York Manor Nursing Home

Based on record review and interview, the facility failed to ensure assessments were encoded and transmitted for 2 (#9 and #45) of 12 sampled residents whose assessments were reviewed.The DON identified 41 residents resided in the facility.Findings: 1. A quarterly assessment, dated 06/11/25, showed Resident #9 had a BIMS score of six, which indicated the resident was severely impaired in cognition for daily decision making. An entry assessment, dated 07/21/25, showed Resident #9 had been readmitted to the facility. A nurse note, dated 07/28/25, showed the resident was sent to the hospital.Review of the assessments in the electronic clinical record did not show a discharge assessment had been completed.An entry assessment, dated 08/04/25, showed Resident #9 had been readmitted to the facility.On 09/11/25 at 12:40 p.m., the MDS coordinator reviewed the assessments in the electronic clinical record and stated they should have completed a discharge return anticipated assessment on 07/28/25.2. A quarterly assessment, dated 06/23/25, showed Resident #45 had a BIMS score of 15, which…

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 assessments were accurate for 1 (#16) of 12 sampled residents whose assessments were reviewed.The DON identified 41 residents resided in the facility. Findings:A nurse note, dated 06/18/25, showed Resident #16 had delusions.A nurse note, dated 06/20/25, showed Resident #16 had delusions.A quarterly assessment, dated 06/23/25, showed Resident #16 had a BIMS score of 13 which indicated the resident was cognitively intact for daily decision making, had a diagnosis of schizophrenia, and did not experience delusions during the seven-day look-back period.On 09/11/25 at 2:12 p.m., the DON stated Resident #16 experienced delusions.On 09/11/25 at 3:38 p.m., the MDS coordinator stated they reviewed nurse progress notes when they completed assessments. They stated they were unsure if the assessment was correct related to delusions for Resident #16.

Based on record review and interview, the facility failed to ensure care plans were comprehensive for 2 (#16 and #4) of 12 sampled residents reviewed for comprehensive care plans.The DON identified 41 residents resided in the facility.Findings:1. On 09/09/25 at 10:03 a.m., Resident #16 was observed to speak, and their dentures did not stay in their mouth correctly. On 09/09/25 at 11:03 a.m., Resident #16's upper denture did not stay in place while talking and they repeatedly pushed the upper denture in place with their hand during the interview. An admission assessment, dated 09/23/24, showed the care area assessment triggered dental concerns due to Resident #16 being edentulous. An undated policy Comprehensive Care Plan, read in part, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental and psychosocial needs. A significant change assessment, dated 07/08/25, showed a BIMS of 13 which indicated Resident #16 was cognitively intact for daily decision…

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 revise and accurately revise a care plan for 2 (#9 and #4) of 2 residents sampled were reviewed for care plans.The administrator identified 41 residents resided in the facility.Findings: 1. A progress note, dated 06/05/25, showed Resident #9 was in the common area for dinner meal when they began walking toward the nurses' station. The note showed Resident #9 began running and hit the front door until it opened. The note showed staff was headed towards them during the time, however no one was able to reach Resident #9 before they made it out the door. The note showed Resident #9 was stopped by staff approximately five feet outside the building. The note showed the police department and emergency medical services arrived and Resident #9 was taken to the emergency department for evaluation due to increased anxiety. A progress note, dated 06/05/25, showed Resident #9 returned to the facility at 10:20 p.m., and began pacing about the facility walking towards doors and was on one-on-one observation with staff. A progress note,…

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 medication error rate of 5% or less. Two medication errors were observed out of 31 opportunities, which indicated a 6.25% medication error rate.The DON identified 41 residents receive medications in the facility.On 09/10/25 at 8:19 a.m., CMA #2 was observed to administer Budesonide-Fomotorol Fumarate (a corticosteroid medication for chronic obstructive pulmonary disease) 80-4.5 mcg/act 2 puffs to Resident #45. CMA #2 was not observed to encourage or instruct Resident #45 to rinse their mouth after using the inhaler. Resident #45 was not observed to receive Daliresp (a medication for chronic obstructive pulmonary disease) 250 MCG tablet by mouth.An undated policy titled Administration of Inhalers by Certified Medication Aides, read in part, Encourage mouth rinse if corticosteroid inhaler was used.A physician order, dated 11/21/24, showed Resident #45 was ordered Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT two puffs twice daily. The order showed to rinse mouth with water after each…

