Belmont Care And Rehabilitation

Based on interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 1 of 1 sampled resident (# 11) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: Resident 11 was admitted to the facility in 10/2023 with diagnoses including delusional disorders (a mental health condition characterized by persistent false beliefs that are not based in reality). A review of Resident 11's Pre-admission Screening/Resident Review (PASRR) Level 1 form completed on 10/19/23 revealed she/he had serious mental illness and was appropriate for further mental health screening upon admission to the facility. No evidence was found in Resident 11's clinical record to indicate the facility referred her/him for further screening related to her/his serious mental illness. On 2/27/25 at 10:04 AM, Staff 5 (Social Services) stated he did not know Resident 11 was not referred for further screening…

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-centered care plan was implemented for 1 of 4 sampled residents (#21) reviewed for abuse. This placed residents at risk for not being provided appropriate bed mobility assistance. Findings include: Resident 21 was admitted to the facility in 5/2022 with diagnoses including hepatic encephalopathy (a disorder that occurs when the liver is unable to filter toxins from the blood resulting in their build up in the brain and causing confusion, disorientation and other changes) and a spinal fracture. Resident 21's 1/6/24 Annual MDS indicated she/he was cognitively intact. A review of Resident 21's care plan dated 11/14/2022 revealed she/he required assistance from two staff members for bed mobility and she/he was to receive cares in pairs. A facility investigation created and signed by Staff 2 (DNS) on 2/15/24 indicated Staff 22 (Agency CNA) attempted to reposition Resident 21 by herself by guiding her/his hand to grab the headboard and having her/him pull herself/himself up in bed. Staff 22 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 2 of 3 sampled residents (#s 16 and 27) reviewed for an activity program. This placed residents at risk for a decreased quality of life and social isolation. Findings include: 1. Resident 27 admitted to the facility in 2022 with diagnoses including a stroke and disease of the pharynx (throat). A 10/10/22 Activities admission Assessment revealed Resident 27 was nonverbal, dependent on staff and needed one-to-one visits. Resident 27 enjoyed hand massages, manicures, to watch television, listen to audio books and music, visits with family, a Pastor and pets. Resident 27's 10/24/24 Annual MDS assessed her/him with memory problems and rarely to never understood her/his ability to talk. Staff assessed Resident 27's leisure and diversional activity preferences as she/he enjoyed to listen to music, animals, to do things with groups of people,…

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 residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice and account for the residents' experiences and preferences to eliminate or mitigate triggers which may cause re-traumatization for 1 of 4 sampled residents (#26) reviewed for abuse. This placed residents at risk for re-traumatization and a decrease in their quality of life. Findings include: The facility's revised 8/2022 Trauma Informed Care and Culturally Competent Care Policy indicated the guide was to provide the trauma-informed care was in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. It directed staff to identify and decrease exposure to triggers that may retraumatize the resident. Resident 26 admitted to the facility in 2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction after a traumatic event 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 observation, interview and record review it was determined the facility failed to obtain dental services for 2 of 2 sampled residents (#s 16 and 22) reviewed for dental services. This placed residents at risk for unmet dental needs. Findings include: The facility's 12/2016 Dental Services Policy indicated routine and emergency dental services were to be available to meet resident oral health needs in accordance with the resident's assessment and plan of care, and social services representatives were to assist residents with appointments and transportation arrangements for dental services. 1. Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). A care conference note dated 11/11/24 and written by Staff 5 (Social Services) indicated Resident 16 was to receive dental care as available. Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their…

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

Based on observation, interview and record review it was determined the facility failed to ensure a bed rail was inspected and maintained according to manufacturer's recommendations for 1 of 2 sampled residents (#22) reviewed for accidents. This placed residents at risk for potential injury. Findings include: The facility's 2/2021 Assistive Devices and Equipment Policy indicated the following: -Certain devices and equipment that assisted residents with mobility, safety and independence were provided for residents. -Devices and equipment were maintained on schedule and according to manufacturer's instructions. Defective or worn devices were discarded or repaired. Resident 22 was admitted to the facility in 9/2023 with diagnoses including history of falls and unsteadiness on her/his feet. Resident 22's 12/17/24 Quarterly MDS revealed the resident was cognitively intact. Resident 22's 12/27/24 Assistive Device Assessment revealed the resident had bilateral mobility bars (a type of bed rail used to provide support and stability for people with limited mobility) on her/his bed in order…

