Tuscany Village Nursing Center

Based on record review and interview, the facility failed to ensure activities of daily living documentation was completed for 1 (#2) of 3 sampled residents reviewed for ADL's.LPN #2 identified 120 residents resided at the facility.Findings:An undated face sheet for Resident #2, showed diagnoses which included hemiplegia and hemiparesis following cerebral infarction affection left non-dominant side, muscle weakness, cerebral infarction, and bipolar disorder. Resident #2's significant change assessment, dated 05/01/25, showed cognitively intact cognition with a BIMS of 15.A policy titled ADL Dysphagia and Dining, dated 01/23/23, read in part, 17. Document percentage consumed in EHR. Review of the ADL documentation for March and April 2025, did not show any documentation of intake and output or meal percentages for 04/01/25 through 04/07/25, the days leading up to the 04/07/25 hospital stay.On 06/18/25 at 3:49 p.m., the regional nurse consultant stated via an email response, they had provided all the ADL documentation they had for March and April 2025.On 06/20/25 at 9:33 a.m., 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 staff did not use disinfectant wipes to clean residents' skin for 2 (#23 and #70) of 2 sampled residents observed during a finger stick for blood sugar and insulin observation. The corporate nurse identified 39 diabetic residents resided in the facility. Findings: On 04/01/25 at 7:41 a.m., LPN #2 was observed to gather supplies to obtain a blood sugar. They were observed to go to Resident #70 and clean the resident's finger with a disinfectant wipe prior to obtaining the blood sugar. On 04/01/25 at 7:49 a.m., the disinfectant wipe container was observed to show Not for use on skin. On 04/01/25 at 7:51 a.m., LPN #2 was observed to gather supplies to obtain another blood sugar. They were observed to go to Resident #23 and clean the resident's finger with a disinfectant wipe prior to obtaining the blood sugar. On 04/01/25 at 8:02 a.m., LPN #2 was observed to clean Resident #23's skin on their abdomen with a disinfectant wipe and administer insulin. A Safety Data Sheet for the disinfectant wipes, dated…

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

Based on observation, record review, and interview, the facility failed to ensure staff were competent with the facility's EMR for 3 (CMA #1, LPN #2, and AD) of 3 staff observed for competent staff. The DON identified 111 residents resided in the facility. Findings: On 04/01/25 at 8:05 a.m., during a medication observation pass with CMA #1, a medication for a Resident #70 was observed not to be administered. In-service sheets for the new EMR, dated 03/05/25, 03/06/25, 03/10/25, and 03/12/25, did not show CMA #1, LPN #2, or the AD attended the in-services. On 04/01/25 at 8:08 a.m., CMA #1 stated the medication was not in the facility. They were asked how medications were ordered. CMA #1 stated as far as they knew, it was on the new EMR system. CMA #1 was asked if they could look at the new EMR and tell if the medication had been ordered. They stated they had not been trained on the new EMR and did not know how to tell if the medication had been ordered. CMA #1 stated they came into work one morning and the new EMR was in place. On 04/02/25 at 10:35 a.m., LPN #2 stated they did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered for 5 (#70, 71, 77, 106, and #226) of 10 sampled residents reviewed for medications. The DON identified 111 residents resided in the facility. Findings: 1. On 04/01/25 at 7:17 a.m., CMA #2 was observed to administer medications to Resident #71. Resident #71 had an order for hydrocodone/acetaminophen (an opiate medication) 7.5/325 mg every six hours that was not administered. 2. On 04/01/25 at 7:25 a.m., CMA #2 was observed to administer medications to Resident #226. Resident #226 was administered Vitamin B12 10 mcg without an order. Resident #226 had physician's orders to administer thiamine (a vitamin) 100 mg daily at 9:00 a.m. and ferrous sulfate (a iron supplement) 325 mg daily at 9:00 a.m. that were not observed to be administered. 3. On 04/01/25 at 7:46 a.m., CMA #2 was observed to administer medications to Resident #106. Resident #106 had an order for lisinopril (an ACE inhibitor)10 mg…

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 was less than 5 percent for 5 (#70, 71 77, 106, and #226) of 10 sampled residents reviewed for medication administration. The medication error rate was 23.68 percent. The DON identified 111 residents resided in the facility. Findings: 1. On 04/01/25 at 7:17 a.m., CMA #2 was observed to administer medications to Resident #71. Resident #71 had an order for hydrocodone/acetaminophen (an opiate medication) 7.5/325 mg every six hours that was not administered. 2. On 04/01/25 at 7:25 a.m., CMA #2 was observed to administer medications to Resident #226. Resident #226 was administered Vitamin B12 10 mcg without an order. Resident #226 had physician's orders to administer thiamine (a vitamin) 100 mg daily at 9:00 a.m. and ferrous sulfate (a iron supplement) 325 mg daily at 9:00 a.m. that were not observed to be administered. 3. On 04/01/25 at 7:46 a.m., CMA #2 was observed to administer medications to Resident #106. Resident #106 had an order for lisinopril (an ACE inhibitor)10 mg daily…

