Evergreen Post Acute

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 dependent residents received required assistance with ADLs for 1 of 2 sampled residents (#21) reviewed for ADLs. This placed residents at risk for lack of personal hygiene. Findings include: Resident 21 was admitted to the facility in 3/2024 with diagnoses including Parkinson's disease and muscle weakness. Resident 21's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment and required one-person total assistance with personal hygiene and grooming. Resident 21 was observed on 2/10/25 at 12:28 PM, and on 2/12/25 at 1:10 PM, with a significant amount of chin hairs. On 2/10/25 at 12:28 PM, Resident 21 stated she/he did not want to have facial hair but was not able to look at herself/himself or touch her/his face due to lack of mobility in her/his arms from Parkinson's disease. Resident 21 stated she/he relied on staff to shave unwanted facial hair. On 2/12/25 at 3:33 PM, Staff 14 (CNA)…

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 daily wound care for 1 of 1 resident (#50) reviewed for discharge. This placed the resident at risk for complications related to chronic wounds. Findings included: Resident 50 was admitted to the facility in 11/2024 for wound care with diagnoses including lower extremity venous stasis ulcers. admission orders dated 11/18/24 included silver sulfadiazine cream 1 %: Apply to right leg topically one time a day and as needed for wound care. Review of the 11/2024 TAR and nursing notes dated 11/20/24 revealed wound care was not provided on 11/20/24 due to the silver sulfadiazine cream not being available. There was no documentation on the TAR or in nursing notes to indicate if wound care was completed on 11/21/24, however, a physician progress note dated 11/22/24 revealed the resident complained to the provider she/he had not received wound care while in the facility. The resident left the facility AMA (against medical advise) later that day. An attempt was made to contact the 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 appropriate treatment and services to maintain and prevent a potential decrease in ROM or mobility for 2 of 2 sampled residents (#s 5 and 28) reviewed for restorative services. This placed residents at risk for loss of ROM and mobility. Findings include: The facility's Restorative Nursing Policy, dated 8/1/24, indicated the following: -It is the policy of this facility to ensure that a resident's communication, mobility, range of motion, performance of ADLs, eating and toileting do not deteriorate unless the deterioration is unavoidable. Residents evaluated with deficits in communication, mobility, range of motion, performance of ADLs, eating or toileting received necessary care and services to attain and maintain their highest practicable physical, mental and psychosocial well-being. -Residents with the need to improve functional status were re-evaluated monthly to determine effectiveness of the current interventions and need to revise goals or interventions. -Residents with the need…

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 received treatment and services related to the use of an indwelling urinary catheter for 1 of 2 sampled residents (#254) reviewed for catheter care. This placed residents at risk for complications of catheter use. Findings include: The facility's 8/2024 Indwelling Urinary Catheter Policy and Procedure revealed a resident with a catheter was evaluated for the ongoing need for an indwelling catheter following their admission. If the resident did not have appropriate indications for continuing its use, the physician was to be contacted to determine if the catheter could be discontinued. If there was an appropriate indication for use, then orders were to be reviewed to include the medical justification for the catheter use, catheter size, frequency of catheter, bag and tubing changes and catheter irrigations if appropriate. Resident 254 was admitted to the facility in 1/2025 with diagnoses including complications associated with an indwelling urinary catheter with the presence of…

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

Based on observation, interview and record review it was determined the facility failed to ensure dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (# 27) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment. Findings include: The facility's Dialysis policy, dated 8/1/24, indicated the following: a. The licensed nurse completes the Dialysis Center Communication Form prior to the resident leaving for dialysis. Weights are obtained from Dialysis Communication Center Form. b. Upon return, the post dialysis assessment portion of the form is completed and attached to the resident's medical record. *Note-Residents who require hemodialysis are provided ongoing assessment and monitoring of the resident's condition before and after dialysis treatments including for complications and interventions as part of nursing standard of practice. Issues are documented, as noted, by the licensed nurse and medical providers are notified. Resident 27 was admitted to the facility…