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 residents who were unable to carry out ADLs independently received personal grooming assistance for 1 of 2 sampled residents (#16) reviewed for ADL care. This placed residents at risk for lack of grooming care needs. Findings include: Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). A physician order dated 1/16/25 revealed Resident 16 was to receive a hair removing face cream as needed for facial hair removal. Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves) and was dependent on staff assistance for all of her/his ADL needs. Resident 16's 2/23/25 ADL Self Care Performance Deficit Care Plan revealed the resident required full assistance from one person to shave. On 2/24/25 at 12:07 PM, Resident 16 was observed in her/his…

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 garbage area dumpsters were covered and free from debris for 1 of 2 facility dumpsters reviewed for sanitation. This placed residents at risk for exposure to used medical supplies. Findings include: On 7/23/24 at 11:00 AM and on 7/24/24 at 8:47 AM the following observations were made: - One bin had one of two lids open throughout both observations - Nine medical gloves were observed under and outside of the bin - One trash bag was observed untied which emitted an odor and contained chucks (bed pads), used briefs, N95 masks, surgical masks, and gloves On 7/24/24 at 10:13 AM Staff 2 (DNS) confirmed the garbage had not been properly maintained.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 1 of 5 sampled residents (#5) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 4 admitted to the facility in 5/2024 with diagnoses including alcohol abuse with alcohol-induced psychotic disorder. Resident 5 admitted to the facility in 5/2024 with diagnoses including chronic respiratory failure. A 10/20/23 facility investigation indicated on either 10/29 or 10/30 an interaction occurred between Resident 4 and Resident 5. Staff indicated Resident 5 was in the hallway near the nurses station when Resident 4 was yelling and swearing at staff calling them bitches. Resident 5 stated Resident 4 was going to leave and Resident 5 was slightly in the way but tried to move out of her/his way. Before Resident 5 could completely move, Resident 4 yelled at her/him stating you're in the fucking way, move! Resident 5 stated she/he felt verbally abused by this statement. On 7/24/24 at 11:40 AM Resident 5…

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 bathing assistance for 1 of 3 residents (#2) reviewed for bathing care. This placed residents at risk for unmet care needs. Findings include: Resident 2 was admitted to the facility in 12/2020 with diagnoses including congestive heart failure. A 4/25/23 Care Plan reported Resident 2 required partial assistance with showers. Review of bathing records from 7/2023 revealed Resident 2 was not provided assistance with showers as scheduled on 7/1/23 and 7/3/23. On 7/23/24 at 1:45 PM Resident 2 stated she/he was not offered showers on 7/1/23 and 7/3/23 which resulted in a period of a week without assistance with showers. On 7/24/24 at 12:13 PM Staff 7 (LPN/Resident Care Manager) confirmed Resident 2's records indicated showers were not provided on 7/1/23 and 7/3/23 and appeared to not have been attempted on these dates.

Based on interview and record review it was determined the facility failed to notify a resident's representative of a change in physician care for 1 of 3 sampled residents (#20) reviewed for care plans. This placed residents and residents' representatives at risk for being uninformed of changes in physician providers. Findings include: Resident 20 was admitted to the facility in 5/2021 with diagnoses including muscular atrophy (the decrease in size and wasting of muscle tissue). Resident 20's 6/5/23 Annual MDS identified the resident with significant cognitive impairment. On 3/4/24 at 11:13 AM Witness 1 stated the facility failed to notify Resident 20 and Resident's Representative of the resident's change in primary care providers. Witness 1 indicated this caused confusion and concern as Resident 20 had developed a long-standing relationship with the previous physician. A review of Resident 20's clinical record revealed Resident 20 was last seen by resident's original primary care provider on 6/21/23. Additional review of records identified Resident 20 was seen by a physician that…