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 medications were secured for 1 (treatment cart #1) of 1 treatment carts observed.The DON identified two treatment carts in the facility. Findings: On 09/09/25 at 11:32 a.m., LPN #1 was observed to enter room [ROOM NUMBER]. LPN # 1 was observed to leave the treatment cart #1 unlocked and unattended. On 09/09/25 at 11:34 a.m., LPN #1 returned to treatment cart #1 and lock it. On 09/09/25 at 11:42 a.m., LPN #1 stated they kept medications secured by locking the treatment carts when they were unattended. LPN #1 stated they had not been paying attention when they left treatment cart #1 unlocked and unattended. On 09/09/25 at 4:30 p.m., the DON stated treatment carts were to be kept locked when they were unattended to secure medications.

Based on observation, record review, and interview, the facility failed to ensure menus were followed for 1 meal of 1 meal observed.The DON identified 41 residents ate meals from the kitchen.Findings:On 09/09/25 at 12:00 p.m., soft beef tacos were observed to be served for lunch, no vegetable was served other than the lettuce and tomatoes. On 09/09/25 at 12:01 p.m., cook #1 used tongs to place lettuce, tomatoes and cheese on each plate. The serving of lettuce, tomatoes and cheese was less than three ounces. An undated facility [policy Menus, read in part, Ensure that menus are developed and prepared to meet resident choices including their nutritional, religious, cultural and ethnic needs while using established national guidelines. The facility Production Guides menu, dated 09/09/25, for the noon meal showed soft beef taco with sauce, Spanish rice, capri blend vegetables, shredded lettuce/tomato and summer fruit cup to be served. The menu showed to use the #8 scoop for the shredded lettuce and tomato. On 09/15/25 at 2:03 p.m., the DM stated the serving size for lettuce tomato and…

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

Based on observation, record review, and interview, the facility failed to ensure trash cans were covered in the kitchen for 1 (the trash can by the handwashing sink) of 2 trash cans observed in the kitchen.The human resources employee identified 2 trash cans in the kitchen, and the DON identified 41 residents received nourishment from the kitchen.Findings: On 09/08/25 at 12:05 p.m., the trashcan by the handwashing sink was observed to be uncovered and without a lid. On 09/09/25 at 11:18 a.m., the trashcan next to the handwashing sink was observed to be uncovered and without a lid. An undated policy titled, Disposal of Garbage/Rubbish, read in part, All containers will have tight-fitting lids or covers and will be kept covered when stored or not in continuous use. On 09/15/25 at 2:03 p.m., the DM stated they had never had a lid for the trashcan by the handwashing sink.

Based on record review and interview, the facility failed to provide written notices of transfer to residents transferred to acute care hospitals by the facility for three (#17, 27, and #45) of three sampled residents reviewed for discharges and hospitalizations. The ADON stated nine residents had transferred to an acute care hospital in the previous three months. Findings: An undated Transfer and Discharge policy, read in part, Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility informs the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family/representative in selecting the new residence. The policy did not include procedures which included notification in writing prior to transfer. 1. Resident #17 had diagnoses which included Parkinson's disease and dementia. A nurse's note, dated 12/28/24 at 6:23 p.m., documented Resident #17 had been transferred to an…

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

Based on observation and interview, the facility failed to post nurse staffing in a prominent place accessible to residents and visitors. The administrator identified 42 residents who resided in the facility. Findings: On 01/26/25 at 8:54 a.m., a tour of the facility was conducted. No nurse staff posting was observed. On 01/27/25 at 1:40 p.m., the nurse staff posting for the facility was not observed. The DON stated they were not aware the nurse staff posting was not posted or needed to be posted.

