Cedar Crossings

Based on observation, interview and record review it was determined the facility failed to ensure staff completed timely smoking assessments and smoking materials were stored safely for 3 of 3 sampled residents (#s 22, 50, and 60) reviewed for accidents. This placed residents at risk for accidents and smoking hazards. Findings include: A Smoking Policy dated 8/2022 revealed the following: -Resident smoking status is evaluated upon admission to ensure all residents are safe to smoke. -A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. -No resident will be allowed to store any smoking materials in their room. All smoking material will be stored in a secured designated area (a lock box) accessible only to staff. If any smoking materials are seen on residents, please report to nurse or the social worker. -If it is believed that residents are not compliant with locking up smoking materials and have them in their possession the IDT (interdisciplinary team) will be notified. IDT members will 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 interview and record review the facility failed to provide sufficient nursing staff to ensure residents attained or maintained their highest practicable mental, physical, and psychosocial well-being for 5 of 9 sampled residents (#s 2, 8, 22, 26 and 57) reviewed for call light wait times and staffing. This placed residents at risk for lack of ADL care needs. Findings include: a. Resident 26 was admitted to the facility in 2/2023 with diagnoses including morbid obesity and diabetes. On 1/13/25 at 10:34 AM, Resident 26 stated call light response times took 45 minutes. Resident 26 stated she/he needed assistance with ADL care. Resident 26's call light response logs from 1/1/25 through 1/14/25 revealed six times when the the response time was 16 to 30 minutes, and six times when the response time was greater than 30 minutes. b. Resident 22 was admitted to the facility in 10/2024 with diagnoses including morbid obesity and right leg lower amputation. On 1/13/25 at 1:00 PM, Resident 22 stated she/he needed assistance to change her/his brief and staff could take 30 minutes or up to…

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

Based on interview and record review it was determined the facility failed to ensure each CNA received annual performance reviews for 5 of 5 randomly selected CNAs (#s 14, 15, 16, 17, and 18) reviewed for staffing. This failure placed residents at risk for lack of care by competent staff. Findings include: On 1/16/25 at 1:00 PM, Staff 2 (DNS) was asked for the annual performance reviews for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18. A review of the personnel profile records for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18 revealed no annual performance reviews were completed. On 1/16/25 at 1:22 PM, and 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated if there was nothing located in the personnel profile folders, the annual performance reviews were not completed. Staff 1 and Staff 2 acknowledged the annual performance reviews were not completed for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for adverse medication effects. Findings include: The facility's Storage of Medication Policy, dated [DATE], states the facility drugs and biologicals will be stored in locked compartments, drugs with missing, incomplete, improper, or incorrect labels would be returned to the pharmacy, and discontinued or outdated drugs would be returned or destroyed. On [DATE] at 5:26 AM, during an observation of the [NAME] Hall diabetic/treatment cart assisted by Staff 23 (LPN) the following items were identified: -Naloxone Nasal Spray Pharmacy Label had an expiration date of [DATE]. -Lantus (Glargine) insulin vial was opened. No open date was written on the supplied label. The pharmacy fill date was [DATE]. This type of insulin had a 28-day use by date after opening. -An unlabeled and…

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

Based on observation, interview, and record review it was determined the facility failed to provide care and treatment for 1 of 2 sampled residents (#56) reviewed for edema. This placed residents at risk for unmet needs. Findings include: Resident 56 was admitted to the facility in 11/2024 with diagnoses including deep vein thrombosis (a blood clot that may cause pain and swelling) in the lower left leg, atrial fibrillation (an irregular, often rapid heart rate), and high blood pressure. On 1/13/2025 at 10:37 AM, Resident 56 stated she/he had discomfort to her/his legs due to swelling. The resident was observed to have edema (swelling) in both feet. The resident stated a provider had ordered compression stockings for the edema about four weeks earlier but she/he did not receive the compression stockings. Compression stockings were not observed on her/his lower extremities. On 1/16/25 at 12:07 PM, Staff 20 (RN) stated she was not aware of an order for compression stockings for Resident 56; however, she was able to locate an order for Tubigrip (a form of compression dressing) in a…

