Census and Condition of Residents, dated 08/30/22, documented a census of 61 residents. Findings: An Advance Directives policy, dated 12/07, documented in parts, .Prior to admission of a resident to our facility, the social services director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care . and the right to formulate advance directives .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. On 08/30/22, health records for residents #12, 13, 14, 30, 33, 38, 54, 55, 56, and #160 were reviewed and an advance directive acknowledgement was not documented. On 08/30/22 at 3:30 p.m., the administrator was asked if the residents had an advance directive acknowledgement. The administrator stated the residents should…

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 residents' rights were honored by failing to provide a nicotine free environment. The administrator reported there were 33 non-smoking residents. Findings: A smoking policy, dated 01/29/22, did not address vaping. On 08/31/22 at 10:27 a.m., several residents were observed vaping in the dining room around non-smoking residents. On 08/31/22 at 12:00 p.m., two residents were observed vaping in the dining room around non-smoking residents. On 08/31/22 at 2:32 p.m., one resident was observed vaping in the lobby around non-smoking residents. On 08/31/22 at 4:00 p.m., one resident was observed vaping in the dining room around non-smoking residents. On 08/31/22 at 3:35 p.m., The DON stated Our smoking policy does not address vaping, so vaping is allowed in the building. On 09/01/22 at 11:35 a.m., an unnamed resident reported they did not smoke and stated I do not want to be around that stuff. I would prefer they didn't 'vape' in here. On 09/01/22 at 11:45 a.m., an unnamed resident reported they had health…

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 develop a comprehensive person centered care plan for four (#14, 33, 56 and #58) of four residents sampled for care plans. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: The Care Plans-Comprehensive policy, dated 08/01, documented in parts .each resident's comprehensive care plan has been designed to .reflect treatment goals and objectives in measurable outcomes. 1. Res #14 was admitted with diagnoses which included pulmonary heart disease, morbid obesity, and chronic obstructive pulmonary disease. Res #14 physician's order, dated 01/11/21, documented oxygen at 2 liters per minute per nasal canula. There was no care plan for oxygen for Res #14. On 08/31/22 at 9:28 a.m., the MDS coordinator stated the oxygen should have been care planned with interventions. On 08/31/22 at 9:28 a.m., the administrator stated the oxygen had not been care planned but should have been. 2. Res #33 was admitted with diagnoses which included end stage renal disease. 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, record review, and interview, the facility failed to provide restorative care as ordered by the physician for two (#54 and #111) of three residents sampled for restorative care. The Resident Census and Condition of Residents, dated 08/30/22, documented 14 residents required restorative care. Findings: 1. Res #54 was admitted with diagnoses which included hemiplegia, mood disorder, and footdrop (left foot). Res #54 physician's order, dated 05/27/22, documented in part, .ROM/stretching LUE & LLE 6 x week or as tolerated . A document titled Point of Care Restorative Nursing Category Report, documented No Restorative Nursing Data Recorded for res #54 from 07/28/22 to 08/04/22 and from 08/16/22 to 08/26/22. A quarterly assessment, dated 08/17/22, documented the resident was cognitively intact and required moderate assistance with activities of daily living. On 08/30/22 at 3:15 p.m., Res #54 was observed in their room and stated they received restorative care occasionally, it's off and on. On 08/31/22 at 1:32 p.m., the DON reviewed the Point of Care Restorative…

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 follow a safe smoking policy for. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: The smoking policy updated on 01/29/22 read in parts, Smoking is only ALLOWED [sic] in designated areas only. The exit doors and the front portico is non-smoking there is non-smoking posted [sic]. The courtyard is the only designated area for residents to smoke . On 08/30/22 at 9:00 a.m., one resident was observed smoking at the front door less than 15 feet from the entrance. On 08/30/22 at 1:00 p.m., four residents were observed smoking at the front door less than 15 feet from the entrance. On 08/31/22 at 2:35 p.m., the DON stated They know they are not allowed to smoke on the front porch.