Based on observation, record review, and interview, the facility failed to ensure: a. the deep fryer was cleaned after use; and b. refrigerated items were labeled and dated for the residents. The dietary manager identified 40 residents who received meals prepared by the kitchen and two residents who received nutrition via tube feeding. Findings: An undated policy titled Storage of Food in Refrigeration, read in parts, Food being returned to storage after cooking or preparation must be covered .All containers must be labeled with the contents and date food item was placed in storage .Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded. A cleaning schedule documented the deep fryer had not been cleaned the week of 01/20/25 through 01/26/25. On 01/26/25 at 9:12 a.m., a kitchen tour was conducted. The deep fryer had dark grease and food particles around the outside edges of the fryer. On 01/26/25 at 9:17 a.m., dietary cook #1 stated they had not used the deep fryer today. The cook stated the deep fryer did not look…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the facility medical director participated in the quality assessment and performance improvement program. The ADON stated there were 42 residents residing at the facility. Findings: A document titled QAPI Plan for [NAME] Manor Nursing Center, dated 09/30/24, read in part, The goal of a QAPI plan is to provide guidance for performance improvement efforts and assistance with achieving he purpose, guiding principles and scope set in the QAPI program. This plan is a living document that should include input from representatives from all disciplines within the organization and needs to be reviewed and refined at least annually. Thirteen documents titled QAPI Meeting & Agenda, dated on and between 01/25/24 and 12/30/24, documented pre-printed titles of attendees followed by handwritten signatures of those who attended individual QAPI meetings. Each of the forms had the pre-printed words Medical Director followed by a signature line. On each form the…

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

Based on record review and interview, the facility failed to ensure a NOMNC form was provided to a resident within the mandated time frame for one (#10) of three sampled residents reviewed for beneficiary notices. The ADON reported there had been five discharges from Medicare covered part A services in the past six months. Findings: A CMS form 10123 - NOMNC, signed 09/19/24, documented Resident #10's Medicare part A services would end on 09/20/24. The document did not have the resident's signature, but those of two staff members with a written statement that documented the resident's unwillingness to sign. A CMS form 20052 - SNF Beneficiary Notification Review completed by the ADON documented Resident #10 had begun Medicare part A services on 08/28/24 and the last day covered was 09/20/24. On 01/28/25 at 9:10 a.m., the ADON stated residents on CMS part A services were given NOMNC forms at least two days prior to the end of those services. They stated they and another staff member signed the document on 09/19/24 after the resident would not sign the form. They stated because the form…

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 infection control practices were followed for one (#26) of two sampled residents who were reviewed for wound care. The DON identified three residents who were currently receiving wound care treatments. Findings: An undated policy titled Hand Hygiene, read in parts, follow the facility's established hand hygiene procedures to prevent the spread of infection and disease to other staff, residents and visitors .Hands should be washed for at least twenty (20) seconds using soap and water under the following conditions .Before performing invasive procedures .Before handling clean or soiled dressings, gauze pads, etc .After handling used dressings, contaminated equipment, etc .Before putting on gloves .After removing gloves. Resident #26 had diagnoses which included cerebral palsy, spina bifida, and a stage four pressure ulcer to the buttock. A physician order, dated 10/18/24, documented the staff was to cleanse the wound to the right buttock with wound wash, pat dry, apply Medihoney and calcium alginate 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility with one resident who required tube feedings. Findings: 1. On 10/10/23 at 4:59 p.m., the DM was observed to enter the facility from outside and started passing catsup to several of the residents in the dining room. The DM was not observed to perform hand hygiene. On 10/10/23 at 5:07 p.m., DA #1 was observed in the kitchen during meal service. DA #1 was observed to have gloves on and wiped their upper lip and did not change gloves or wash their hands before serving a meal out the window pass. On 10/10/23 at 5:11 p.m., the DM was observed passing tarter sauce in the dining room with gloves on. The DM was observed to place a hand on the cart at the pass then told the kitchen staff a resident wanted more shrimp. The DM then was observed to touch a bowl by the rim, moved something on the table, and then placed the…