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

Based on observation, interview and record review it was determined the facility failed to ensure resident respiratory services were in place and equipment was maintained for 1 of 2 sampled residents (#54) reviewed for respiratory care. This placed residents at risk for breathing complications. Findings include: Resident 54 was admitted to the facility in 5/2024 with diagnoses including anxiety and depression. A care plan dated 5/24/24, revealed Resident 54 had sleep apnea and utilized a CPAP/BIPAP machine. The device was to be cleaned, including the mask, tubing and head gear. Random observations from 1/13/25 through 1/17/25 revealed Resident 54 utilized a BIPAP (a ventilator that helps people breathe by delivering pressurized air through a mask) machine adjacent to her/his bed on a nightstand. The BIPAP machine was dusty, and the tubing and mask were in a drawer covered with magazines and under a saltine cracker box. On 1/13/25 at 8:08 AM, and 11:38 AM, and on 1/17/25 at 8:17 AM, Resident 54 stated she/he utilized a BIPAP machine at night. Resident 54 stated staff did not 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 administer medications and ensure communication forms were completed accurately for 1 of 1 sampled resident (#50) reviewed for dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly). This placed residents at risk for lack of care and services, and potential medication side effects. Findings include: Resident 50 was admitted in 6/2024 with diagnoses including end stage renal disease and diabetes. a. A care plan dated 8/12/24 and revised on 1/17/25 revealed Resident 50 received dialysis related to renal failure. Resident 50 went out for dialysis at 5:00 AM on Tuesday, Thursday, and Saturday and returned at 2:00 PM. A review of Resident 50's Physician Recapitulation Orders dated 12/8/24, revealed the following medications to be administered in the morning at 7:00 AM or 7:30 AM: *Midodrine (a cardiovascular agent) 5 mg, administer every Tuesday, Thursday, and Saturday 20 minutes prior to dialysis to treat hypotension.…

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 pharmacist recommendations were addressed for 1 of 5 sampled residents (#66) reviewed for unnecessary medications. This placed residents at risk for receiving ineffective or unnecessary medications. Findings include: Resident 66 was admitted to the facility in 9/2024 with diagnoses including insomnia. The 11/2024 Monthly Pharmacist Review of Resident 66's medication regimen revealed the following: -On 11/27/24 the pharmacist's recommendation advised the prescriber to reassess Resident 66's Melatonin 1 mg at bedtime (helps regulate sleep) and determine if the resident would benefit from an increase to 3 mg due to Resident 66 sleeping between one and four hours per night. Resident 66's clinical record revealed no indication the pharmacist's recommendation to increase the resident's Melatonin was addressed. On 1/15/25 at 11:42 AM Staff 4 (RNCM) reported she did not receive any follow up to Resident 66's 11/27/24 pharmacist recommendation to increase the resident's Melatonin from 1 mg to 3 mg. 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 provide dental services for 1 of 1 sampled resident (#36) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 36 was admitted to the facility in 1/2024 with diagnoses including dysphagia (inability to chew and swallow safely) and pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit. A review of Resident 36's 11/9/24 Significant Change MDS revealed she/he had severe cognitive impairment, her/his own teeth that were not broken or decayed, did not wear dentures and required substantial to maximal physical assistance to perform oral hygiene. A review of Resident 36's clinical record revealed no indication the resident was seen by a dentist since admission to the facility. On 1/13/25 at 12:27 PM and 1/14/25 at 2:14 PM Resident 36 was observed to have jagged, broken and decayed teeth. She/he also had thick accumulations of oral secretions on her/his teeth and gums. On 1/14/25 at 8:59 AM Witness 1 (Family…

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 waste was properly contained in dumpsters and the garbage storage area was maintained in a sanitary condition for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for potential exposure to pathogens related to the harborage and feeding of pests. Findings include: The facility's Food-Related Garbage and Refuse Disposal Policy dated October 2017 outlined the following: - Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. - Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 1/13/25 at 9:15 AM the outside dumpsters adjacent to the kitchen door to the parking lot were observed to be uncovered with garbage bags full of kitchen and resident care waste spilling over and covering the ground around the dumpsters. A minimum of 20 bags of garbage were piled on the ground in the parking lot in front of the dumpsters. On 1/13/25 at 9:36 AM Staff 9 (Dietary…

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 infection control practices for 2 of 4 sampled residents (#s 36 and 49) reviewed for infection control. This placed residents at risk for cross contamination. Findings include: 1. Resident 36 was admitted to the facility in 1/2024 with diagnoses including dysphagia (inability to chew and swallow safely) and pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit. A review of Resident 36's 11/9/24 Significant Change MDS revealed she/he had severe cognitive impairment and required substantial to maximal physical assistance to complete toileting hygiene. Resident 36's care plan and signed physician's orders indicated staff were to follow enhanced barrier precautions when providing her/him care that involved physical contact. A sign posted on the outside of Resident 36's room outlined the following information and guidance: - Everyone must clean their hands, including before entering and when leaving the room. - Providers and staff must also wear gloves and a gown…