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 maintained for handling soiled linen and hand hygiene during incontinent care for 1 (#52) of 23 sampled residents reviewed for infection control. The DON identified 111 residents resided in the facility. Findings: On 03/25/25 at 9:18 a.m., LPN #1 was observed exiting a resident's room while holding a soiled incontinent pad and took it into the soiled utility room. On 03/31/25 at 5:46 a.m., CNA #1 was observed to provide incontinent care to Resident #52 whose brief was soiled with urine and feces. CNA #1 did not change their gloves after cleaning the resident. CNA #1 used soiled gloves to put a clean brief on Resident #52 and placed a clean incontinent pad and a clean draw sheet under the resident. CNA #1 placed the soiled linen and soiled wipes onto the floor and not into a plastic bag. On 03/31/25 at 6:01 a.m., CNA #1 was observed to place soiled items from the floor into a plastic bag. CNA #1 used soiled gloves to place a clean sheet on top of Resident #52. CNA #1 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 provide treatment and services to promote the healing of a pressure ulcer for one (#2) of three residents reviewed for pressure ulcers. The DON identified eight residents in the facility with pressure ulcers. Findings: A policy titled An Overview of Wound Care, dated July 2018, read in parts .The comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a PU/PI .Effective prevention and treatment are based upon consistently providing routine and individualized interventions .Repositioning or relieving constant pressure is a common, effective intervention for an individual with a PU/PI or who is at risk of developing one . Resident #2 had diagnoses which included Parkinson's disease, cognitive communication deficit, and overactive bladder. A care plan, dated 08/09/23, documented at risk for/actual skin breakdown. The care plan documented staff where to assist the resident to turn and reposition frequently and inspect skin of the…

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

The facility failed to ensure a care plan meeting was held and a resident's representative was included for one (#4) of three sampled residents reviewed for representative included in plan of care. The Administrator identified a census of 128. Findings: Resident #4 had diagnoses which included chronic kidney disease and chronic pain. Resident #4 had a Care Plan Conference on 07/31/23. Resident #4's Annual Resident Assessment was completed on 10/10/23. A Nurse's Note, dated 10/17/24, documented an email was sent to Resident #4's representative regarding setting up a care plan meeting. The next documented Care Plan Conference for Resident #4 was on 02/09/24. On 03/27/24 at 9:18 a.m., LPN #1 stated they were responsible for care plan meetings. They stated the meetings were supposed to be every three months. They stated Resident #4 had a care plan meeting that was missed. They stated the meeting was scheduled, but LPN #1 wasn't working, and no one covered them. They stated it was the meeting that fell between the 07/23 and the 02/24 care plan meetings.

Based on record review and interview, the facility failed to ensure resident records were accurate for one (#3) of three sampled residents reviewed for accurate records. The Administrator identified a census of 128. Findings: A Records Management policy, revised 06/01/17, read in part, .The Organization requires that its records be maintained in a consistent and logical manner and be managed so that the Organization .Meets legal standards for protection, storage, and retrieval .Protects the privacy of healthcare facility residents and patients . Resident #3 had diagnoses which included cerebral infarction and aphasia. Resident #14's hospital records, dated 08/05/23, were observed in Resident #3's clinical record. Resident #13's hospital records, dated 08/07/23, were observed in Resident #3's clinical record. Resident #11's hospital records, dated 09/08/23, were observed in Resident #3's clinical record. Resident #12's hospital records, dated 09/25/23, were observed in Resident #3's clinical record. On 03/21/24 at 2:42 p.m., Medical Records stated they received any resident…

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 food items were properly securely, dated, and labeled for one of one kitchen observation. The Administrator identified 130 residents received services from the kitchen in the facility. Findings: The FOOD STORAGE policy, dated 08/01/18, read in part, .Air-tight containers or bags are used for all opened packages of food. All containers are accurately labeled with the item or date opened .All foods are covered, labeled and dated . On 02/26/24 at 9:00 a.m., during the initial kitchen visit of the dry storage pantry, two opened boxes of quick creamy wheat were observed. The opened boxes were not secured. On 02/26/24 at 9:01 a.m., the CDM picked the two boxes up. They stated the boxes were not secured. On 02/26/24 at 9:02 a.m., two white bulk storage containers containing a white substance were not labeled or dated. On 02/26/24 at 9:04 a.m., the CDM was observed putting a label on each bulk storage container. One container was labeled flour and dated 02/26 and the other was labeled sugar and dated 02/26. On…

