Hillside Heights Rehabilitation Center

Based on interview and record review it was determined the facility failed to maintain a safe environment free from accident hazards for 1 of 3 sampled residents (#103) reviewed for accidents. This placed residents at risk for injury. Findings include:Resident 103 was admitted to the facility in 5/2024 with diagnoses including unsteadiness on feet and traumatic brain injury.A baseline care plan initiated on 5/20/24 indicated Resident 103 experienced two falls on 5/20/24. Interventions included a PT consultation for strength and mobility, one on one activities if bed bound, and monitoring for bruising, changes in mental status, confusion, and sleepiness.An Unwitnessed Fall investigation dated 5/21/24 revealed at 3:11 AM, Resident 103 rolled out of bed onto the floor. The brakes on both beds in the resident's room were not functioning properly. The incident was considered avoidable due to the bed malfunction.On 11/3/25 at 9:05 AM, Staff 18 (Maintenance Director) stated the bed brakes were checked monthly in the facility. Staff 18 confirmed there was no documentation to verify 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, interview, and record review it was determined the facility failed to provide assistance with eating as care planned for 1 of 3 resident (#112) reviewed for hydration. This placed residents at risk for unmet needs. Findings include:Resident 112 was admitted to the facility in 2/2025 with diagnoses including dysphagia and dementia. A 10/3/25 Quarterly MDS indicated Resident 112 required supervision or touch assistance with eating. A revised care plan dated 9/3/25 revealed Resident 112 had an ADL self-care performance deficit and was dependent on staff to eat. Resident 112 fed herself/himself some of the time but was not consistent and required assistance. In a continuous observation on 11/3/25 at 12:31 PM Resident 112 was observed sitting up in bed with a food tray in front of her/him. He was unable to answer questions, and no staff were observed in room. At 12:45 PM Staff 6 (CNA) was observed walking by Resident 112's room and did not check on Resident 112. At 12:47 PM Staff 6 went into Resident 112's room and asked if she/he was all done and Resident 112…

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

Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 1 of 1 sampled resident (#113) reviewed for abuse. This placed residents at risk for untreated medical needs. Findings include:Resident 113 was admitted to the facility in 11/2024 with diagnoses including stroke and anxiety.A 12/13/24 physician order instructed staff to obtain a sexually transmitted infection (STI) risk panel laboratory test. A 12/14/24 risk panel report indicated no test was specified on the requisition (official request form) for the specimen. The report requested the test code and corresponding test name for the specimen received. The STI increased risk panel required an Aptima swab (A device designed for the collection of samples from various specimen sites to detect infections.) The word URGENT appeared in large letters across the page.A 12/16/24 Encounter Note written by Staff 32 (Former Doctor of Nursing Practice) revealed Resident 113 had foul smelling vaginal discharge and the STI test was denied by the lab. UTI testing was positive,…

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

Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to honor resident food preferences for 4 of 4 sampled residents (#s 17, 19, 21, and 37) reviewed for dietary needs. This placed residents at risk for unmet nutritional needs and lessened quality of life. 1. Resident 17 was admitted to the facility in 2016 with diagnoses including diabetes. On 8/27/24 at 10:36 AM Resident 17 stated she/he was not given a menu to select her/his preferred meals. On 8/29/24 at 10:38 AM Staff 22 (CNA) stated about one month ago the facility stopped providing residents with a menu to choose between the main or alternate meal. Staff 22 stated several residents, including Resident 17, were upset about this as their opportunity to make a choice was taken away. On 8/29/24 at 2:00 PM Staff 18 (Dietitian) stated the facility recently changed the menu system from providing menus to residents each day to providing menus once per week on Fridays. On 8/30/24 at 9:54 AM Resident 17 stated she/he did not receive a weekly menu on Fridays. On 8/30/24…