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 RN coverage for 8 hours a day, 7 days a week, for 4 of 28 days reviewed for sufficient staff. This placed residents at risk for lack of RN oversight including resident care and services. Findings include: The facility's Direct Care Staff Daily Reports from 11/1/23 through 11/28/23 revealed the following days where no RN worked eight consecutive hours as a charge nurse: -11/10/23; -11/16/23; -11/19/23 and -11/26/23 On 12/1/23 at 1:03 PM Staff 2 (DNS) confirmed the facility's failure to ensure an RN worked eight consecutive hours as a charge nurse on the days identified. This is a repeat citation previously cited on 5/23/23.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of care by competent staff. Findings include: A review of personnel records on 12/1/23 indicated the following employees had not received their annual performance evaluations: -Staff 11 (CNA), hire date 8/1/22; had no annual performance review documentation on file; -Staff 12 (CNA), hire date 8/1/22; had no annual performance review documentation on file; -Staff 13 (CNA), hire date 8/1/22; had no annual performance review documentation on file; -Staff 14 (CNA), hire date 8/1/22; had no annual performance review documentation on file and -Staff 15 (CNA), hire date 8/1/22; had no annual performance review documentation on file. On 12/1/23 at 12:40 PM Staff 2 (DNS) confirmed annual performance reviews were not completed for the identified staff.

Based on observation, interview and record review it was determined the facility failed to employ a director of food and nutrition services with the required certification for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs. Findings include: The facility's Director of Food Services job description, undated, indicated the qualifications/specifications of the position included: -The employee must be registered as a Food Service/Dietary Manager. Observations from 11/28/23 through 12/1/23 from 7:00 AM to 4:30 PM revealed Staff 6 (Dietary Manager) functioned in the capacity of the facility's director of food and nutrition services. On 11/28/23 at 7:04 AM Staff 6 reported he was not certified as a dietary or food service manager but was currently enrolled in a program to become a certified dietary manager and estimated he would have the course completed in 8/2024. On 12/1/23 at 10:26 AM Staff 1 (Administrator) stated she expected Staff 6 to have the proper credentials for his role as the Dietary Manager.

Based on observation, interview and record review it was determined the facility failed to ensure the resident refrigerators were maintained at 41 degrees F or less for 1 of 2 resident refrigerators reviewed for food storage and handling. This place residents at risk for food-borne illnesses. Findings include: The facility's Food Receiving and Storage Policy, dated 10/2017, indicated refrigerated foods must be stored below 41 degrees F unless otherwise specified by law. On 11/29/23, observations of two resident refrigerators revealed the following: -9:22 AM: The small residents' refrigerator located on the east wall of the dining room near the kitchen entrance revealed a temperature of 45 degrees F. Staff 6 (Dietary Manager) removed the thermometer and placed a new thermometer in the refrigerator. -9:54 AM: Staff 6 reviewed the small resident refrigerator and the new thermometer read 60 degrees F. Staff 6 removed the thermometer and placed another new thermometer in the refrigerator. -11:04 AM: Staff 6 reviewed the small resident refrigerator and the temperature read 48 degrees F.…

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 have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 sampled CNAs (#s 11, 12, 13, 14 and 15) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 11/30/23 CNA records were reviewed and revealed the following: -Staff 11 (CNA), hire date 8/1/22: received 1.50 annual training hours; -Staff 12 (CNA), hire date 8/1/22: received 0 annual training hours; -Staff 13 (CNA), hire date 8/1/22: received 1.04 annual training hours; -Staff 14 (CNA), hire date 8/1/22: received 3.04 annual training hours and -Staff 15 (CNA), hire date 8/1/22: received 7.54 annual training hours. On 12/1/23 at 12:40 PM Staff 2 (DNS) acknowledged the required 12 hours of annual in-service training was not completed by Staff 11, Staff 12, Staff 13, Staff 14 and Staff 15.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 1 sampled resident (#38) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation. Findings include: The facility's 6/2018 Activity Programs Policy and Procedure specified activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. The programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. Resident 38 was admitted to the facility in 10/2023 with diagnoses including dementia, psychotic disturbance, mood disturbance and anxiety. Resident 38's 10/19/23 admission MDS revealed the resident experienced short-term and long-term memory loss, was severely impaired in decision-making and no activity preferences were identified. A 10/12/23 Activities Care Plan indicated Resident 38: -Needed staff assistance to all…