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

Based on record review and interview, the facility failed to notify the physician when a resident's blood pressure was abnormal for one (#105) of three sampled residents reviewed for hospitalization. The Administrator identified 134 residents resided in the facility. Findings: The MEASURING BLOOD PRESSURE policy, revised 01/12/18, read in part, .Report abnormal findings to the nurse in charge or the healthcare provider . Resident #105 had a diagnosis of hypertension. A physician's order, dated 07/17/23, documented amlodipine 5 mg give one tablet by mouth one time per day related to hypertension. Hold for systolic blood pressure below 100 or diastolic blood pressure below 60. Notify physician if held times three days. Resident #105's January 2024 EMAR documented the following blood pressures with the administration of amlodipine 5 mg: a. 198/78 on 01/08/24; b. 189/89 on 01/09/24; c. 176/87 on 01/14/24; d. 171/96 on 01/19/24; e. 165/97 on 01/20/24; f. 166/92 on 01/21/24; g. 160/93 on 01/24/24; h. 173/94 on 01/26/24; and i. 197/92 on 01/27/24. On 02/28/24 at 1:54 p.m., the ADON 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.

Based on observation, record review, and interview, the facility failed to maintain a homelike environment for one (#29) of 27 sampled residents reviewed for home like environment. The Administrator identified 134 residents resided in the facility. Findings: Resident #29 had diagnoses which included hemiplegia and hemiparesis affecting the left non-dominant side. On 02/26/24 at 3:17 p.m., a hole was observed on the wall behind Resident #29's head of the bed. There was a tan, rectangular wall plate with a silver adapter hanging below the hole. On 02/26/24 at 3:20 p.m., a hole was observed on the wall by the air conditioner in Resident #29's room. Resident #29 stated they did not know what caused the holes or when they occurred. On 02/26/24 at 3:29 p.m., CNA #1 observed the holes in Resident #29's room. They stated they saw the holes the night before but did not know when they occurred. On 02/26/24 at 3:30 p.m., CNA #1 stated they had not put in a maintenance request for the holes in the Resident's room. On 02/28/24 at 1:45 p.m., the Maintenance Supervisor stated they expected staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#124) of two residents reviewed for discharge. The administrator identified 134 residents resided in the facility. Findings: A Recapitulation Summary policy, revised 01/12/20, read in part, .The staff will complete a recapitulation summary per standard practice guidelines .The recapitulation summary should be completed as an interdisciplinary teams at the time of discharge .The summary should be completed within 20 days of the date of discharge . Resident #124 admitted on [DATE] with diagnoses that included metabolic encephalopathy and malignant neoplasm of brain. Resident #124's face sheet documented the resident discharged on 12/23/23. On 02/28/24 at 11:00 a.m., the DON was asked for Resident #124's discharge summary. On 02/28/24 at 11:02 a.m., the DON stated the discharge summary had not been completed.

Based on record review and interview, the facility failed to ensure residents toenails were trimmed for one (#232) of 27 sampled residents who were reviewed for ADL's. The Administrator identified 134 resident who resided in the facility. Findings: A Foot and Toenail Care, Routine policy, read in part, Residents will be provided routine foot and toenail care within the professional scope of practice for CNAs, LVN/LPNs and RNs as is dictated per state guidelines and in accordance with standard practice . Resident #232 had diagnoses which included brain stem stroke syndrome and pain. They did not have diagnoses of diabetes or peripheral vascular disease. A physician's order, dated 02/24/24, documented podiatrist consult to evaluate and treat and trim painful, mycotic, toenails and calluses for prophylactic measures. On 2/26/24 at 2:56 p.m., resident #232's right foot was observed to have long, thick, curved toe nails. The resident stated they would like them cut. On 2/27/24 at 8:51 a.m., resident #232's bilateral feet were observed to have long, thick, curved toe nails. There was no…

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 pressure ulcers were assessed upon admission for one (#38) of three residents reviewed for pressure ulcers. The DON identified 18 residents had pressure ulcers. Findings: An Overview of Wound Care policy, effective July 2018, read in part, .It is important that each existing PU/PI be identified, whether present on admission or developed after admission .When assessing the PU/PI itself, it is important that documentation addresses .The type of injury .The PU/PI's stage .A description of the PU/PI's characteristics The progress toward healing .Presence of infection .The presence of pain .A description of dressings and treatments . Resident #38 admitted on [DATE] with diagnoses which included pressure ulcer of right hip, stage 4, pressure ulcer of sacral region, stage 4, and pressure ulcer of left heel, stage 4. A Skin Data form, dated 08/30/23, read in part, .Upon assessment, this nurse noticed all wounds were covered with dressings. 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.