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 received trauma informed care for 2 of 7 sampled residents (#s 27 and 46) reviewed for behavioral-emotional care and abuse. This placed residents at risk for re-traumatization. Findings include: The facility's 8/2024 Trauma-Informed Care Policy and Procedure revealed the following: -The facility screened newly admitted resident for indications of trauma as part of the comprehensive care plan process, accomplished through interview with the resident and/or her/his representative as appropriate. -The center developed an appropriate plan of care and interventions based upon the screening responses and observations of the resident. 1. Resident 27 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease and PTSD (Post-traumatic stress disorder). Resident 27's 11/22/24 Quarterly MDS revealed the resident was cognitively intact, able to make herself/himself understood and understood others without difficulty. On 2/10/25 at 10:16 AM, and on 2/11/25 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 it was determined the facility failed to provide necessary behavioral health care and services for 1 of 5 sampled residents (#46) reviewed for abuse. This placed residents at risk for unaddressed behavioral and emotional needs and a decrease in their quality of life. Findings include: The facility's 8/2024 Behavior Monitor Policy and Procedure directed the following: -Residents who resided in the facility who developed behavior symptoms received a comprehensive assessment completed by social services to identify potential precipitating factors as possible causes for behavior. -Target behavior was to be described as specifically as possible and interventions developed based on the resident's targeted behaviors. -If all behavior interventions were attempted and not effective, the charge nurse was to be notified. -The charge nurse was to further evaluate the resident and take further action to manage the behavioral symptoms. -The RNCM and DNS were to be notified through the 24-Hour Report of effectiveness or ineffectiveness of…

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

Based on observation, interview and record review it was determined the facility failed to accommodate resident dietary preferences for 1 of 2 sampled residents (#46) reviewed for nutrition. This placed residents at risk for not receiving preferred food. Findings include: Resident 46 was admitted to the facility in 12/2024 with diagnoses including dysphagia (difficulty swallowing) and cognitive and communication deficit. Resident 46's 1/21/25 Physician Orders directed the resident to receive a regular diet with a minced and moist texture. Resident 46's 1/24/25 Nutrition At Risk Evaluation revealed weight gain was desirable for the resident. A 1/24/25 Social Service Note revealed Witness 1 (Family Member) was informed Resident 46's meal portion size would be increased after she reported to Staff 5 (Social Services Director) the resident was hungry all of the time. On 2/10/25 at 3:04 PM, Witness 1 stated Resident 46 was hungry all of the time. Witness 1 stated she spoke with a staff member at the facility a few weeks ago and requested the resident to receive double portions 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 it was determined the facility failed to ensure enhanced barrier precautions (EBPs) were followed for 1 of 2 sampled residents (#45) reviewed for catheter care. This placed residents at risk for infections, communicable disease and cross-contamination. Findings include: The CDC webinar titled Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 11/15/22, indicated the following: -EBPs were a risk based approach to PPE use designed to reduce the spread of multidrug-resistent organisms (MDROs). -EBPs involved use of gown and gloves during high-contact resident care activities with residents known to be colonized or infected with a MDRO as well as, residents with wounds, indwelling catheters, central lines, feeding tubes, tracheostomies (a surgical opening in the neck where a tube is inserted to provide an artificial airway) and ventilators (a machine that helps people breath). The facility's Transmission Based Precautions Policy, dated 8/1/24, indicated the following: -When a resident was colonized with a MDRO, enhanced…

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 protect the residents' right to be free from physical abuse by a resident for 1 of 5 sampled residents (#10) reviewed for abuse. This placed residents at risk for abuse. Findings include: The facility's Abuse Policy and Procedure dated 8/2024, stated: Abuse is defined as: a. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. c. Instances of abuse of all residents, irrespective of any mental, physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Resident 10 was admitted to the facility in 4/2017 with diagnoses including obstructive pulmonary disease and dementia. Resident 10's 1/13/25 Annual MDS indicated the resident was cognitively intact. Resident 27 was admitted to the facility in 2/2023 with diagnoses including end stage renal disease and PTSD…