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 it was determined the facility failed to ensure the kitchen was cleaned, failed to ensure food was stored appropriately and discarded in a timely manner, and failed to monitor refrigerator temperatures for 1 of 1 kitchen and 1 of 2 refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: 1. On 8/26/24 at 9:29 AM during the initial tour of the kitchen the following was observed: a. Walk-in refrigerator: -A plastic container with pickle spears, opened and undated. -A cardboard box containing bananas that were dark brown in color. -A stick of margarine, open to air and undated. -Food crumbs, brown splatters, and various small debris on the floor throughout the walk-in refrigerator. b. Walk-in freezer: -A bag of frozen tapioca hot dog buns with a manufacture expiration of 12/22/22. -A bag of frozen chicken strips, opened to air and undated. -A bag of frozen hamburger patties, opened to air and undated. -A bag of frozen veggie vegan patties, opened to air and undated. -A zip lock gallon bag…

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

Based on observation, interview, and record review it was determined the facility failed to ensure a resident rooms were in good repair and free of odors for 5 of 5 sampled residents (#s 6, 19, 27, 32 and 33) reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. On 8/26/24 at 1:33 PM the following observation was made: Resident 19's air conditioner unit made a loud, high pitch squeak. On 8/30/24 at 10:59 AM Staff 1 (Administrator) and Staff 9 (Maintenance Director) acknowledged the identified environment issue. 2. On 8/27/24 at 9:17 AM the following observation was made: Resident 6's light in the bathroom was burned out. On 8/30/24 at 10:31 AM Staff 20 (Nursing Assistant) stated Resident 6's bathroom light had been burned out for about one week. Staff 20 stated he reported the light and it had not been fixed. On 8/30/24 at 10:59 AM Staff 1 (Administrator) and Staff 9 (Maintenance Director) acknowledged the identified environment issue. 3. On 8/26/24 at 10:57 AM the following observation was made: Resident 27's head of the…

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

Based on observation, interview and record review it was determined the facility failed to ensure Staff 13 (LPN) had the appropriate competencies and skills for infection control during CBG checks and administration of insulin. This placed residents at risk for bloodborne illness and reduced efficacy of medications. Findings include: a. On 8/29/24 at 12:17 PM Staff 13 (LPN) was observed to obtain a CBG for Resident 24. Staff 13 exited the room and placed the glucometer in the east hall treatment cart without cleaning it. On 8/29/24 from 12:17 PM to 12:40 PM continuous observations were made. Staff 13 passed medication and administered insulin to multiple residents. Staff 13 did not clean the glucometer during the observations. On 8/29/24 at 12:40 PM Staff 13 stated Resident 24 was the last CBG check she had to complete prior to lunch. Staff 13 stated she cleaned the glucometers at the beginning and end of shift with purple wipes. Staff 13 further stated she worked at the facility for one month and this was her first nursing job. Staff 13 stated she was trained for about three weeks…

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

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day for 3 of 31 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: A review of the Direct Care Staff Daily Reports from 7/26/24 through 8/25/24 revealed the following dates with no RN coverage: -8/20/24 -8/21/24 -8/22/24 On 8/29/24 at 10:38 AM Staff 1 (Administrator) acknowledged the lack of RN coverage on the identified dates.