Based on record review and interview, the facility failed to ensure there was ongoing communication with the dialysis center and ongoing assessment of a resident before and after dialysis for one (#20) of one resident reviewed for dialysis. The DON identified 4 residents residing in the facility received dialysis. Findings: A facility policy, titled Dialysis - Hemodialysis, reviewed 04/14/23, read in part, .The dialysis staff and the community staff will participate in ongoing communication by completing the dialysis collection form as follows: .EHR .Resident Data Collection>Dialysis .Pre-Dialysis: Section A to be completed by the sending community licensed nurse and to accompany patient to the dialysis center .Post Dialysis: Community nurse to complete Section B with dialysis with dialysis center information. Community nurse to assess and complete Section C .Place document in the appropriate section of the medical record . Resident #20 had diagnoses which included end stage renal disease, hypertensive heart, chronic kidney disease with heart failure with stage 5 chronic kidney…

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 administer medications as ordered for one (#105) of three sampled residents reviewed for hospitalization. The Administrator identified 134 residents resided in the facility. Findings: The PHYSICIAN ORDERS (ADMISSION) policy, revised 01/12/20, read in part, .The licensed nurse reviews orders from the transfer record from an acute care hospital or other entity .A call is placed to the physician to confirm the orders . Resident #105 had a diagnosis of hypertension. A physician's order, dated 07/17/23, documented amlodipine 5 mg give one tablet by mouth one time per day related to hypertension. Hold for systolic blood pressure below 100 or diastolic blood pressure below 60. Notify physician if held times three days. A hospital Discharge Summary Notes, dated 01/29/24, documented to continue taking amlodipine 10 mg take one tablet by mouth daily. A nursing note, dated 01/29/24, documented Resident #105 returned from the emergency room with no new order. On 02/28/24 at 10:59 a.m., LPN #1 stated when a resident returned from 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 ensure medications were secured for one (Hall 200) of 7 treatment carts observed for medication storage. The facility identified three medication carts and four nurse carts. Findings: A Storage of Medication policy, read in part, .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .allowed access to medication carts .should remain locked when not in use or attended by persons with authorized access. On 02/29/24 at 9:05 a.m., LPN #3 was observed to walk away from the treatment cart without locking it, and went to the nurses' station. Observed inside the cart were insulin syringes, needles, insulin, alcohol pads, and creams. On 02/29/24 at 9:08 a.m., LPN #3 stated the cart was not locked when they returned and that it should always be kept locked. LPN #3 stated that a resident could get something out of the cart and harm themselves if it was not locked.

Based on observation, record review, and interview, the facility failed to ensure adequate portion sizes were offered to residents for one of one meal service observed. The Administrator identified 130 residents received services from the kitchen in the facility. Findings: The PORTION CONTROL policy, dated 08/01/18, read in part, .Portion control will be maintained to ensure nutritional value for all foods offered .Spreadsheets indicating portion sizes per diet are posted at tray line and used to guide the serving at each meal . An undated SSC Tuscany Village F/W 2023, Alternate extended menu for lunch documented a number eight scoop for Spanish rice. On 02/26/24 at 11:15 p.m., the CDM identified the above menu as scheduled to be served for lunch on 02/26/24. On 02/26/24 at 12:15 p.m., [NAME] #2 added one quesadilla, one green scoop of Spanish rice, and one green spoodle of zucchini to a plate. On 02/26/24 at 12:19 p.m., [NAME] #2 added one green scoop of Spanish rice, one green spoodle of pork roast, one black spoodle of potatoes, and one ladle of gravy to a plate. On 02/26/24 at…

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

Based on record review and interview, the facility failed to ensure an antibiotic stewardship program was implemented for one (#119) of six sampled residents whose medications were reviewed. The Administrator identified 134 residents resided in the facility and 20 residents were on antibiotics. Findings: The Antibiotic Stewardship policy, revised 11/17, read in part, .We will monitor antibiotic use .Antibiotic Starts .Days of therapy .Measurement process .Will include tracking of specific key aspects of antibiotic use data for each resident .Antibiotic use data will be compiled monthly by the Director of Nursing or designee, and the Infection Preventionist will interpret the monthly data . Resident #119 had diagnoses which included sepsis and acute respiratory failure with hypoxia. A physician's order, dated 02/20/24, documented zyvox 600 mg give one tablet by mouth two times per day related to sepsis. It had an end date of 12/31/9998. The Infection Control Log dated 02/02/24 to 02/27/24 was reviewed. There was no documentation Resident #119's antibiotic use was monitored. 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 maintain a functioning call light system for one (#29) of 27 sampled residents reviewed for a functioning call light system. The Administrator identified 134 residents resided in the facility. Findings: The CALL LIGHTS ANSWERING policy, revised 02/12/20, read in part, .When leaving the room, be sure the call light is placed within the resident's reach . Resident #29 had diagnoses which included hemiplegia and hemiparesis affecting the left non-dominant side. Resident #29's care plan for stroke, revised 12/06/23, documented to keep call light and most frequently used personal items within reach of the Resident. On 02/26/24 at 3:13 p.m., Resident #29's call light was out of reach of the Resident. The call light was on the recliner with one half of the plate on the floor. Resident #29 was laying in bed. The call light wall plate had exposed red and blue cables. Resident #29 stated the call light was broken a week ago and they holler when they needed help. On 02/26/24 at 3:25 p.m., CNA #1 stated Resident #29 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 dishware was clean for one of one kitchen observation. The Administrator identified 114 Residents received nutrition from the kitchen. Findings: A Cleaning Dishes in Dish Machine policy, dated 08/01/18, read in part, .remove dishes, inspect, and put away if clean and dry .if dishes are not clean, repeat steps . On 01/26/24 at 2:54 p.m., blue handled coffee cups were observed in the clean dish area stacked on trays inverted. 32 cups had a white residue, white small particles, and visible contaminants inside. On 01/26/24 at 2:58 p.m., cook #1 was shown the blue handle plastic coffee cups. They stated they saw some white stuff inside the cup and it did not look clean. [NAME] #1 stated, I don't know what that stuff is, you can wipe it out. On 01/26/24 at 3:05 p.m., the Corporate Dietary Manager was shown the blue plastic coffee cups stored in the clean dish area. They stated they could see the debris and residue inside the cups.