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

Based on observation, record review, and interview, the facility failed to ensure residents on the resident trust fund had the right to manage their own financial affairs for three (#1, 37, and #38) of three residents reviewed for trust funds. The facility administrator reported 39 residents were on the trust fund. Findings: On 10/10/23 at 4:23 p.m., Res #38 stated they were on the trust fund and could only get money on Fridays. The resident stated they had asked to have access to it on other days and were told they had to wait until Friday. On 10/10/23 at 6:05 p.m., Res #37 stated they were on the trust fund and could only get money on Fridays. On 10/11/23 at 10:29 a.m., Res #1 stated they could get money from the trust fund on Fridays. The resident stated they though they might have been able to get money every other day but they had only tried to get money on Fridays. On 10/13/23 at 10:16 a.m., the administrator stated residents could get their money Monday through Friday but not on the weekends. The administrator stated currently the residents came on Fridays to get some of…

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

Based on record review and interview the facility failed to ensure quarterly statements were provided to the residents who were on the trust fund for one (#27) of three residents reviewed for trust funds. The administrator reported 39 residents were on the trust fund. Findings: On 10/10/23 at 6:05 p.m., Res #27 stated they were on the trust fund and used to receive quarterly statements but had not received one for a while. The resident stated the person who used to provide them no longer worked at the facility. On 10/13/23 at 10:16 a.m., the administrator stated quarterly statements were mailed to the seven or so residents who wanted them. The administrator stated they would tell others in the trust fund what their balance was if they wanted to know, but did not have documentation of this.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for three (#12, 23, and #28) of 16 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented a census of 42 residents. Findings: 1. Res #28 had diagnoses which included cerebral palsy, chronic total occlusion of artery of the extremities, and immobility syndrome. A quarterly assessment, dated 09/18/23, documented in the restraints section P that bed rails were used daily. On 10/10/23 at 2:41 p.m., two quarter bed rails were observed in the up position on the resident's bed. The resident was not in the bed. The resident was observed in their wheelchair in the room. The resident stated they did not use the bed rails and they were on the bed already. Res #28 stated they did not know why the rails were on the bed. On 10/13/23 at 9:02 a.m., the MDS coordinator stated the bed rails are not used as a restraint for the resident they were used to assist in positioning. The MDS coordinator stated the MDS…

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

Based on observation and interview, the facility failed to ensure: a. dirty linens were stored properly. b. proper PPE was present in the laundry room. c. a program was designed to help prevent the development of Legionnaires' disease and Pontiac fever cased by Legionella bacteria. The Resident Census and Conditions of Residents form documented a census of 42 residents. Findings: 1. On 10/16/23 at 4:09 p.m., the laundry in the facility was observed not to have eye protection or a clothing cover in the laundry room. Two barrels of dirty laundry were observed in the hallway outside of the laundry and near the kitchen door, one with the lid not secure on the barrel of soiled laundry . On 10/16/23 at 4:44 p.m., Laundry #1 stated they were not aware of any goggles or a clothing protector in the laundry room. The laundry staff member stated the two barrels in the hall contained dirty laundry and they brought it back there to get it off the halls. On 10/16/23 at 4:54 p.m., the DM who was also over laundry at that time stated they were not aware of PPE was needed in the laundry room. The DM…

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 code status was documented correctly throughout the residents' clinical records for one (#31) and a DNR consent form documented complete information for one (#3) of two residents reviewed for code status. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: 1. Res #31 had diagnoses which included mood disorder due to known physiological condition with major depressive episodes and Alzheimer's disease. A care plan, dated [DATE], documented the resident had chosen not to execute an Advanced Directive at that time. The care plan documented Res #31 was a full code and wanted life sustaining measures. The care plan documented the Advance Directive wishes would be reviewed annually and was scanned into the residents EHR. An advanced directive/DNR information acknowledgement form dated [DATE], documented the resident did not wish to have CPR. A quarterly assessment,…