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 ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 14, 15, 16, 17, and 18) reviewed for in-service training. This placed residents at risk for lack of competent staff. Findings include: On 1/16/25 at 1:00 PM, Staff 2 (DNS) was asked for a list of training hours for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18. A review of the personal profile records for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18 revealed no training hours were completed. On 1/16/25 at 1:22 PM, and 1/17/25 at 1:23 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated if there was nothing located in the personal profile folders, the 12 hours of in-service training annually was not completed. Staff 1 and Staff 2 acknowledged the 12 hour in-service training were not completed for Staff 14, Staff 15, Staff 16, Staff 17, and Staff 18.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to provide bed rails needed for bed mobility for 1 of 3 sampled resident (#11) reviewed for environment. This placed residents at risk of ADL decline. Findings include: Resident 11 admitted to the facility in 5/17/24, with diagnoses including chronic kidney disease with dialysis. The admission MDS dated [DATE] revealed Resident 11 had a BIMS score of 15, which indicated the resident was cognitively intact and required moderate assist with bed mobility. A 6/28/24 public complaint indicated Resident 11 had requested bed rails to assist with bed mobility. Resident 11 had to use the headboard to reposition herself/himself in bed, and waited a couple of weeks to have bed rails placed on her/his bed. A 5/17/24 nursing admission note indicated the Resident 11 requested side rails (bed rails). A 5/29/24 Resident Grievance Form filed by Resident 11 revealed the resident wanted bed rails. On 10/1/24 at 12:44 PM, Staff 9 (LPN) stated he recalled…

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 permit a resident to return to the facility for 1 of 4 sampled residents (#9) reviewed for discharge. This placed residents at risk for being unhoused. Findings include: Resident 9 admitted to the facility in 12/2023, with diagnoses including absence of right foot, heart failure and cocaine abuse. The 12/27/23 Discharge Care Plan indicated Resident 9 was homeless, and stayed in her/his car or in motels. A 3/4/24 Progress Note indicated Resident 9 was out of the facility at her/his mother's house. A 3/5/24 Progress note indicated Resident 9 continued to be out of the facility. Staff left a voice message for a return call. A 3/9/13 Progress Note indicated Resident 9 returned to the facility at approximately 4:30 AM and was out of the facility since 3/3/24. Staff 8 (RN) informed Resident 9 she/he was discharged per facility policy however Resident 9 went to her/his previous room and went to bed. Staff 8 placed a call the the on-call manager. A 5/3/24 public complaint indicated upon Resident 9's return to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure meals were provided for a discharge for 1 of 3 sampled residents (#5) reviewed for discharge. This placed residents at risk for unsafe discharge. Findings include: Resident 5 admitted to the facility in 12/2023, with diagnoses including hypertension. Resident 5 discharged from the facility on 1/11/24. The 1/10/24 Discharge Instructions indicated Resident 5 was to be discharged to another state on 1/11/24. There was no indication a meal was ordered or provided for the resident for the extended transport. On 1/23/24 Witness 5 indicated Resident 5 was discharged from the facility and was transported to a nursing facility in another state. The Progress notes revealed Resident 5 discharged from the facility on 1/11/24 at 10:15 AM and was expected to arrive at the new facility at 5:30 PM. On 10/3/24 at 10:14 AM, Staff 10 (CNA) stated she observed Resident 5 discharge on [DATE]. Staff 10 stated the resident was sent out by medical…

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 ensure optometry services were provided timely for 1 of 3 sampled residents (#5) reviewed for quality of care. This placed residents at risk for unmet optical needs. Findings include: Resident 5 admitted to the facility in 3/2022 with diagnoses including congestive heart failure and diabetes mellitus. Resident 5's initial care plan dated 4/5/22 revealed she/he had cataracts in both eyes. Interventions listed were to refer Resident 5 for an eye exam. Resident 5's admission MDS dated [DATE] revealed a CAA for visual function was triggered for cataracts. A 6/17/23 progress note revealed Staff 13 (SSD) had spoken to Resident 5 about scheduling a vision appointment. There was no documentation any appointments were made by Staff 13. On 7/9/24 at 1:59 PM, Resident 5 stated she/he made requests for an eye exam since she/he admitted to the facility but the facility did not schedule any opthamology appointments until recently. On 7/17/24 at…