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 were treated with dignity for 1 of 7 sampled residents (#105) reviewed for dignity and abuse. This placed residents at risk for lack of dignity. Findings include: The facility's Courtesy Policy, last revised 5/2019, indicated all employees were expected to treat residents, families, visitors and fellow workers with kindness, respect and dignity. Resident 105 was admitted to the facility in 12/2022 with diagnoses including major depressive disorder. On 7/3/24 a public complaint was received by the State Agency which alleged Staff 7 (CNA) talked down to Resident 105 like she/he was a kid and stated, I don't know why you pee in the bed when you have a urinal. You do not need to pee in the bed. On 9/18/24 at 11:43 AM Resident 105 stated Staff 7 kept yelling and talking to her/him like, I am a teenager. Resident 105 stated she/he told Staff 7, I don't have to take it. Resident 105 stated she/he told other CNAs that Staff 7 yelled and cussed at her/him but nothing had gotten better. Resident 105…

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 transport clean laundry to prevent cross contamination for 1 of 1 facility reviewed for infection control. This placed residents at risk for cross contamination for spread of infection. Findings include: The facility's 4/2019 Laundry Handling Policy and Procedure indicated laundry personnel were to transport clean linens in a covered cart. On 10/18/23 at 8:57 AM Staff 16 (Housekeeping/Laundry Manager) was observed to transport and distribute clean laundry to residents using an uncovered wire basket on wheels. Staff 16 confirmed the clean laundry was to be covered while she delivered it to residents. On 10/18/23 at 1:56 PM Staff 1 (Administrator) confirmed laundry personnel were to transport clean linens in a covered cart. 2. Based on observation, interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water borne pathogens for 1 of 1 facility…

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 were assessed for self-administration of medications and a physician order was in place for 1 of 1 sampled resident (#142) observed for medication administration. This placed residents at risk for adverse medication-related consequences. Findings include: The facility's 3/2020 Self Administration of Medication Policy and Procedure outlined the following: -During the 14-day admission assessment period, the RCM (Resident Care Manager) evaluates the resident's ability to self-administer medications using the Self Administration Evaluation form. No medications are stored at bedside nor self-administered until evaluation [is] complete. -If the evaluation indicates that the resident has the cognitive, physical and emotional ability to self-administer his or her own medications in a safe and prudent manner, a plan for self-administration is established with the resident. A physician order is obtained indicating the specific medications that resident is able to self-administer.…

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 provide a comfortable, clean and homelike environment for 1 of 1 dining room and 1 of 2 sampled residents (#13) reviewed for dining experience and environment. This placed residents at risk for an unsatisfying meal experience and living in an institutionalized environment. Findings include: 1. During an observation of the dining room for the lunch meal service on 10/18/23 between 11:54 AM and 12:35 PM, six residents were observed to sit at the dining room tables. In addition to nine dining room tables, the following items were observed in the dining room: -Two weight scales -A bed mattress -A wooden tripod -A power wheelchair -An orthopedic walker On 10/19/23 at 12:14 PM Staff 1 (Administrator) observed the dining room with the surveyor. Staff 1 acknowledged he expected the residents dining experience to be homelike, and the items stored in the dining room were not homelike. 2. On 10/17/23 at 10:52 AM the following was observed in Resident 13's room: -Small brown stains scattered on the wall beneath the…

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

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse by another resident for 1 of 5 sampled residents (#192) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 192 was admitted to the facility in 1/2020 with diagnoses including morbid (severe) obesity due to excess calories. A review of Resident 192's 3/10/23 Annual MDS revealed she/he was cognitively intact. Resident 193 was admitted to the facility in 4/2023 with diagnoses including diabetes mellitus. A review of Resident 193's 4/19/23 admission MDS revealed she/he was severely cognitively impaired. A 5/29/23 FRI revealed on 5/29/23 at approximately 1:05 AM Resident 192 awoke and saw Resident 193's feet below the privacy curtain. Resident 192 opened the curtain and asked Resident 193 what she/he wanted. Resident 193 yelled at Resident 192 and accused her/him of taking Resident 193's watch. Resident 192 explained to Resident 193 the watch was on Resident 193's table. Resident 193 then struck Resident 192 across the face.…