Based on observation, interview, and record review it was determined the facility failed to ensure proper storage temperatures were maintained for 1 of 2 medication storage refrigerators, and proper labeling of biologicals and securing of treatment carts for 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications. Findings include: 1. The 8/2024 east hall medication refrigerator temperature logs indicated the temperatures exceeded 46 degrees F on multiple occasions and the temperatures were as high as 73 degrees on 8/21/24. On 8/30/24 at 12:00 PM the medication refrigerator on the East Hall was observed with Staff 2 (DNS) and contained flu vaccines and insulin. On 8/30/24 at 12:00 PM Staff 2 (DNS) stated the medication refrigerator on the east hall contained flu vaccines and insulin and the temperatures were to be kept between 36 degrees F and 46 degrees F. Staff 2 acknowledged the 8/2024 temperature logs indicated the east hall medication refrigerator exceeded 46 degrees F 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 interview and record review it was determined the facility failed to provide risk and benefit information for a psychotropic medication for 1 of 5 sampled residents (#37) reviewed for unnecessary medications. This placed the residents at risk for lack of ability to make informed decisions about their care. Findings include: Resident 37 admitted to the facility in 7/2022 with diagnoses including depression, anxiety, and insomnia. The 1/24/24 physician order indicated Resident 37 received Trazodone (antidepressant) for insomnia. Review of Resident 37's medical record revealed no indication the risks and benefits of the medication was reviewed with the resident. On 8/27/24 at 12:05 PM Resident 37 stated she/he received Trazodone for sleep, depression, and anxiety. Resident 37 stated she/he did not recall going over the risks and benefits of the medication with facility staff or signing a consent for the medication. On 8/29/24 at 1:21 PM Staff 3 (LPN-Unit Manager)) acknowledged there was no evidence to indicate the risk and benefits for Trazodone were reviewed with Resident 37.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 3 of 4 sampled residents (#s 17, 34 and 37) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored. Findings include: 1. Resident 17 was admitted to the facility in 7/2016 with diagnoses including depression. A review of Resident 17's clinical record revealed no evidence the resident was provided with information on the right to formulate an advance directive. On 8/29/24 at 1:40 PM Staff 7 (Director of Social Services) confirmed Resident 17 was not provided information on formulating an advance directive. 2. Resident 34 admitted to the facility in 6/2024 with diagnoses diabetes. Review of Resident 34's medical record indicated no documentation an advance directive was offered or reviewed with the resident or her/his family. On 8/29/24 at 1:42 PM Staff 7 (Director of Social Services) stated he was unable to recall or provide documentation of an advance directive being…

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

Based on observation, interview, and record review it was determined the facility failed to ensure oxygen was administered as ordered and failed to ensure residents' respiratory equipment was maintained for 2 of 2 sampled residents (#s 6 and 10) reviewed for respiratory care, ADLs and dialysis. This placed residents at risk for respiratory concerns. Findings include: 1. Resident 6 was admitted to the facility in 2018 with diagnoses including chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The 10/13/23 Annual MDS indicated Resident 6 was cognitively intact. Resident 6's physician order dated 7/12/24 revealed the oxygen concentrator filter was to be changed weekly. The 8/2024 TAR indicated the external filters were changed weekly and it was last completed on 8/25/24. On 8/27/24 at 9:17 AM the external filters on the oxygen concentrator were observed to have a layer of dust. Resident 6 stated she/he used the oxygen concentrator nightly. On 8/29/24 at 11:11 AM Staff 16 (Med Tech) stated the evening nurse was to clean…

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

Based on observation, interview and record review it was determined the facility failed to ensure the community use CBG glucometer was properly cleaned and sanitized between resident uses for 1 of 1 sampled resident (#24) reviewed during CBG checks. This placed all residents who required CBG checks at risk for bloodborne illness. Findings include: The facility's undated Glucometer Cleaning Competency Check indicated glucometers were to be cleaned with bleach wipes after each use. On 8/29/24 at 12:17 PM Staff 13 (LPN) was observed to obtain a CBG for Resident 24 on the East Hall. Staff 13 exited the room and placed the glucometer in the East Hall treatment cart without cleaning it. On 8/29/24 from 12:17 PM to 12:40 PM continuous observations were made. Staff 13 passed medication and administered insulin to multiple residents. Staff 13 did not clean the glucometer during the observations. On 8/29/24 at 12:40 PM Staff 13 stated Resident 24 was the last CBG check she had to complete prior to lunch. Staff 13 stated she cleaned the glucometers at the beginning and end of shift with purple…

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 it was determined the facility failed to maintain essential kitchen equipment in safe operating condition for 1 of 1 kitchen reviewed for kitchen services. Findings include: On 8/26/24 at 9:34 AM an observation of the walk-in refrigerator in the kitchen revealed a missing door handle to exit the refrigerator. On 8/26/24 at 9:53 AM Staff 19 (Dietary) stated the door handle fell off and Staff 19 was not sure where it went. On 8/26/24 at 10:04 AM Staff 17 (Dietary Manager) acknowledged the door handle fell off and needed to be repaired. On 8/28/24 at 11:30 AM during a follow up visit to the kitchen the walk-in refrigerator door handle was still missing. On 8/30/24 at 10:45 AM Staff 8 (Dietitian) stated the staff needed to find the door handle and screw it in.