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 follow physician orders for 1 of 5 sampled residents (#22) reviewed for unnecessary medications. This placed residents at risk for unmonitored weight gain. Findings include: Resident 22 was admitted to the facility in 9/2022 with peripheral vascular disease (a circulatory disorder). An 8/6/22 Physician Order instructed staff to obtain Resident 22's weight each day. Resident 22's 11/2023 TAR revealed daily weights were not obtained on the following days: 11/5/23, 11/7/23, 11/8/23, 11/11/23, 11/12/23, 11/14/23, 11/15/23, 11/18/23, 11/19/23, 11/20/23, 11/22/23, 11/23/23, 11/24/23, 11/26/23, 11/27/23 and 11/28/23. On 12/1/23 at 12:37 PM Staff 4 (LPN) confirmed daily weights were not completed per physician order. On 12/1/23 at 1:00 PM Staff 2 (DNS) acknowledged Resident 22's weights should have been completed daily.

Based on observation, interview and record review it was determined the facility failed to follow safety procedures for 1 of 1 sampled resident (#11) reviewed for smoking. This placed residents at risk for smoking related injuries. Findings include: The facility's Smoking Policy and Procedure for Independent and Supervised, last revised 11/2023, indicated the following: -Residents who were dependent for smoking would be provided supervision on the property during designated smoke times. -A resident smoking assessment determined what (if any) assistance or adaptive devices might be need for the resident's smoking safety. -Any recommended adaptive devices would be required to participate in supervised smoke breaks. Resident 11 was admitted to the facility in 9/2023 with diagnosis including schizophrenia (a psychiatric disorder). Resident 11's 9/15/23 smoking assessment revealed she/he required supervision and use of a smoking apron. On 11/30/23 at 3:41 PM Resident 11 was observed smoking in the outside smoking area with no smoking apron on while Staff 7 (CNA) provided supervision. 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, interview and record review it was determined the facility failed to conduct post-dialysis assessments and to ensure post-dialysis communication with the dialysis center was received for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for delayed treatment. Findings include: Resident 28 was admitted to the facility in 11/2023 with diagnoses including chronic kidney disease and diabetes. a. Resident 28's 11/7/23 Care Plan indicated the resident received dialysis three times per week and had a shunt in her/his left arm. On 11/30/23 at 10:57 AM Resident 2 was observed in her/his wheelchair at the end of the west hallway, waiting for transportation to pick her/him up for her/his dialysis appointment. Resident 28 returned from dialysis at 4:23 PM. Observations on 11/30/23 between 4:23 PM and 5:15 PM revealed nursing did not complete a post-dialysis assessment on Resident 28 upon her/his return from dialysis. On 11/30/23 at 10:08 AM and 4:58 PM Resident 28 stated no nursing staff ever checked her/his dialysis shunt or bandage after…

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 rehabilitation services for 1 of 2 sampled residents (#35) reviewed for rehabilitation services. This placed residents at risk for reduced mobility and quality of life. Findings include: Resident 35 was admitted to the facility in 11/2023 with diagnosis including paraplegia (inability to move lower body). Resident 35's 4/7/23 Physician's Order indicated the resident was to be evaluated and treated by PT. The 8/5/23 Physical Therapy Recertification, Progress Report & Updated Therapy Plan indicated Resident 35 was to receive 20 PT treatment sessions from 8/5/23 through 11/2/23. On 11/28/23 at 10:36 AM Resident 35 stated she/he came to the facility for rehabilitation and had not received PT as it was ordered. Resident 35's PT Service Log Matrix from 8/5/23 through 11/2/23 indicated the resident received eight of the 20 planned PT treatment sessions. On 11/30/23 at 3:49 PM Staff 19 (OT Rehab Director) stated facility PT sessions were missed due to staffing shortages in the PT department. On 12/1/23 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 observation and interview it was determined the facility failed to keep door frames to resident rooms in good repair for 2 of 2 halls and maintain safe and clean vents in 1 of 1 library reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Observations made from 5/16/23 to 5/23/23 revealed the door frames to all 19 resident rooms to be chipped, dented or missing paint. On 5/19/23 at 12:51 PM Staff 7 (Maintenance Director) stated he was told he did not need to worry about completing paint touch-ups to resident room door frames as the company's painter was responsible to complete this task. Staff 7 stated the painting project for the building was to start in October 2022 but was delayed due to other priorities. During a facility walkthrough, Staff 7 confirmed the company's painter did not paint or touch up any resident room door frames. On 5/22/23 at 12:07 PM Staff 1 (Administrator) stated the facility's painting project, which included resident room door frames, was to start months ago. Staff 1 acknowledged the door…