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 resident centered care plans were implemented for 1 of 4 sampled residents (#29) reviewed for ADLs. This placed residents at risk for unmet needs. Findings include: The facility's 2/2019 Care Plan-[NAME] Policy and Procedure directed the following: -Staff to give care per the [NAME] (a condensed version of the resident Care Plan). -If the resident refused care or was unable to complete the task as outlined in the Care Plan, staff were responsible to report this to the charge nurse. Resident 29 was admitted to the facility in 9/2022 with diagnoses including other specified diseases of the spinal cord. Resident 29's 9/20/23 Quarterly MDS revealed the resident was cognitively intact and required physical assistance from one person to walk in her/his room, to walk in the corridor and for locomotion on unit (how the resident moves between locations in his/her room and adjacent corridor on same floor). Resident 29's…

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

Based on observation, interview and record review it was determined the facility failed to ensure smoking materials were secured and not accessible to residents for 1 of 3 sampled residents (#13) reviewed for accidents. This placed residents at risk for access to hazardous materials and accidents. Findings include: The facility's 3/2020 Smoking Policy and Procedure Independent and Supervised outlined the following: -Residents who wish to smoke have a smoking evaluation completed on admission or at the time they decide to smoke to evaluate their ability to smoke safely and appropriately manage their smoking materials. -For residents requiring assistance/supervision with managing their smoking material the center establishes and provides appropriate storage method per assessment. -Residents who are safe to smoke independently and safely manage their smoking materials are allowed to do so in a manner that is safe according to the assessment. -Should any incidents of unsafe smoking or unsafe management of smoking materials occur, nursing staff are notified immediately, and a new smoking…

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 meals were palatable and attractive for 1 of 4 sampled residents (#18) reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: Resident 18 admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (chronic breathing condition). Resident 18's 6/24/23 Quarterly MDS indicated the resident was cognitively intact. On 10/17/23 at 1:29 PM Resident 18 stated she/he often received food she/he was not able to eat because it was overcooked and hard. Resident 18 stated she/he received a toasted cheese sandwich which was burnt on one side and not toasted on the other side. On 10/18/23 at 12:54 PM Resident 18 was observed to sit in her/his room with an untouched meal tray on the bedside table in front of her/him. Resident 18 stated the meat looked awful and was too hard to eat. Resident 18 stated she/he tried to eat a slimy looking Brussels sprouts but she/he spit it out. Resident 18 stated the mashed potatoes were not…

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

Based on observation, interview and record review it was determined the facility failed to accommodate resident alternative meal replacements for 1 of 1 sampled resident (#18) reviewed for choices. This placed residents at risk for food choices not being honored and unmet nutritional needs. Findings include: Resident 18 admitted to the facility in 2019 with diagnoses including chronic obstructive pulmonary disease (chronic breathing condition). Resident 18's 6/24/23 Quarterly MDS indicated the resident was cognitively intact. Resident 18's 10/2023 Physician Diet Order instructed the facility to provide a heart healthy meal and extra protein with every meal. On 10/19/23 at 12:47 PM a test tray consisting of fish sticks, tartar sauce, a slice of bread, cooked cabbage, pudding and condiments was sampled. The sampled food lacked flavor. No alternative meal tray was provided to the surveyors due to inadequate food supply. The Alternative Menu indicated the following options were available for lunch and dinner meals (no alternatives offered for breakfast): - Peanut Butter and Jelly:…

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 complete nurse aide performance reviews at least every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 5 CNAs (#s 9, 12, 20, 22 and 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 8/10/22 at 10:01 AM facility staff records for Staff 9 (CNA), Staff 12 (CNA), Staff 20 (CNA), Staff 22 (CNA) and Staff 23 (CNA) were reviewed with Staff 16 (HR/Payroll/Staffing) and revealed no information related to annual CNA performance reviews being completed and no regular in-service education was done based on the outcome of the reviews. On 8/10/22 at 9:18 AM and 10:15 AM Staff 9 (CNA) and Staff 12 (CNA) stated they did not receive annual performance reviews. On 8/10/22 at 3:20 PM and 4:09 PM Staff 1 (Administrator) and Staff 8 (Director of Operations) stated they had no annual performance reviews for the identified CNA staff and they were aware the facility was not in…