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

Based on record review and interview, the facility failed to notify a representative of a discharge to the hospital for one (#96) of three residents sampled for discharges. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: Res #96 had diagnoses which included hypertensive heart and chronic kidney disease. A nurse note, dated 8/29/23, documented the resident was awake but did not respond and was sent to the emergency department of a local hospital. The note did not document the resident's representative was notified of the transfer. The resident's MDS assessments documented a Discharge Return Anticipated assessment on 08/29/23 and an Entry assessment on 08/31/23. A Discharge Return Anticipated assessment, dated 09/14/23, documented the resident was severely impaired in cognition, had rejection of care and wandering, and required supervision to limited assistance with ADLs. On 10/16/23 at 2:28 p.m., the ADON reviewed the note documented on 08/29/23 and confirmed the note did not document the resident's representative 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 record review and interview the facility failed to ensure a significant change assessment was submitted to CMS within 14 days of completion for one (#7) of 21 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: A significant change assessment for Res #7, dated 09/10/23, was completed in the EHR program and documented, Export Ready. On 10/12/23 at 3:30 p.m., the ADON confirmed the significant change assessment had been completed on 09/14/23. They stated the program was having issues with the CAA section when completing assessments for about three weeks but it had been fixed for a while. The ADON stated they did not submit the assessments to CMS, the corporate MDS person did this offsite. The stated they had no way to know if assessments had been submitted to CMS or not. The ADON stated the assessment should have been submitted within 14 days.

Based on record review and interview, the facility failed to ensure a resident with a newly evident possible serious mental disorder was referred to OHCA for one (#12) of one sampled resident whose PASRR screening was reviewed. The Resident Census and Conditions of Residents form documented a census of 42 residents. Findings: Res #12 had diagnoses which included CHF, dementia with behavioral disturbances, and major depressive disorder. A PASRR level I, dated 06/18/09, documented the resident did not have a serious mental illness. On 05/20/13 a new diagnosis of schizoaffective disorder was added to the resident's diagnoses. A significant change assessment, dated 02/02/23, documented the resident was not considered by the state level II PASRR process to have serious mental illness and /or intellectual disability or related condition. The assessment documented the resident received an antipsychotic and an antidepressant for seven days during the look back period. A quarterly assessment, dated 08/02/23, documented the resident was moderately impaired with cognition and required…

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, it was determined the facility failed to ensure baths were performed for one (#31) of three residents sampled for ADLs. The Resident Census and Conditions of Residents form documented a census of 42 residents. Findings: Res #31 had diagnoses which included mood disorder due to known physiological condition with major depressive episodes and Alzheimer's Disease. A care plan, dated 05/17/21, documented the resident required assistance with ADLs. The care plan documented the caregivers would allow the resident a choice between a shower or a tub bath on the resident's scheduled shower days. The care plan documented the resident required assistance with bathing. The care plan documented the care givers would notify the nurse if a noticeable decline in the residents ability to perform ADLs. The care plan did not contain documentation the resident refused bathing. A quarterly assessment, dated 08/23/23, documented the resident was intact with cognition and was independent to requiring supervision with ADLs. The assessment documented the…

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

Based on observation, record review, and interview, the facility failed to administer oxygen according to physician orders for one (#3) of one resident reviewed for respiratory care. The Resident Census and Conditions of Residents form documented 10 residents received respiratory treatments. Findings: Res #3 had diagnoses which included schizoaffective disorder and dissociative identity disorder. A care plan, dated 08/08/22, documented the resident received oxygen therapy. The care plan documented to administer the medication as ordered by the physician and monitor and document side effects and effectiveness. The care plan documented the resident often refused to wear oxygen. A physician order, dated 03/29/23, documented oxygen at 2 L per nasal cannula while sleeping due to severe sleep apnea. A quarterly assessment, dated 08/05/23 documented the resident was intact with cognition and required supervision with most ADLs. The assessment documented the resident received oxygen therapy. The October TAR documented the resident used oxygen 2L at HS. On 10/10/23 at 3:16 p.m., Res #3 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 ensure residents with a diagnosis of post traumatic stress disorder received culturally competent trauma informed care in order to eliminate or mitigate triggers which could cause re-traumatization of the resident for one (#39) of one resident reviewed for behavior. The Resident Census and Conditions of Residents form documented 34 residents had psychiatric diagnoses and two had behavioral needs. Findings: Res #39 had diagnoses which included chronic post-traumatic stress disorder and recurrent major depressive disorder. An annual assessment, dated 08/12/23, documented the resident was independent with most ADLs, had no issues with their mood, and had no behaviors. On 10/11/23 at 10:12 a.m., the resident was observed sitting in her room on her bed. The resident stated they received medications in the morning to help with their depression but it did not help much. The resident's care plan was reviewed and did not document a plan of care to mitigate the resident's possible triggers for the diagnosis of post…