Based on observation, record review and interview, the facility failed to: a. maintain infection control during the provision of incontinent care for two (#8 and #10) of three sampled residents observed receiving incontinent care; and b. ensure staff donned PPE prior to entering a covid-19 positive room for one (#11) of three sampled residents positive for Covid-19. The Administrator identified 123 residents resided in the facility. Findings: The PERINEAL CARE policy, revised 04/10/23, read in part, .Dispose of gloves and used supplies and perform hand hygiene .Apply new gloves and place new brief and change linens as needed . The CORONAVIRUS 2-2019; SARS-CoV-2; COVID-19 policy, revised 08/23, read in part, .The required PPE for COVID-19 isolation rooms or when providing care or services to a COVID-19 positive resident .staff should wear an N95, face shield or goggles, gown, and gloves . 1. Resident #8 had diagnoses which included generalized muscle weakness. On 01/29/23 at 5:33 a.m., CNA #3 entered Resident #8's room and informed the Resident they would be performing incontinent…

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 thorough incontinent care was provided for one (#9) of three sampled residents observed receiving incontinent care. The Administrator identified 123 residents resided in the facility and 70 residents were dependent on staff for incontinent care. Findings: The PERINEAL CARE policy, revised 04/10/23, read in part, Staff will provide perineal care in accordance with standard of practice .Perineal care for a female .Wash labia majora .With dominant hand wash downward from pubic area toward rectum in one smooth stroke . Resident #9 had diagnoses which included hemiplegia and hemiparesis. Resident #9's care plan for elimination, reviewed 10/02/23, documented to provide pericare with incontinent changes. On 01/29/23 at 5:16 a.m., CNA #1 informed Resident #9 they would be performing incontinent care. CNA #1 donned gloves, lowered the Resident's head of the bed, pulled down their brief and wiped the Resident's groin with one wipe. They stated the brief was wet. CNA #1 turned Resident #9 and used one wipe to wipe…

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 incontinence care for dependent residents in a timely manner for one (#9) of three sampled residents reviewed for incontinence care. The Administrator identified 125 residents resided in the facility and 71 residents needed assistance with incontinence care. Findings: The Perineal Care policy, revised 04/10/23, read in part, .Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection . Resident #9 had diagnoses which included abnormalities of gait and mobility. Resident #9's admission resident assessment, dated 10/13/23, documented Resident #9 was cognitively intact and they are dependent on another person for toileting hygiene. Resident #9's care plan for self-care deficit, dated 10/05/23, documented, to provide assistance with self-care as needed. On 12/29/23 at 8:17 a.m., Resident #9 stated incontinence care was last provided around 2:00 a.m. Resident #9 stated they told staff an hour ago that he was incontinent. Resident #9 stated they were…

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

Based on observation, record review, and interview, the facility failed to administer medications as ordered for one (#9) of two sampled residents observed during medication pass. The Administrator identified 125 residents resided in the facility. Findings: The Medication Administration General Guidelines policy, dated 09/18, read in part, .Medications are administered in accordance with written orders of the prescriber . Resident #9 had diagnoses which included vitamin deficiency, GERD, congestive heart failure. A physician's order, dated 10/09/23, documented magnesium oxide 420 mg give one tablet two times a day. A physician's order, dated 10/05/23, documented pantoprazole 40 mg delayed release give one tablet one time a day. A physician's order, dated 10/09/23, documented probiotic 100 billion cell capsule, give one capsule two times a day dietary supplement. On 12/28/23 at 9:20 a.m., a medication pass for Resident #9 was observed. A review of Resident #9's medication administration record for 12/28/23 documented the following medications were not administered in the morning due…