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 proper hand hygiene and failed to store and handle food in a sanitary manner in 1 of 1 kitchen reviewed for food sanitation. This placed residents at risk for cross contamination and food borne illness. Findings include: Observations in the kitchen, dry storage area, refrigerator and freezer revealed the following: -On 8/8/22 at 9:34 AM raw fruit peels were observed to be placed on top of fresh strawberries that were observed sitting on the kitchen countertop; -On 8/8/22 at 9:44 AM the reach in freezer contained used, unmarked, unlabeled meat, vegetables and fruits, all with significant freezer burn; -On 8/9/22 at 2:27 PM a reach in refrigerator contained undated roast beef which was heavily grayed from freezer burn. The refrigerator contained an open bowl of of shriveled and wilted onions. -On 8/9/22 at 2:36 PM multiple open containers of spices including oregano, cream of tartar, bay leaves and cocoa powder were noted without a date; -On 8/9/22 at 2:38 PM the reach in freezer…

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 the building was clean and kept in good repair for 3 of 3 resident halls and 1 of 1 main resident lobby area reviewed for environment. This placed residents at risk for living in an unkempt and unhomelike environment. Findings include: From 8/8/22 through 8/10/22 between the hours of 10:30 AM and 12:20 PM, the following observations were made: -A blue cloth chair in the east hallway was stained on the seat cushion and an end table had large white stains on the table top; -The main resident lobby area door where residents exited to the back patio had numerous large, deep scrapes and areas lacking paint; -Walls were scraped and gouged behind chairs in the resident main lobby area; -The wall to the left of the dining room door and the wall under the light switch near the administrative offices were scraped and gouged; -Hand railings down each hallway were scraped and gouged; -The windows or sliding glass doors in room [ROOM NUMBER],…

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 a written Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 2 of 3 sampled residents (#s 5 and 35) reviewed for Beneficiary Protection Notification. This placed residents at risk for unknown financial liabilities. Findings include: 1. Resident 5 admitted to the facility with Medicare Part A services on 2/2/22. The resident's last covered day of Part A services was 2/18/22 and the facility intiated a discharge from Part A services when benefit days were not exhausted. The resident remained in the facility. A review of the resident's medical record indicated written SNF ABN information was not issued to Resident 5. On 8/11/22 at 10:32 AM Staff 1 (Administrator) stated the facility was required to provide written notification of non-coverage to Resident 5 and the facility failed to provide the resident with the required written information. 2. Resident 35 admitted to the facility with Medicare Part A services on 7/21/22. The resident's last covered day of Part 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 interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#7) reviewed for abuse. This placed residents at risk for negative physical and psychosocial outcomes. Findings include: Resident 7 was admitted in 2/2022 with diagnoses including altered mental status. Resident 31 was admitted in 4/2017 with diagnoses including adult personality and behavior disorder. A facility Resident to Resident Incident investigation revealed on 3/25/22 at approximately 2:25 PM, Resident 31 was outside in the smoking area with Resident 7. Resident 31 walked towards Resident 7 and Resident 7 stated, don't come by me thief. Resident 31 pinched and pushed Resident 7, then followed the resident to the outside door and hit Resident 7 on the back. On 8/8/22 at 11:56 AM and 8/11/22 at 11:31 AM Resident 7 confirmed Resident 31 pinched her/his arm and struck her/him on the back and stated she/he still felt angry and uneasy about the incident. Resident 7 stated it hurt when Resident 31 pinched and punched her/him. On 8/8/22 at…