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 review the risks and benefits of side rails with the resident or resident representative and obtain an informed consent prior to installation for two (#13 and #28) of two sampled residents reviewed for side rails. The administrator identified 15 residents in the facility had bed rails on their beds. Findings: A undated policy titled Bed Rails, read in part, .The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation .1. The facility will assess the resident's need for bed trails and all factors involved, including alternatives. Alternatives to bed rails will always be attempted before consideration of bed rail application. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs .the facility must obtain informed consent from the resident or if applicable, the resident representative…

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

Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week and failed to ensure an RN was designated to serve as the DON. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: Documents titled Shiftkey Schedule documented an RN was not present in the building on the dates of 09/03/23, 09/04/23, or 09/06/23. On 10/16/23 at 6:30 p.m., the administrator confirmed there was not on RN in the building on the dated listed above. On 10/16/23 at 7:13 p.m., the administrator stated the previous DON had left the facility employ in August and the facility went without an RN/DON during this time. The administrator stated the facility had an RN in the building most days but there were three days were there was also no RN in the facility.

Based on observation, record review, and interview, the facility failed to ensure the attending physician documented they had reviewed a consultant pharmacist's recommendation or provide a rational for disagreeing with a request to reduce a medication for one (#23) of five residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: Res #23 had diagnoses which included schizoaffective disorder - bipolar type, anxiety disorder, insomnia, and depressive episodes. A consultant pharmacist recommendation, dated 12/14/22, asked the physician to consider a reduction of Latuda 40 mg, Zyprexa 10 mg, Risperidone 3 mg BID (antipsychotic medications), and Topamax 50 mg (a antiseizure medication). The physician responded pt stable; no change on 12/28/22. A consultant pharmacist recommendation, dated 03/07/23, asked the physician to consider a reduction of the resident's dose of Trazodone (an antidepressant medication). The form did not document a response from the physician. A care plan, reviewed 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 significant medication errors did not occur for one (#23) of five residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: Res #23 had diagnoses which included type two diabetes mellitus with hyperglycemia. A physician order, dated 07/13/19, documented the facility was to administer Novolin N (a type of insulin) 20 units daily for a diagnosis of diabetes. A physician order, dated 10/28/22, documented the facility was to administer Novolog by sliding scale daily for a diagnosis of type two diabetes with other diabetic ophthalmic complication. A quarterly assessment, dated 09/22/23, documented the resident was intact in cognition and received insulin daily during the assessment period. A review of the May 2023 TAR did not document the resident's insulin doses were given on 05/10/23 and 05/31/23. A review of the July 2023 TAR did not document the resident's insulin doses were given on 07/05/23 and 07/31/23. 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 prepare food in a form which met the individual needs of residents for one (#10) of one resident reviewed for a mechanically altered diet. The Resident Census and Conditions of Residents form documented a nine resident in the facility with mechanically altered diets and one resident who required tube feedings. Findings: An undated policy titled Therapeutic Diets, read in part .Mechanically altered diet means one in which the texture of a diet is altered . Res #10 had diagnoses which included COPD, schizophrenia, and Alzheimer's Disease. A physician order, dated 10/17/19, documented a regular diet, mechanical soft texture, regular consistency. A care plan, updated 08/18/20, documented the resident was edentulous and received a regular mechanical diet. The care plan documented Res #10's swallow study precautions are as followed remain up right for minimum of 45 minutes after po intake and elevate HOB at all times. The swallow study precautions were to be upright at 90 degrees, multiply swallow x 2 after each bite to clear…

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.