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 report the results of an investigation that resulted in a resident being found in possession of an illegal substance for one (#2) of four sampled residents reviewed for being treated with dignity and respect. The Resident Census and Conditions of Residents report, dated 10/02/23, documented 121 residents resided in the facility. Findings: An Internal Investigative Summary, dated 09/22/23, read in part, .residents complaining about a resident smoking/selling marijuana to other residents A Medication Destruction Log, dated 09/22/23, read in part, .Confiscated marijuana from resident . On 10/03/23 at 3:45 p.m., the Administrator acknowledged a report had not been submitted to OSDH regarding the incident documented in the Internal Investigative Summary written on 09/22/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure: a. call lights were in reach for three (#3,18, and #75), and b. a call light was provided that communicated the resident's needs to staff on duty for one (#36) of 24 sampled resident reviewed for call lights . The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: A Call Lights policy, revised 02/12/20, read in parts, .be sure the call light is placed within the resident's reach . 1. Resident #36 had diagnoses which included seizure disorder, schizoaffective disorder, and bipolar type. A Quarterly Resident Assessment, dated 12/23/22, documented Resident #36's cognition was intact and they used a wheelchair and walker to ambulate. On 01/17/23 at 9:51 a.m., Resident #36 stated they had no call light and were given a hand bell, but staff couldn't hear it. On 01/18/23 at 5:31 p.m., Resident #36 was observed ringing their hand held call bell. The bell sound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide maintenance services necessary to ensure the following: a. a cold water faucet was in good working order one (#49), b. a power wheelchair was clean for one (#10) of 24 sampled residents reviewed for homelike environment, c. carpets were clean and flat for one (Hall 500) of five halls, and d. odors did not linger on one (Hall 500) of five halls observed for odors and homelike environment. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: 1. Resident #49 had diagnoses which included muscle weakness. A Quarterly Assessment, dated 12/15/22, documented Resident #49's cognition was intact. On 01/18/23 at 6:50 p.m., Resident #49 was sitting in their wheelchair outside their room. Resident #49 stated the cold water faucet was broken in their bathroom. Resident #49 stated it had been broken for a couple of months. Resident #49's bathroom's sink was observed…

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: A. provide assistance with eating for one (#71), and B. provide incontinent care in a timely manner for one (#33) of six sampled residents reviewed for ADLs. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. It documented 63 residents required assistance with eating, and 25 residents were dependent on staff for eating. It documented 85 residents were occasionally or frequently incontinent of bladder. Findings: 1. Resident #71 had a diagnoses of quadriplegia. A Quarterly Assessment, dated 12/13/22, documented Resident #71's cognition was intact and they required extensive assistance from staff for eating. On 01/17/23 at 8:51 a.m., Resident #71 stated they didn't get assisted with breakfast a couple of days ago. They stated the staff told them they would be back but didn't return. On 01/18/23 at 5:09 p.m., Resident #71 was laying in bed and their dinner tray was observed next to the resident. The dinner plate was observed to have saran…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure equipment and hall areas were free from potential fall hazards for one (#49) of three sampled residents and one (Hall 500) of five halls observed for accidents hazards. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: 1. Resident #49 had diagnoses which included muscle weakness. A Physician Progress Note, dated 11/11/22, documented the resident was able to self propel short distances in a manual wheelchair. A Quarterly Assessment, dated 12/15/22, documented Resident #49's cognition was intact, the resident utilized a wheelchair, and the resident was independent with locomotion on the unit. On 01/18/23 at 6:50 p.m., Resident #49 was sitting in their wheelchair outside their room. Resident #49 stated the lock on their wheelchair was broken. Resident #49 was observed to push the handle forward, on the right side of the wheelchair, to place it in 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.

3. Resident #24 had diagnoses which included hemiplegia. A Resident Assessment, dated 12/07/22, documented Resident #24 required total assistance of two staff for transfers. A Care Plan, dated 12/27/22, documented Resident #24 required total assistance of two and a lift for transfers. On 01/18/23 at 6:00 p.m., Resident #24's call light sounded. On 01/18/23 at 6:01 p.m., LPN #3 was observed to enter Resident #24's room. Resident #24 told LPN #3 they wanted to go to bed. LPN #3 was observed to go inform CNA #11 that Resident #24 wanted to go to bed. On 01/18/23 at 7:04 p.m., CNA's #11 and #12 were observed to enter Resident #24's room with a total body lift. They were observed to use the lift and transferred Resident #24 to bed. On 01/18/23 at 7:23 p.m., CNA #11 was asked how long Resident #24 waited to be transferred to bed. They stated over an hour. Based on record review, observation, and interview, the facility failed to provide sufficient staffing to ensure: A. feeding assistance was provided timely for one (#71), B. incontinent care was completed timely for one (#33), C. hoyer…