Based on interview and record review it was determined the facility failed to notify the resident's family after a change of condition and transfer to a local hospital for 1 of 3 sampled residents (#23) reviewed for change of condition. This placed residents at risk for lack of notification. Findings include: Resident 23 was admitted to the facility in 6/2023 with diagnosis including diabetes. Review of a progress note dated 6/9/23 at 9:01 PM revealed the resident was alert and oriented, delayed responses, possible right upper extremity drift, right lip droop, dizziness and was fidgety. The note indicated the resident was sent to a local hospital for possible transient ischemic attack (mini stroke). Review of a progress note dated 6/10/23 at 1:32 AM revealed the resident returned to the facility with diagnoses of hyponatremia (low sodium) and fatigue. No documentation was found the resident's representative was notified of the transfer to the hospital. In an interview on 12/1/23 at 9:47 AM Witness 1 (Complainant) indicated the facility did not notify the resident's family of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Bassed on interview and record review it was determined the facility failed to provide ADL care for 1 of 8 (#13) sampled residents reviewed for ADLs. This placed other residents at risk for lack of daily care. Findings include: Resident 13 was admitted to the facility on [DATE] with diagnosis including leg and clavicle fractures. Resident 13's care plan revealed she/he was dependent on one person for assistance with bathing/showering. On 2/21/23, Witness 15 (Complainant) stated Resident 13 reported she/he did not receive a shower or bath while at the facilty, which was 21 days. Shower and bath logs reviewed for 2/2023 revealed no showers or baths were given to the resident during her/his stay at the facility. On 12/6/23 at 10:00 AM, Staff 2 (DNS) acknowledged these findings.

Based on observation, interview and record review it was determined the facility failed to ensure the kitchen was cleaned and standard food safety practices were followed for 1 of 1 kitchen. This placed residents at risk for food borne illnesses. Findings include: 1. On 3/20/23 at 10:54 AM the kitchen was toured and the following was observed: -Shelves containing spices and random small cooking tools were unfinished and had a greasy brown film on the surface. The ceiling around the spice area had brown splatters. -Drips of brown debris were located along the edge of the steam table. -The back splash of the grill had large splashes of thick brown and black streaks. -The inside of the microwave contained splatters of food debris and the microwave door had metal that was chipped. -The counters around the microwave and work area had areas of both dust and food particles. -The white air vent above the steam table was covered with black streaks with dust hanging off the vents. -The doorway entrance of the walk-in refrigerator had exposed plaster and the corner molding of the wall 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, interview and record review it was determined the facility failed to follow physicians' orders and care plan interventions for 5 of 16 sampled residents (#s 7, 21, 25, 38 and 44) reviewed for edema, medications, constipation/diarrhea, ADLs and accidents. This placed residents at risk for unmet needs. Finding include: 1. Resident 21 was admitted to the facility in 2022 with diagnoses including stroke. A care plan intervention dated 11/8/22 instructed staff to ensure Resident 21's left upper arm was in a sling and propped on pillows when up in the wheelchair. A care plan revision dated 1/11/23 instructed staff to keep Resident 21's left arm in a sling and supported at all times. On 3/23/23 at 10:07 AM Resident 21 was asked about her/his sling and stated she/he was supposed to wear it but did not know where it was and it was lost. On 3/23/23 at 3:11 PM Staff 31 (RN Unit Manager) was asked about Resident 21's sling. Staff 31 agreed Resident 21 was to wear the sling at all times, he did not know why the sling was not on, and would follow up with therapy and update…

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

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours in a 24-hour period for 17 out of 29 days reviewed for staffing. This placed residents at risk for unassessed needs and lack of care. Findings include: A review of the Direct Care Staff Daily Reports dated 2/20/23 through 3/20/23 revealed no RN coverage for 17 out of 29 days reviewed. On 3/24/23 at 9:11 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility continued to work to find RN coverage for the facility.