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

Based on observation, interview and record review review it was determined the facility failed to ensure routine dental services were provided for 1 of 3 sampled residents (#5) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 5 admitted to the facility in 3/2022 with diagnoses including congestive heart failure and diabetes mellitus. Resident 5's initial care plan dated 4/5/22 revealed she/he had dental care needs related to her/his edentulous (no natural teeth or tooth fragments only) status. Interventions listed were to obtain a dental consult. Care conference notes dated 8/19/22 revealed Resident 5 requested a dental exam. A 6/17/23 progress note revealed Staff 13 (SSD) had spoken to Resident 5 about scheduling a dental appointment. There was no documentation any appointments were made until new orders were issued on 8/31/23. On 7/9/24 at 1:59 PM, Resident 5 was observed to be missing most of her/his natural teeth. She/he stated she/he requested to see a dentist since she/he admitted to the facility because she/he…

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 develop and present a QAPI plan to the State Survey Agency (SSA) and failed to present documentation and evidence of an ongoing QAPI Program. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: A review of facility QAPI records presented by Staff 1 (Administrator) showed no evidence the facility had developed a QAPI plan. Staff 1 also acknowledged there was no ongoing QAPI program. On 6/17/24 at 11:39 AM, Staff 1 (Administrator) acknowledged the facility had not developed a QAPI Plan.

Based on interview and record review it was determined the facility failed to have a quarterly QAA (Quality Assessment and Assurance) committee meeting and failed to include the Medical Director reviewed for quality assurance. This placed residents at risk of not receiving the care and services for optimal resident outcomes. Findings include: A review of facility records presented by Staff 1 (Administrator) showed no evidence nor documentation the facility conducted quarterly QAA meetings and with no Medical Director involvement. On 6/17/24 at 11:39 AM Staff 1 (Administrator) acknowledged the facility QAA committee had not met quarterly and the facility's Medical Director had no involvement.

Based on interview and record review, it was determined the facility failed to ensure a resident was spoken to in a dignified manner for 1 of 3 sampled residents (#2) reviewed for dignity. This placed residents at risk for decreased self-worth. Findings include: Resident 2 was admitted to the facility in 3/2023 with diagnoses including fracture of the thoracic vertebra (spinal fracture) and anxiety disorder. Resident 2's 4/3/23 admission MDS identified the resident with no cognitive impairment. Resident 2's 3/29/23 Care Plan identified the resident with a mood problem related to depression, paranoia, anxiety, and panic disorder. A 2/27/24 Facility Investigation form indicated Resident 2 reported on 2/22/24 that Staff 10 (CNA) was witnessed being yelled at, which caused Resident 2 anxiety. Staff 10 was placed on administrative leave and upon completion of the facility's investigation was terminated. On 3/19/24 at 12:53 PM, Resident 2 confirmed Staff 10 yelled at her/him and it made her/him anxious. Resident 2 confirmed this behavior was disrespectful and it frightened her/him.…

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 care and services to maintain mobility with transfers for 1 of 4 sampled residents (#3) reviewed for ADL care. This placed residents at risk for unmet ADL needs. Findings include: Resident 3 was admitted to the facility in 10/2023 with diagnoses including multiple sclerosis (a disease that damages the central nervous system) and paraplegia. Resident 3's 10/25/23 Care Plan indicated the facility was to assist the resident with ADL's including locomotion and range of motion activities due to paraplegia that affects her/his lower extremities. On 3/19/24 at 12:20 PM, Resident 3 stated that the facility didn't assist Resident 3 out of bed and did not provide her/him with her/his daily range of motion exercises due to lack of time the care staff had throughout the day. On 3/19/24 at 12:40 PM, Staff 8 (CNA) confirmed care staff did not always have enough time to get Resident 3 out of bed or assist with her/his daily ADL care needs due to the number of tasks that needed to be completed…

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 medical records for each resident were complete for 1 of 5 sampled resident (#1) reviewed for accidents. This placed residents at risk for incomplete medical records. Findings include: Resident 1 was admitted to the facility in 2/2023 with diagnoses including congestive heart failure (chronic heart condition), Stage IV chronic kidney disease and history of right lower leg amputation. A 3/8/23 Incident Report indicated Resident 1 experienced a fall at 5:09 PM in her/his room. The resident's medical record did not include a fall documentation in a progress note or a fall assessment on 3/8/23. An Alert progress note on 3/8/23 at 10:16 PM (five hours after the fall) directed staff to monitor for [signs and symptoms] of pain on back right sided scapula/flank [shoulder/lower back] area. The progress note did not indicate the resident experienced a fall. On 11/9/23 at 12:24 PM Staff 20 (LPN) stated she checked Resident 1 after the 3/8/23 fall for a head injury and observed an abrasion on her/his scapula…