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 4. Resident 140 was admitted to the facility on [DATE] with diagnoses including stroke and traumatic brain injury. Resident 140's 5/17/23 admission MDS was incomplete. Observations of Resident 140 from 5/16/23 to 5/17/23 between the hours of 7:51 AM and 2:05 PM revealed the resident in her/his bed. Resident 140's hair was shoulder-length and unkempt, her/his facial hair was unshaven and her/his clothing was disheveled. The resident's right arm hung loosely and was limp at her/his side. When asked questions regarding her/his grooming and hygiene, Resident 140 was focused on her/his television remote, stated she/he could not use her/his right arm and hand and did not provide clear and consistent answers. Resident 140's Care Plan revealed the following: - Focus: Requires assistance/potential to restore function to maximum self-sufficiency for bathing, personal hygiene (combing hair, brushing teeth, shaving, applying makeup, washing/drying face, hands and perineum (genital area). - Goal: Hygiene needs will be met…

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 8 consecutive hours 7 days per week for 20 of 122 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: A review of the Direct Care Staff Daily Reports dated 7/1/22 through 9/30/22 and 4/1/23 through 4/30/23 revealed there were 20 days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period: -7/9/22 -7/30/22 -8/6/22 -8/13/22 -8/16/22 -8/17/22 -8/18/22 -8/20/22 -8/27/22 -9/3/22 -9/10/22 -9/17/22 -9/24/22 -9/29/22 -4/1/23 -4/8/23 -4/15/23 -4/22/23 -4/23/23 -4/29/23 On 5/23/23 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) were informed of the lack of RN coverage for the time period reviewed. No further information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure hair restraints were worn during meal preparation for 1 of 1 sampled kitchen reviewed for sanitary food practices. This placed residents at risk of contaminated food. Findings include: On 5/16/23 at 7:35 AM Staff 11 (Diet Aide) was observed to prepare food in the kitchen without a hair restraint. She stated, oh I forgot mine and put on a hair net. On 5/18/23 at 6:34 AM Staff 12 (Diet Aide) was observed to prepare breakfast sandwiches in the kitchen. She assembled sandwiches and did not wear a hair restraint. She reported she normally wore a hair net but forgot to put one on. A review of the facility's policy, Food Preparation and Service (Revised April 2019), revealed food and nutrition services staff were expected to wear hair restraints, so that hair does not contact food. On 5/18/23 at 10:06 AM staff 8 (Dietary Manager) confirmed he expected kitchen staff to wear hair restraints while they worked with food.

Based on observation and interview, it was determined the facility failed to process laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible for 2 of 2 laundry washing machines reviewed for infection control. This placed residents at risk of contaminated laundry. The findings include: According to the Center for Disease Control and Prevention: Guidelines for Environmental Control in Healthcare Facilities (2003); Laundry and Bedding Section G.II.D: -Do not leave damp textiles or fabrics in machines overnight. On 5/16/23 at 4:01 PM wet laundry which included resident clothing was observed in one washing machine. Condensation was visible on the inside of door windows and the wash cycle was complete. On 5/17/23 at 4:24 PM wet laundry which included resident clothing was observed in both washing machines. Condensation was visible on the inside of door windows and the wash cycles were complete. On 5/18/23 at 6:00 AM wet laundry which included resident clothing was observed in both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to firmly secure handrails in the corridors for 2 of 2 halls reviewed for environment. This placed residents at risk for accidents. Findings include: Observations made on 5/16/23 at 9:48 AM included the following: - The hand rail between room [ROOM NUMBER] and the Bath Room was observed to be loose and missing screws to ensure a secure attachment. - The hand rail between room [ROOM NUMBER] and the Oxygen Room was observed to be loose and missing a screw on the right side. The right side of the hand rail was not attached to the wall. On 5/19/23 at 12:45 PM Staff 7 (Maintenance Director) stated he constantly fixed and repaired the railings at the facility. Staff 7 stated he started working at the facility in October 2022 and the hand rails slowly worsened since that time. During a facility walk-through with Staff 7 on 5/19/23 at 12:51 PM, Staff 7 observed the loose hand rails and stated he last completed a hand rail audit on 4/3/23 and 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 and interview it was determined the facility failed to ensure a resident's privacy was maintained for 1 of 1 sampled resident (#5) reviewed for privacy. This placed residents at risk for loss of dignity and privacy. Findings include: Resident 5 was re-admitted to the facility in 11/2022 with diagnoses including chronic obstructive pulmonary disease (a disease that damages the lungs in ways that make it hard to breathe). Resident 5's 4/27/23 Quarterly MDS revealed the resident was cognitively intact. Resident 5 had a roommate and her/his room was connected to another shared resident room by a common bathroom. On 5/16/23 at 9:48 AM a resident from the connecting room was observed washing her/his hands at the sink in the common bathroom during the Surveyor's interview with Resident 5 which took place in Resident 5's room. Resident 5 stated the door to her/his bathroom did not close, and as a result, she/he did not have privacy. Resident 5 stated this was very upsetting. On 5/17/23 at 8:30 AM the Surveyor entered the resident's common bathroom and attempted to close…