Based on interview and record review it was determined the facility failed to ensure the required annual training and annual performance reviews were completed for 4 of 4 sampled CNA staff (#s 15, 25, 28 and 29) reviewed for staffing. This placed residents at risk for unmet needs. Findings include: On 3/23/23 at 9:22 AM Staff 15 (CNA) stated he worked at the facility for a year. Staff 15 stated he did not remember receiving any training about abuse. On 3/23/23 staff start dates, annual performance reviews and annual trainings were requested for Staff 15, Staff 25 (CNA), Staff 28 (CNA) and Staff 29 (CNA). No documentation was received for staff start dates, performance reviews, or annual trainings. On 3/24/23 at 9:16 AM Staff 1 (Administrator) and Staff 2 (DNS) stated the facility changed ownership and there was difficulty obtaining documentation for staff trainings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to follow transmission based precautions for aerosol generating procedures for 1 of 4 halls (East Hall) reviewed for infection control and failed to follow infection control standards for 2 of 4 halls (South and West) reviewed for infection control. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. On 3/22/23 at 9:51 AM room [ROOM NUMBER] had a sign which indicated droplet precautions were in place due to an aerosol generating procedure and facility staff were to wear an N95 mask, gown, gloves and eye protection when in the room from 9:26 AM through 11:26 AM. Staff 25 (CNA) put on a gown and gloves and entered room [ROOM NUMBER]. On 3/22/23 at 9:54 AM Staff 25 confirmed he did not wear an N95 mask or eye protection in room [ROOM NUMBER] and stated he was unaware of the additional precautions. On 3/24/23 at 8:36 AM room [ROOM NUMBER] had a sign which indicated droplet…

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

Based on interview and record review it was determined the facility failed to provide written notification to 2 of 3 sampled residents (#s 303 and 304) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 303 was admitted to the facility with Medicare Part A services in 8/2022. The resident's last covered day of Part A services was 9/2/22. A review of Resident 303's medical record revealed no evidence an Advanced Beneficiary Notice of Non-Coverage was issued. On 3/22/23 at 11:15 AM Staff 27 (Business Office Manager) stated Resident 303 remained in the facility after Medicare Part A services ended and was not issued an Advanced Beneficiary Notice of Non-Coverage. 2. Resident 304 was admitted to the facility with Medicare Part A services in 11/2022. The resident's last covered day of Part A services was on 12/11/22. A review of Resident 304's medical record revealed no evidence an Advanced Beneficiary Notice of Non-Coverage was issued. On 3/22/23 at 11:15 AM Staff 27 (Business Office Manager) 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, interview and record review it was determined the facility failed to comprehensively assess 1 of 2 sampled residents (# 3) reviewed for positioning and mobility. This placed residents at risk for lack of proper care and services. Findings include: Resident 3 was admitted to the facility in 2022 with diagnoses including right-sided paralysis following a stroke. A 3/12/22 Hospital Progress Note revealed Resident 3 had a right hand contracture (a condition of shortening or hardening of muscles, tendons or other tissues). A 3/21/22 admission MDS revealed Resident 3 was documented as having no upper extremity range of motion impairment. A 12/22/22 Quarterly MDS revealed Resident 3 was documented as having no upper extremity range of motion impairment. An ADL care plan revised 8/8/22 revealed no care plan related to range of motion impairment. On 3/20/23 at 4:23 PM Resident 3 stated she/he had a contracture of her/his right hand from years ago. On 3/23/23 at 11:45 AM Resident 3's right hand was observed to be closed in a fist with a soft tube held in the palm of…