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 call lights were in good working order for 1 of 3 sampled residents (#3) reviewed for call lights. This placed residents at risk for unmet needs. Findings include: Resident 7 admitted to the facility in April 2023 with diagnoses including stroke. On 11/8/23 at 9:25 AM Witness 11 (Complainant) stated Resident 7's call light did not work and the issue was reported to staff daily until it was fixed. A 5/1/23 Grievance Record indicated Resident 7's call light did not work for the first four days at the facility. On 11/7/23 at 11:20 AM Staff 1 (Administrator) acknowledged Resident 7's call light did not work the first four days of her/his admission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure a homelike environment was maintained in 2 of 4 halls and 1 of 3 dining rooms reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 55 was admitted to the facility in 3/2023 with diagnoses including hemiplegia and hemiparesis (paralysis and muscle weakness of one side of the body) following a stroke. Her/his 7/8/23 Quarterly MDS indicated the resident was cognitively intact. On 8/9/23 at 2:36 PM Resident 55 stated the television noise from room [ROOM NUMBER] was very loud and goes on all night until morning. She/he reported the noise to staff and stated, They don't seem to be concerned that it is so damned loud. On 8/10/23 at 5:05 AM the audio from the television in room [ROOM NUMBER] was heard throughout the entirety of the hallway and from the facility lobby. On 8/10/23 at 5:40 AM Staff 16 (LPN) stated the television was loud and it was on all night. He reported…

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 ensure medications and biologicals were secured and only accessible to authorized persons for 3 of 4 medication/treatment carts observed. This placed residents at risk for drug diversion. Findings include: On 8/10/23 at 5:05 AM a medication cart was observed unlocked in the hallway adjacent to room [ROOM NUMBER]. No nurses or CMAs were in the hallway. On 8/10/23 at 5:06 AM a treatment cart was observed unlocked and unattended adjacent to room [ROOM NUMBER]. Staff 16 (LPN) was observed in the nursing station room and the unlocked cart was out of his line of sight. On 8/10/23 at 5:07 AM a medication cart was observed unlocked in the hallway between rooms eight and nine. Staff 30 (LPN) was not observed in the hallway or in the line of sight of the medication cart. Between 5:10 AM and 5:11 AM multiple staff were observed to pass the unlocked cart. On 8/10/23 at 5:12 AM Staff 30 returned to the unlocked medication cart between rooms eight and…

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

1. Based on observation and interview it was determined the facility failed to ensure staff performed appropriate and adequate hand hygiene and the provision of appropriate hand hygiene for residents during meal delivery for 1 of 4 halls observed during the lunch time meal. This placed residents at risk for infection and lack of hygiene. Findings include: The Centers for Disease Control and Prevention (CDC) website section titled, Hand Hygiene in Healthcare Settings indicated the following: - Patients should clean hands before preparing or eating food. - Healthcare personnel should perform hand hygiene every time they enter a patient room and when they remove gloves. - Healthcare personnel should use an alcohol based hand rub (ABHR) or wash with soap and water immediately after touching a patient and the patient's immediate environment. Healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with CDC recommendations. On 8/9/23 from 11:56 AM to 12:11 PM observations were made of Staff 13 (CNA) and Staff 35 (CNA) delivering meal trays to…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents' call lights were functional for 1 of 1 sampled facility reviewed for call lights. This placed residents at risk for unmet care needs. Findings include: On 8/8/23 at 8:45 AM Staff 5 (LPN Resident Care Manager) was observed distributing bells to residents in Unity hallway and advised the residents to Ring if you need assistance. She reported the call light system was not working since 4:00 PM on 8/7/23. On 8/8/23 at 9:16 AM Resident 55 stated staff gave her/him a bell about 10 minutes earlier and she/he heard staff members talking in the hallway last night about the call light system not working. Resident 55 stated she/he pressed the call button between 10:00 PM and 11:00 PM on 8/7/23 to request assistance to empty her/his urinal. She/he verbalized concern that she/he did not have a functioning call light all night. On 8/8/23 at 9:36 AM Resident 227 reported she noticed the call light system was not working during the previous night and she/he hollered to staff passing in the…