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 protect the resident's right to be free from physical abuse by a resident for 2 of 7 sampled residents (#s 31 and 89) reviewed for 6 allegations of resident-to-resident abuse. This placed residents at risk for abuse. Findings include: 1. Resident 29 was admitted to the facility in 5/2022 with diagnoses including dementia and schizophrenia (mental condition). Resident 29's 3/9/23 Quarterly MDS indicated a BIMS score of 10 (moderately impaired) and no behaviors demonstrated. Resident 31 was admitted to the facility in 9/2022 with diagnoses including dementia and speech and language deficits from a stroke. Resident 31's 1/3/23 Quarterly MDS indicated she/he was unable to answer the questions and staff assessed her/him with severely impaired cognitive skills and non-verbal. On 2/1/23 at 7:55 PM Staff 36 (LPN) initiated an Incident Audit Report for Resident 29 and Resident 31. Staff 36 documented Staff 18 (CNA) reported Resident 29 slapped Resident 31 on the head. Staff 36 assessed Resident 31 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to develop, review with the resident and provide a written summary of a baseline care plan within 48 hours of admission for 1 of 1 sampled resident (#140) reviewed for new admissions. This placed residents at risk for not receiving person centered care. Findings include: Resident 140 was admitted to the facility on [DATE] with diagnoses including urinary retention. Resident 140's 5/17/23 admission MDS was incomplete. On 5/16/23 at 7:51 AM and 11:59 AM and on 5/17/23 at 10:27 AM, Resident 140 was asked questions regarding her/his plan of care. During the interviews, Resident 140 was focused on her/his television remote and did not provide clear and consistent answers regarding her/his plan of care and if she/he was provided a written summary. Review of Resident 140's health record revealed no baseline care plan, no documentation the resident's plan of care was reviewed with her/him or no evidence the resident was provided a written summary…

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

2. Resident 31 was admitted to the facility in 9/2022 with diagnoses including Vascular dementia (brain damage caused by multiple strokes) with agitation. Resident 31's 4/5/23 Quarterly MDS revealed the resident experienced short-term and long-term memory loss and was severely impaired in decision-making. Resident 31's 5/12/23 Care Plan indicated the resident was to wear a soft helmet at all times for safety except when showering. Observations of Resident 31 from 5/16/23 to 5/18/23 between 6:00 AM to 4:15 PM revealed the resident was in her/his wheelchair or in bed in her/his room. Resident 31 was not observed to wear a soft helmet at any time. On 5/18/23 at 12:03 PM Staff 24 (CNA) stated Resident 31 did not wear a soft helmet at this time. On 5/18/23 at 2:18 PM Staff 25 (CNA) stated Resident 31 stopped wearing the soft helmet about a month and a half ago. On 5/19/23 at 11:11 AM Staff 2 (DNS) expected Resident 31 to wear a soft helmet as instructed in her/his care plan. Based on observation, interview and record review it was determined the facility failed to ensure the care plan…