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

Based on observation, interview and record review it was determined the facility failed to accurately assess 1 of 1 sampled resident (#s 12) reviewed for privacy. This placed residents at risk for lack of proper care and services. Findings include: Resident 12 was admitted to the facility in 2014 with diagnoses including cellulitis (bacterial skin infection) and diabetes. A 9/2/22 Encounter Note from the physician indicated the plan was to provide a suppressive (long-term) dose of Keflex (antibiotic medication) was to be administered to Resident 12 twice daily for three months. A 12/3/22 hospital Discharge Orders Report indicated Resident 12's Keflex was discontinued. The 1/26/23 Quarterly MDS indicated Resident 12 received antibiotics during the previous seven days. The 1/2023 MAR indicated no antibiotic medications were provided to Resident 12 during that month. On 3/23/23 at 3:01 PM Staff 2 (DNS) confirmed the Quarterly MDS for Resident 12 was inaccurate.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 5 sampled residents (#34) reviewed for medications. This placed residents at risk for unmet needs. Findings include: Resident 34 admitted to the facility in 2023 with diagnoses of cognitive deficit and PTSD (post-traumatic stress disorder). A 1/5/23 Hospital Discharge Summary revealed Resident 34 had a MoCA score (dementia assessment) of 24/30 indicating mild congitve impairment and PTSD. A 1/5/23 care plan revealed Resident 34 was not care planned for cognitive impairment or PTSD. On 3/23/23 at 11:23 AM Staff 16 (Social Service Assistant) stated she completed a PTSD evaluation for Resident 34 and was unaware the PTSD care plan did not automatically trigger from the evaluation. On 3/23/23 at 3:14 PM Staff 9 (Activity Director/Former Social Service Director) confirmed Resident 34 was expected to be care planned for cognitive deficit and PTSD.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to revise care plans for 3 of 5 sampled residents (#s 24, 28 and 38) reviewed for ADLs, nutrition and accidents. This placed residents at risk for unmet needs. Findings include: 1. Resident 24 was admitted to the facility in 2022 with diagnoses including prostate problems and urinary retention. An admission MDS dated [DATE] identified Resident 24: - Had no behaviors, - required extensive assistance (weight bearing) for bed mobility, - limited assistance (non-weight bearing, hands on, guided movements) for transfers, - was independent for eating, - needed limited assistance for toileting, - had no chewing or swallowing problems and no or unknown weight loss or gain. A care plan developed at the time of admission and revised identified: - Behaviors problems revised 10/8/22 for verbal aggression and threatening to staff and others, - limited assistance for bed mobility, - extensive assistance for transfers revised 3/13/23, - set up tray for…

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

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 6 sampled residents (#s 14 and 44) reviewed for ADLs. This placed resident at risk for unmet needs. Findings include: 1. Resident 14 was admitted to the facility in 2015 with diagnoses including stroke and dementia. A public complaint was received on 12/10/21 indicating Resident 14 was not bathed for over a month. The 11/2021 and 12/2021 DSRs (Documentation Survey Report) revealed Resident 14 did not receive any type of bathing from 11/1/21 through 11/8/21 (eight days), 11/11/21 through 11/22/21 (11 days), 11/24/21 through 12/18/21 (25 days) and 12/20/21 through 12/31/21 (12 days). The 2/2023 and 3/2023 DSRs revealed the following: -Resident 14 did not receive any type of bathing from 2/4/23 through 2/9/23 (six days) 2/11/23 through 2/23/23 (13 days), 2/25/23 through 3/20/23 (24 days). -From 3/1/23 through 3/23/23 Resident 14 did not receive personal hygiene four instances on day shift and seven instances on evening…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to accurately assess, identify and provide treatment to wounds for 2 of 2 sampled residents (#s 4 and 28) reviewed for pressure ulcers. This place residents at risk for unmet wound care needs. Findings include: 1. Resident 4 was admitted to the facility in 2022 with diagnoses including heart failure and an ankle fracture. An 10/15/22 Hospital History and Physical identified Resident 4 broke her/his ankle and required surgery. An Operative Report dated 10/15/22 indicated Resident 4's ankle incisions were dressed, a sugar tong (U shaped device used to stabilize a injury) splint was placed and the foot and ankle were wrapped with elastic wrap. The 10/20/22 admission Database (nursing assessment) noted Resident 4 had an ankle fracture, an ADL deficit with no impairments or devices, the resident was non-weight bearing, right and left pedal pulses (ankle and foot) were palpable (felt), normal and the incision could not be…