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

1. Based on observation, interview and record review it was determined the facility failed to ensure a resident was treated with dignity and respect for 2 of 3 sampled residents (#s 9 and 41) reviewed for abuse. This placed residents at risk for impaired dignity. Findings include: Resident 9 was admitted to the facility in 1/2022 with diagnoses including heart failure. Resident 9's 5/6/2023 Quarterly MDS indicated the resident experienced moderate impairment in cognition and did not have any behaviors or mood symptoms. Resident 41 was admitted to the facility in 1/2022 with diagnoses including brain cancer. Resident 41's 4/24/2023 Quarterly MDS indicated the resident had severe cognitive impairment and did not have any behaviors or mood symptoms. Resident 41's 5/17/23 Care Plan revealed the resident had a behavior problem which included verbal aggression, accusations the building was attempting to choke her/him with food, suicidal ideations and attention seeking. The care plan listed the following interventions: - intervene as necessary to protect the rights and safety of others. -…

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 obtain informed consent prior to administration of psychotropic medications for 2 of 5 sampled residents (#s 15 and 26) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications. Findings include: 1. Resident 15 was admitted to the facility in 6/2021 with diagnoses including depression and anxiety. Resident 15's health record revealed a Psychotropic Disclosure and Consent Form was input into the health record on 6/24/21. The form had an indecipherable signature on the resident line, no resident name, no information written, and no check mark to indicate what medication(s) she/he received. No other evidence was found to indicate the resident was informed regarding the risks and benefits of venlafaxine [mental health disorder] medication) or Vistaril (anti-anxiety medication) or evidence to indicate the resident consented to receive the medications. Resident 26's 7/7/23 Quarterly MDS indicated the resident was cognitively intact,…

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.

1. Based on observation, interview and record review it was determined the facility failed to ensure the call light was in reach of the resident for 1 of 2 sampled residents (#65) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: Resident 65 was admitted to the facility in 5/2023 with diagnoses including traumatic brain injury. Resident 65's 5/26/23 admission MDS revealed the resident required the assistance of two staff for ADLs. Resident 65's current Care Plan specified to keep the call light within reach of the resident. On 8/7/23 at 1:22 PM Resident 65 was in her/his bed. The resident's call light cord was wrapped around the left bed rail and the call button was on the floor. When asked how to ask for help, Resident 65 pointed to the left bed rail and indicated the call light. When asked if she/he was able to reach the call light, Resident 20 shook her/his head no. Observations from 8/7/23 through 8/10/23 between the hours of 6:01 AM and 3:23 PM revealed the call light cord wrapped around the left bed rail and the call button on the floor. 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 report an allegation of abuse to the state agency within the required timeframe for 2 of 5 sampled residents (#s 41 and 227) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. The facility investigation initiated on 4/29/23 and ended on 6/1/23 indicated an allegation of abuse between Resident 41 and Resident 40 occurred on 4/29/23 at 11:00 AM. The FRI form was received by the state agency on 5/1/23 at 6:05 PM. On 8/11/23 at 12:37 PM Staff 1 (Administrator) acknowledged the incident was reported to the state agency after the required time frame. No further information was provided. 2. The facility reported an allegation of abuse between Resident 227 and Resident 228 which occurred on 8/7/23 at 1:30 AM. The FRI form was received by the state agency on 8/8/23 at 3:20 PM. On 8/11/23 at 12:37 PM Staff 1 (Administrator) acknowledged the incident was reported to the state agency after the required time frame. No further information was provided.

Based on observation, interview and record review it was determined the facility failed to accurately code the resident MDS assessments for 2 of 8 sampled residents (#s 15 and 59) reviewed for dental, communication and sensory care. This placed residents at risk for inaccurate assessments and unmet care needs. Findings include: 1. Resident 59 was admitted to the facility in 2/2023 with diagnoses including stroke. Resident 59's 2/16/23 SNF Nursing admission Assessment revealed the resident had an obvious or likely cavity or broken natural teeth and experienced mouth or facial pain, discomfort or difficulty with chewing. Resident 59's 2/23/23 admission MDS revealed the resident was cognitively intact and had no obvious or likely cavities or broken natural teeth. Resident 59's 5/26/23 Quarterly MDS revealed the resident did not experience mouth of facial pain, discomfort or difficulty with chewing. On 8/7/23 Resident 59 stated she/he admitted to the facility with multiple teeth broken below the gum line. Resident 59 stated her/his teeth caused her/him pain and she/he needed them 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to develop and provide a baseline care plan within 48 hours of admission for 1 of 5 sampled residents (#26) reviewed for medications. This placed residents at risk for being uninformed about their plan of care. Findings include: The facility's 3/2022 Care Plan - Baseline Policy & Procedure specified, A baseline plan of care was developed for each resident within 48 hours of admission and the resident was provided a written summary of the baseline care plan. Resident 26 was admitted to the facility on [DATE] with diagnoses including blood clots in both legs. Resident 26's health record revealed a Baseline Care Plan dated 1/10/23, 34 days after the resident was admitted to the facility. The section titled, Resident/Responsible Party given copy of Baseline Care Plan was marked No. On 8/14/23 at 12:56 PM Staff 2 (DNS) stated a Baseline Care Plan was completed upon admission, included information needed to direct the resident's care and a copy…