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. medications were administered as ordered for three (#98, 121, and #59) of 11 sampled residents reviewed for medications, and B. an adequate system to track and verify discontinued narcotics to prevent potential misappropriation for five (#181, 183, 125, 184, and #180) of five sampled residents reviewed for narcotic destruction. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: A Medical Administration General Guideline, policy dated 09/16, read in part, .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .An explanatory note is entered on the reverse side of the record . 1. Resident #98 had diagnoses which included vitamin deficiency. A Resident's Consolidated Order report, dated 05/19/21, documented Resident #98 was to receive folic acid 1 mg every day. On 01/23/23 at 8:50 a.m., CMA #1 was observed to administer folic acid 400 mcg to Resident #98. On 01/23/23…

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.

Based on record review, observation, and interview, the facility failed to ensure: a. staff wore masks covering their mouth and nose and washed their hands after touching their face while serving food to residents, b. a Foley catheter bag was not on the floor for one (#71), and c. oxygen tubing was not stepped on or in contact with dried fecal matter on the floor for one (#22) of two sampled residents reviewed for infection control practices. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility, seven had indwelling catheters. The DON identified 117 residents received nutrition from the kitchen and 24 residents had orders for oxygen. Findings: A Personal Protective Equipment Audit policy, undated, read in part , .Mask fits snug to face and below chin . 1. On 01/17/23 at 12:39 p.m., Dietary aide #1 was observed in the kitchen preparing lunch meal trays for in room service. Dietary aide #1 was observed with their mask below their nose. Dietary aide #1 was observed touching their face and nose without washing or…

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 neurological checks were conducted after a fall for one (#1) of three sampled residents reviewed for falls. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: A Neurological Evaluation policy, revised 01/12/20, read in part, .nursing staff will evaluate the resident following suspected head injury or change in level of consciousness .Every fifteen (15) minutes times four .Every thirty (30) minutes times four .Every one (1) hour times four .Every four (4) hours times four .Every eight (8) hours times four .Level of Consciousness .Pupil Reaction .Hand Grasp . Resident #1 had diagnoses which included epilepsy and aphasia. An Incident Report, dated 06/14/22, read in part, .Fall .Witnesses No .Action Taken - Neuro check . A Nurse Progress note, dated 06/14/22 at 10:31 p.m., documented the family requested Resident #1 be sent to the hospital due to the fall. A Discharge Hospital record, dated 06/14/22, documented Resident #1 had a mild,…

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 range of motion restorative care to one (#93) of one sampled resident reviewed for restorative care. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: A Program Philosophy, Goals and Objectives policy, dated 04/2012, read in parts, .The restorative program, promotes and enhance quality of life for patient/residents by assisting them in obtaining or maintaining as much independence and functional skills as possible, as well as preserving, dignity, and self-esteem . Resident #93 had diagnosis of impairment to upper and lower right side. A Restorative Care Plan sheet, dated 04/27/22, documented Resident #93 was to receive continuous restorative care six times a week to maintain and improve adequate range of motion for upper and lower right side range of motion impairment. A Nursing Restorative Care Program, dated from 04/07/22 through 01/24/23, Resident # 93 did not receive restorative care 219 ordered days out of 236 scheduled…

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 physician's orders were obtained for a Foley catheter and catheter care for one (#378) of four sampled residents reviewed for catheters. The DON identified four residents with Foley catheters. Findings: A Physician Orders policy, dated 01/12/20, read in part, .The licensed nurse will receive and transcribe the physician's orders . Resident #378 had diagnosis of unstageable pressure ulcer to right buttock. On 01/17/23 at 10:37 a.m., Resident #378 was observed to have a Foley catheter bag. On 01/24/23 at 9:13 a.m., Corporate Nurse #1 stated there were no orders for the resident's Foley or catheter care in the resident's clinical records.