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

Based on observation, interview and record review it was determined the facility failed to ensure appropriate foot care was provided for 1 of 6 sampled residents (#14) reviewed for ADLs. This placed residents at risk for unmet foot care needs. Findings include: Resident 14 was admitted to the facility in 2015 with diagnoses including diabetes. A public complaint was received on 12/10/21 indicating Resident 14's toenails were long. A review of 12/2021, 1/2022 and 2/2022 TARs and physician orders revealed no nail care was provided to Resident 14. Physician orders dated 1/13/23 instructed staff to provide nail care weekly on Fridays. On 3/22/23 at 11:39 AM Witness 1 (Complainant) stated in 12/2021 Resident 14's toenails were long and she/he had a lot of dead skin built up on her/his feet and in between her/his toes. On 3/20/23 at 11:03 AM Resident 14 stated her/his toenails did not get trimmed regularly and at times her/his toenails got caught on the blanket because they were so long. On 3/22/23 at 11:25 AM Resident 14's toenails were observed with Staff 25 (CNA). Resident 14's…

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

Based on observation, interview and record review it was determined the facility failed to providerange of motionservices and care for contractures for 3 of 7 sampled residents (#s 3, 7 and 9) reviewed for ROM and ADLs. This placed residents at risk for ROM decline. Findings include: 1. Resident 9 was admitted to the facility in 9/2022 with diagnoses including stroke and adult failure to thrive. An 10/11/22 revised care plan indicated Resident 9 required extensive assist of one staff to transfer to the toilet and stand-by assistance with a front-wheel walker for ambulation (ability to walk from place to place with or without an assistive devise). A 1/20/23 Physical Therapy Discharge Summary indicated Resident 9 ambulated 75 feet with stand-by assist, use of a four-wheel walker, and bed mobility and transfers were supervised assist. The 2/2023 Documented Survey Report indicated Resident 9 walked in the corridor three times with assistance, but otherwise the activity did not occur. Resident 9 was totally dependent on others for assistance with toileting for six days. On 3/20/23 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 interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#44) reviewed for behavioral needs. This placed residents at risk for unmet trauma needs and a decrease in their quality of life. Findings include: Resident 44 was admitted to the facility in 2022 with diagnoses including stroke, anxiety, post-traumatic stress disorder, depression, bipolar disorder and cognitive communication deficit. A 12/1/22 admission MDS revealed Resident 44's BIMS score was 14 which indicated she/he was cognitively intact. Resident 14 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble with sleep, felt tired or had no energy, had eating difficulties, felt bad about herself/himself, trouble concentrating and moving and spoke slowly. A review of Resident 44's 12/8/22 care plan revealed four areas which discussed trauma. All areas listed a history of trauma with lists of different examples but did not describe Resident 44's history of trauma.…

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

Based on observation, interview and record review, it was determined the facility failed to complete a person-centered care plan, provide ongoing behavioral health needs and timely address mood symptoms for 1 of 1 sampled resident (#44) reviewed for behavioral needs. This placed residents at risk for unmet behavioral health needs and decrease in their quality of life. Findings include: Resident 44 was admitted to the facility in 2022 with diagnoses including stroke, anxiety, post-traumatic stress disorder, depression, bipolar disorder and cognitive communication deficit. A 12/1/22 admission MDS revealed Resident 44's BIMS score was 14 which indicated she/he was cognitively intact. Resident 14 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble with sleep, felt tired or had no energy, eating difficulties, felt bad about herself/himself, trouble concentrating and moving and spoke slowly. A review of Resident 44's 12/8/22 care plan revealed four areas which discussed trauma. All areas listed a history of trauma with lists of different…

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

Based on interview and record review it was determined the facility failed to provide medically related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 1 resident (#44) reviewed for behavioral and emotional needs. This placed residents at risk for unmet needs. Findings include: Resident 44 was admitted to the facility in 2022, with diagnoses including stroke, anxiety, post-traumatic stress disorder, depression, bipolar disorder and cognitive communication deficit. A 12/1/22 admission MDS revealed Resident 44's BIMS score was 14 which indicated she/he was cognitively intact. Resident 14 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble with sleep, felt tired or had no energy, had eating difficulties, felt bad about herself/himself, had trouble concentrating and moved and spoke slowly. A review of Resident 44's 12/8/22 care plan revealed four areas which discussed trauma. All areas listed a history of trauma with lists of different examples but did not describe Resident 44's history…

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.