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 adequate bathing for 1 of 2 sampled residents (#227) reviewed for ADLs. This placed residents at risk for unmet bathing and personal hygiene needs. Findings include: Resident 227 was admitted to the facility in 7/2023 with diagnoses including fracture of her/his femur (thigh bone). Resident 227's 7/28/23 Care Plan directed staff to keep her/his skin clean and dry, to use lotion on dry skin and her/his showers were scheduled on Wednesdays, Saturdays and PRN. Resident 227's 8/4/23 admission MDS indicated she/he was cognitively intact and required assistance from two staff for bathing related to weakness and deconditioning. On 8/7/23 at 10:26 AM Resident 227 stated she/he received one shower since she/he was admitted to the facility. A review of Resident 227's 7/28/23 and 8/12/23 Bathing Task Records revealed no evidence a shower was offered or received on 7/29/23, 8/2/23, 8/9/23 or 8/12/23. On 8/10/23 at 6:11 AM Staff 21 (CNA) stated she worked with Resident 227 regularly and [she/he]…

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 an ongoing person-centered activities program for 3 of 4 sampled residents (#s 27, 41 and 65) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's 6/2018 Individual Activities and Room Visit Program Policy & Procedure indicated the following: - Individualized activities offered are reflective of the resident's activity interests, as identified in the Activity Assessment, progress notes and the resident's Comprehensive Care Plan. - It was recommended residents with in-room activity programs received, at a minimum, three in-room visits per week. A typical in-room visit was ten to fifteen minutes in length, but may be longer if appropriate for the resident. The facility's 6/2018 Activities Attendance Policy indicated attendance and participation was recorded for every resident in group and individual activities on a daily basis. 1. Resident 41 was admitted to the facility in 1/2022…

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 treatment and services to maintain vision and hearing abilities were received for 2 of 4 sampled residents (#s 9 and 59) reviewed for communication and sensory care. This placed residents at risk for unmet vision and hearing needs. Findings include: 1. Resident 9 was admitted to the facility in 1/2022 with diagnoses including heart failure. Resident 9's 5/6/23 Quarterly MDS revealed the resident had moderately impaired cognition and adequate vision without the use of corrective lenses. Resident 9's 5/30/23 Care Plan revealed the following: - Focus: Vision deficit characterized by pain, decreased/impaired vision related to decreased visual acuity. - Goal: Visual support needs will be met by staff. - Obtain eye exam to ensure appropriate meds and compensatory mechanism. A 6/17/23 Progress Note completed by Staff 8 (Social Services Director) indicated Resident 9 was interested in scheduling a vision appointment. On 8/7/23 at 1:45 PM and on 8/10/23 at 7:17 AM Resident 9 stated 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, interview and record review it was determined the facility failed to ensure the resident environment was free of potential fire hazards for 1 of 1 sampled resident (#15) reviewed for accidents. This placed residents at risk for injury and exposure to a fire. Findings include: The facility's current Smoking Policy and Procedure outlined the following: - Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitors or volunteer worker at all times while smoking. - No resident will be allowed to store any smoking materials in their room. All smoking material will be stored in a secured designated area accessible only to staff. Resident 15 was admitted to the facility in 6/2021 with diagnoses including depression. Resident 15's 7/7/23 Annual MDS indicated she/he was cognitively intact. Resident 15's 7/7/23 Smoking Assessment revealed she/he was unable to retrieve a lit cigarette from the ground or her/his lap, smoked more than 10 times a day and was unable to smoke safely or independently…

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 respond to pharmacy recommendations for 3 of 5 sampled residents (#s 15, 20, and 27) reviewed for unnecessary medications. This placed residents at risk for potential adverse consequences related to medications and lack of medication oversight. Findings include: The facility's 5/2019 Medication Regimen Review Policy & Procedure specified a Consultant Pharmacist reviewed the medication regimen of each resident at least monthly to identify irregularities and minimize potential risks associated with medications. The attending physician documents in the medical record that the irregularity was reviewed and what action was taken to address it. 1. Resident 15 was admitted to the facility in 6/2021 with diagnoses including anxiety and depression. A 6/1/23 Consultant Pharmacist's Medication Regimen Review revealed the following: - consider adding maximum dose parameters to PRN Acetaminophen order. - consider adding maximum dose parameters to PRN Sumatriptan (treats migraines). Review of Resident 15's health record…