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 develop and implement an activity care plan and failed to include residents in group and individual activities for 2 of 2 sampled residents (#s 31 and 140) reviewed for activities. This placed residents at risk for isolation and lack of social interaction and engagement. Findings include: The facility's 6/2018 Activity Programs Policy and Procedure specified activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. The programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. 1. Resident 140 was admitted to the facility on [DATE] with diagnoses including urinary retention. Resident 140's 5/17/23 admission MDS was incomplete. Resident 140's health record revealed no activities care plan, no assessments regarding the resident's leisure, social and activity preferences and 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 3. Resident 27 was admitted to the facility in 3/2023 with diagnoses including morbid obesity. A review of Resident 27's 3/2023 admission MDS revealed she/he used an indwelling catheter and was cognitively intact. On 5/18/23 at 12:54 PM Staff 28 (CNA) did not express if Resident 27's catheter bag was to be covered. She confirmed the catheter bag was left uncovered. Resident 27's uncovered catheter bag was visible from the hallway outside her/his room during day and evening shift observations conducted from 5/18/23 through 5/22/23. On 5/22/23 at 2:29 PM Resident 27 stated having her/his catheter bag visible from the hallway made her/him feel pretty bad. Based on observation, interview and record review it was determined the facility failed to ensure a catheter bag was properly placed and failed to ensure a privacy/dignity bag was used for 3 of 4 sampled residents (#s 27, 35 and 140) reviewed for urinary catheters. This placed residents at risk of infection and lack of privacy/dignity issues. Findings include: 1.…

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 dental services for 1 of 2 sampled residents (#23) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 23 was admitted to the facility in 12/2021 with diagnoses including fracture of the left lower leg. On 5/16/23 at 11:32 AM Resident 23 was observed with grey teeth which appeared broken and decayed. She/he stated, I have some holes in my teeth and told staff she/he wanted to see a dentist but staff did not look in her/his mouth. A review of Resident 23's 1/2023 Significant Change MDS revealed she/he was cognitively intact and no obvious or likely cavities or broken natural teeth. No evidence was found in Resident 23's health record indicating a referral was made for dental services. On 5/19/23 at 3:05 PM Staff 6 (Social Services Director) stated he was responsible to submit a referral for dental work immediately or as soon as possible once the resident was assessed by a facility nurse and the need or request for dental work…

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 adequate provision of a variety of snacks outside of mealtimes for 1 of 3 sampled residents (#35) reviewed for food. This placed residents at risk for lack of snacks. Findings include: Resident 35 was admitted to the facility in 4/2023 with diagnoses including protein/calorie malnutrition. Resident 35's 4/14/23 admission MDS indicated the resident was cognitively intact and her/his plan of care included the goal to maintain or improve her/his current weight and nutritional status. Resident 35's current physician diet orders included a regular textured general diet with thin liquids. Review of the 3/2023, 4/2023 and 5/2023 Resident Council Meeting Minutes revealed the following resident concerns related to snacks: 3/14/23: - Resident Feedback/Concern: Snack cart isn't being handed out to all residents, even if they are sleeping, they would like to be woken up for a snack cart. - Facility response/solution: Will add proper snack distribution to all staff meeting. - 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, interview and record review it was determined the facility failed to provide adaptive equipment for 1 of 4 sampled residents (#27) reviewed for ADLs. This placed residents at risk for decreased independence and weight loss. Findings include: Resident 27 was admitted to the facility in 2/2023 with diagnoses including morbid obesity. A review of Resident 27's 3/1/23 admission MDS revealed she/he was cognitively intact and required supervision and setup assistance for meals. On 5/22/23 at 12:34 PM Resident 27's lunch tray was observed with built-up handled utensils which included two forks and one spoon. She/he reported, They never bring me a knife with the built-up handle. I need to cut my sandwich in half but I didn't have a knife. She/he continued, This morning I had a bagel with cream cheese and no knife. How am I supposed to spread my cream cheese on my bagel with no knife? I can spread it myself but not without a knife. The instructions on her/his meal ticket indicated, adaptive equipment built up utensil handles. On 5/22/23 at 12:37 PM Staff 30 (CNA) 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.