Based on observation, record review, and interview, the facility failed to follow their Covid 19 policy for visitors. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: The Core Principles of Covid 19 Infection Prevention policy, dated 04/05/21, read in parts, Screening of all who enter the facility for S/Sx of COVID-19 (e.g. temperature checks, questionnaire regarding signs/symptoms, travel .) & DENIAL OF ENTRY OF THOSE WHO SIGNS/SYMPTOMS OR THOSE WHO HAVE HAD CLOSE CONTACT WITH SOMEONE WITH COVID-19 INFECTION IN THE PRIOR 14 DAYS (regardless of the visitors vaccination status) .Hand hygiene (use of alcohol-based hand rub is preferred .Face covering/mask (COVERING MOUTH & NOSE) . On 08/30/22 at 1:30 p.m., a delivery driver was let into the facility by a staff member and walked into the dining room, stopping at the kitchen door to deliver pizza to the staff. The delivery driver was not screened, did not perform hand hygiene or put on a mask. The delivery driver left at 1:38 p.m. On 08/30/22 at 2:30 p.m., the IP stated, 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 and interview, the facility failed to maintain a safe, clean and sanitary environment. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: On 08/30/22 at 10:00 a.m., a strong odor of urine was noted on the [NAME] Hall. The floors in multiple resident rooms on the [NAME] Hall were not clean. On 08/30/22 at 10:20 a.m., multiple tiles throughout the hallways had pieces missing, were broken and/or held together with black tape. Stained and dirty areas were noted on the hallway floors. On 08/31/22 at 11:30 a.m., a strong odor of urine was noted on the East Hall. Stained and dirty areas were noted on the hallway floors. On 09/01/22 at 1:25 p.m., a strong odor of urine was noted on the [NAME] Hall. On 08/31/22 at 3:18 p.m., the DON reported that it was a challenge to keep the facility clean. On 09/01/22 at 11:30 a.m., the administrator reported the tiles in the hallways should have been fixed and the tape removed.

Based on observation and interview, the facility failed to ensure handrails were secure for one of four halls in the facility. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: On 08/31/22 at 9:00 a.m., the hand rails on each side of the storage closet on the [NAME] Hall were observed to be loose. The handrail on the left side of the linen closet on the [NAME] Hall was loose. On 09/01/22 at 2:00 p.m., the administrator reported the hand rails should have been attached and secured.

Based on observation and interview, the facility failed to have an effective pest control program. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: On 08/30/22 at 10:00 a.m., a large number of flies were noted in the hallway and in resident's rooms on the [NAME] Hall. On 08/31/22 at 11:30 a.m., a large number of flies were noted in the hallway and in resident's rooms on the [NAME] Hall. On 09/01/22 at 1:25 p.m., a large number of flies were noted in the hallway and in resident's rooms on the [NAME] Hall. On 08/31/22 at 9:00 a.m., CMA #1 reported there was a problem with flies on the [NAME] Hall. On 08/31/22 at 3:53 p.m., the DON reported there was a problem with flies in the building. On 09/01/22 at 2:42 p.m., the administrator reported flies were a problem in the building.

Based on record review and interview, the facility failed to review and revise a care plan for one (#58) of five residents whose care plans were reviewed. The Resident Census and Conditions of Residents, dated 08/30/22, documented a census of 61 residents. Findings: Res #58 was admitted with diagnoses which included end stage renal disease and dependence on renal dialysis. A physician's order dated, 11/27/20, read in part, Upon return from dialysis check if dressing is intact, is there any edema or new orders . A physician's order dated, 01/21/20, read in part, Keep dressing to port clean and dry. Special instructions: Port site and dressing to stay dry at all times The Resident Progress Notes dated, 01/01/22 through 09/01/22 documented Res #58 refused dialysis 26 times. The dialysis care plan for Resident #58 was not revised to include their non-compliance with going to dialysis and their specific physician's orders related to dialysis care. On 09/01/22 at 12:00 p.m., the DON stated the care plan should have been revised to reflect Res #58's physician's orders and 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.