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 ensure antipsychotic and psychotropic medications were clinically indicated, adequately monitored for effectiveness and routinely assessed for appropriate use for 1 of 5 sampled residents (# 26) reviewed for medications. This placed residents at risk for adverse medication consequences and receiving unnecessary medications. Findings include: The facility's 7/2022 Antipsychotic Medication Use Policy & Procedure specified residents would not receive medications that were not clinically indicated to treat a specific condition, medications would be prescribed at the lowest possible dosage for the shortest period of time and were subject to a dose reduction and review. Resident 26 was admitted to the facility on [DATE] with diagnoses including blood clots in both legs. Resident 26's 12/14/22 admission MDS, 3/13/23 Quarterly MDS and 6/13/23 Quarterly MDS indicated the resident was cognitively intact, had a psychotic disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 27 was admitted to the facility in 2/2022 with diagnoses including Alzheimer's disease. A 5/2023 Consultant Pharmacist's Medication Regimen Review of Resident 27's medications revealed the following: - The resident has been taking haloperidol (antipsychotic medication) twice daily since 9/27/23. Please evaluate the current dose and consider a dose reduction to haloperidol every afternoon. Resident 27's 6/27/23 Annual MDS revealed the resident was severely cognitively impaired, had no mood symptoms or behaviors and received haloperidol. Resident 27's 9/2022 through 8/2023 physician orders included haloperidol 0.25mg twice daily. Resident 27's 9/2022 through 8/2023 MARs revealed the resident received haloperidol 0.25mg twice daily. Review of Resident 27's health record revealed no evidence to indicate a GDR for haloperidol was attempted as required. On 8/14/23 at 12:56 PM Staff 2 (DNS) and Staff 4 (RNCM) were informed of the findings. Staff 2 acknowledged there was no attempt to reduce the haloperidol…

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 routine dental services were provided for 1 of 4 sampled residents (#62) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: Resident 62 was admitted to the facility in 3/2023 with diagnoses including encounter for orthopedic aftercare following surgical amputation (the removal of a limb). Resident 62's 4/7/23 admission MDS indicated she/he was cognitively intact and had no dental health problems. A 6/27/23 Progress Note indicated the resident told Staff 8 (Social Services Director) she/he was interested in having dental work completed. On 8/7/23 at 3:40 PM Resident 62 was observed to be edentulous (having no teeth). The resident stated she/he spoke with Staff 8 about her/his need for dental work but had not received an update from her. On 8/11/23 at 12:51 PM Staff 8 stated Resident 62 had an appointment on 6/10/23 but it was canceled by the provider. She stated, It was just the size of the caseload that caused the delay. It should…

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

Based on observation, interview and record review it was determined the facility failed to ensure routine dental services were provided for 3 of 4 sampled residents (#s 4, 30 & 59) reviewed for dental care needs. This placed residents at risk for unmet dental needs. Findings include: 1. Resident 4 was admitted to the facility in 3/2022 with diagnoses including multiple sclerosis (a disease of the central nervous system that disrupts communication between the brain and the body). Resident 4's 4/10/23 Annual MDS indicated she/he had no natural teeth or teeth fragments, received food with a mechanically altered texture and was not assessed for cognition. The Dental CAA indicated dental care was to be addressed to minimize her/his decline related to impaired dentition. A review of Resident 4's 5/2/23 Care Plan revealed a goal to maintain oral hygiene through a dental consult and monitoring for gum, mouth and jaw pain. A progress note dated 6/17/23 indicated Resident 4 told Staff 8 (Social Services Director) she/he was interested in a dental appointment. Resident 4's 7/11/23 Quarterly…

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 accommodate resident food choices for 1 of 1 sampled resident (#30) reviewed for choices. This placed residents at risk for food choices not being honored. Findings include: Resident 30 was admitted to the facility in 2/2023 with diagnoses including acute and chronic respiratory failure with hypoxia (impairment of the lungs resulting in inadequate oxygen delivery to the tissues). Resident 30's 3/6/23 admission MDS indicated she/he was cognitively intact. Resident 30's 6/23/23 signed physician orders revealed the resident received a renal diet. Resident 30's 8/7/23 Care Plan indicated staff members were to explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules and options. On 8/7/23 at 1:00 PM Resident 30 stated, I'm on a renal diet and what is on my plate and my tray doesn't match what is on the menu. I think I should know ahead of time what I'm going to have for my meals. On 8/9/23 at 12:40 PM Resident 30 was observed during lunch. She/he 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.