Based on record review, observation and interview, the facility failed to ensure urostomy supplies were available for one (#10) of five sampled residents reviewed for urinary catheter care. The DON identified one resident had a urostomy. Findings: Resident #10 had diagnoses which included cerebral palsy. A Care plan, dated 11/05/22, documented to keep Resident #10's urostomy tubing below the level of the bladder. A Resident Assessment, dated 12/16/22, documented the resident's cognition was intact. On 01/18/23 at 6:12 p.m., Resident #10 was being assisted to bed. CNA #11 asked Resident #10 where the urostomy drain bag was. Resident #10 stated the staff were using a colostomy bag because the facility didn't have the correct supplies. Resident #10 was observed to have a colostomy bag in place. The bag was observed to be two thirds full of urine. CNA #12 stated LPN #3 had placed the colostomy bag over the urostomy last night. CNA #12 stated LPN #3 couldn't locate a urostomy bag. On 01/18/23 at 7:00 p.m., LPN #3 was asked the reason Resident #10 had a colostomy bag in place over 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, observation, and interview, the facility failed to ensure tube feeding formula was changed within the manufacturers recommended time frames for one (#1) of three sampled residents reviewed for tube feeding. The Resident Census and Conditions of Residents report, dated 01/18/23, documented seven residents received tube feedings. Resident #1 had diagnosis which included aphasia. Findings: A Physician's Order, dated 08/24/22, documented Isosource 1.5 formula to be administered at 60 cc per hour for tube feeding. A Resident Assessment, dated 11/03/22, documented Resident #1 had a tube feeding. A Care plan, revised 12/13/22, documented Resident #1 had enteral tube feeding. On 01/18/23 at 5:04 p.m., Resident #1 was observed to be in bed. Isosource 1.5 formula was observed to be infusing via pump at 60 cc per hour. The formula bag was labeled with the date of 01/17/23 and a time of 1:30 p.m. On 01/18/23 at 5:13 p.m., LPN #5 was asked what the policy was for staff changing out a residents' tube feeding formula. They stated staff changed it every 24 hours. LPN #5 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 record review, observation, and interview, the facility failed to ensure a medication administration observation error rate was less than five percent. There were three errors out of 27 opportunities observed during a medication pass which made the medication error rate 11.11%. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: 1. Resident #98 had diagnoses which included vitamin deficiency. A Resident's Consolidated Order report, dated 05/19/21, documented Resident #98 was to receive folic acid 1 mg every day. On 01/23/23 at 8:50 a.m., CMA #1 was observed to administer folic acid 400 mcg to Resident #98. On 01/23/23 at 9:51 a.m., CMA #1 was asked how they ensured medications were administered as ordered. CMA #1 stated they look at the physician's orders. CMA #1 showed the bottle of folic acid 400 mcg they had administered to Resident #98. CMA #1 stated it wasn't the correct dose and it should have been 1 mg. 2. Resident #121 had diagnoses which included severe protein-calorie malnutrition 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 obtain physician ordered labs for one (#102) of five sampled residents reviewed for laboratory services. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. Findings: Resident #102 had diagnoses which included diabetes mellitus type two and seizures. A Resident's Consolidated Order report, documented lab orders as follows: a. on 06/10/22 for a Complete Blood Count With Auto Differential and a complete metabolic panel to be completed every six months, b. on 10/24/22 for a Hemoglobin A1C to be completed every February, May, August, and November, and c. on 11/16/22 for a LEVETIRACETAM to be completed every December and June. On 01/23/23 at 12:35 p.m., the DON was asked to provide the lab orders listed in the physician orders from January 2022 to current. On 01/23/23 at 1:11 p.m., Corporate nurse #1 stated there were no lab results located. Corporate nurse #1 was asked if the labs should have been completed. They stated Yeah.

Based on record review , observation, and interview, the facility failed to accommodate a resident's religious diet restrictions for one (#36) of one sampled resident reviewed for religious dietary preferences. The Resident Census and Conditions of Residents report, dated 01/18/23, documented there were 120 residents residing in the facility. The DON identified 117 residents received nutrition from the kitchen. Findings: A Food and Nutrition policy, dated 08/01/18, read in part, .Menus are personalized to reflect religious, cultural/ethnic needs and preferences . Resident # 36 had a diagnoses which included type 2 diabetes mellitus with hyperglycemia. A Care Plan, dated 10/24/22, read in part, .Doesn't want coffee or tea on [their] meal tray . On 01/17/23 at 9:51 a.m., Resident #36 was observed to have tea served with their meal in the resident's room. Resident #36 stated they were served tea which is against their religious practices. Resident #36 stated they have informed the facility and they continued to be served tea. On 01/19/23 at 11:34 a.m., MDS Coordinator #2 was asked if…

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 meals were palatable and at an appetizing temperature for one (#71) of eight sampled residents reviewed for dietary services. The Resident Census and Conditions of Residents report, dated 01/18/23, documented 120 residents resided in the facility. The DON identified 117 residents received services from the kitchen. Findings: The facility's Hot and Cold Food Temperatures policy, dated 08/01/18, read in part, .All hot food items must be served to the resident at a palatable temperature . Resident #71 had a diagnosis of quadriplegia. A Quarterly Assessment, dated 12/13/22, documented Resident #71's cognition was intact and they required extensive assistance from staff for eating. On 01/18/23 at 5:09 p.m., Resident #71 was laying in bed and their dinner tray was observed next to the resident. The dinner plate was observed to have saran wrap over the food. Resident #71 stated the tray had been there 40 to 45 minutes. On 01/18/23 at 5:40 p.m., CNA #8 gave Resident #71 a french fry. Resident #71 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.