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

Based on interview and record review it was determined the facility failed to provide bathing assistance for 1 of 1 sampled resident (#5) reviewed for bathing services. This placed residents at risk for lack of personal hygiene. Findings include: Resident 5 was admitted to the facility in 2/2022 with diagnoses including Multiple Sclerosis and muscle pain. Resident 5's 2/9/22 admission MDS indicated the resident had no cognitive impairment and required extensive assistance of one person for bathing. Resident 5's current bathing Care Plan indicated the resident required one person extensive assistance for bathing with bathing scheduled on Tuesday and Friday mornings. The 7/2022 and 8/2022 Bathing Documentation Survey Report indicated the resident received bathing on 7/6/22 and 7/20/22. No bathing was provided in 8/2022 until 8/10/22. On 8/8/22 at 1:49 PM Resident 5 stated she/he did not receive bathing services very often which bothered her/him. On 8/10/22 at 9:10 AM and 10:28 AM Staff 9 (CNA) and Staff 10 (CNA) stated Resident 5 was supposed to receive bathing services twice a week.…

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's orders for medication administration, failed to monitor the resident when medication was missed and failed to notify the resident's provider of missed medication doses for 1 of 7 sampled residents (# 35) reviewed for medications. This placed residents at risk for adverse consequences of missed medication doses. Findings include: Resident 35 was admitted to the facility in 7/2022 with diagnoses including atrial fibrillation (an irregular, rapid heart rate) and diabetes. Resident 35's 7/28/22 admission MDS revealed no cognitive impairment. A 7/21/22 physician's order indicated Resident 35 was prescribed amlodipine (a medication to treat high blood pressure and heart disease) 2.5 mg by mouth one time a day for [resident's] heart. A review of Resident 35's 8/2022 MAR revealed Resident 35 was not administered amlodipine on 8/7, 8/8 or 8/9. The medication was marked as NA (not available) on all three days. The resident's blood pressure was within normal limits on the above mentioned dates per…

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 the Direct Care Staff Daily Report (DCSDR) postings were accurate for 18 of 39 days reviewed for staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 7/2022 through 8/8/22 DCSDR postings and Daily Nursing Rosters indicated the following days when CNA numbers and hours worked were inaccurately recorded: -7/2, 7/7, 7/8, 7/9, 7/11, 7/12, 7/18, 7/20, 7/21, 7/25, 7/28, 7/30, 8/1, 8/3, 8/4, 8/5, 8/6 and 8/7. On 8/9/22 at 9:58 AM Staff 16 (HR/Payroll/Staffing) reported she was responsible to ensure the DCSDR postings were accurate. Staff 16 stated she counted all CNAs as one CNA regardless of how many hours they worked per shift and reported she was unsure how CNA numbers were properly counted. On 8/11/22 at 11:13 AM Staff 1 (Administrator) confirmed CNA numbers on the DCSDR postings were incorrectly reported on the days identified.

Based on observation, interview and record review it was determined the facility failed to ensure medication was stored securely for 1 of 1 sampled resident (#35) assessed to be safe to have medications at bedside. This placed residents at risk for a loss of medications or unauthorized individuals to access medications. Findings include: Resident 35 was admitted to the facility in 7/2022 with diagnoses including COPD (a lung disease which makes it difficult to breathe). On 8/8/22 at 9:16 AM and 8/9/22 at 12:34 PM and 3:19 PM Resident 35 was observed to have the following medications unsecured on her/his bed or on top of her/his bedside table: -Fluticasone Nasal Suspension (nasal spray); -Ipratropium Bromide Nasal Solution (nasal spray) and -Anoro Ellipta (inhaler to treat COPD). A review of Resident 35's physician orders indicated the resident had current orders for the medications observed at the resident's bedside on 8/8/22 and 8/9/22. Resident 35's 7/28/22 admission MDS revealed no cognitive impairment. Resident 35's 8/4/22 Administration of Medication Evaluation revealed the…

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

Based on interview and record review it was determined the facility failed to ensure residents received scheduled therapy service for 1 of 1 sampled resident (#17) reviewed for therapy services. This placed residents at risk for decreased mobility independence. Findings include: Resident 17 was admitted to the facility in 3/2022 with diagnoses including a right lower extremity below the knee amputation. In a therapy encounter note from 6/24/22 at 2:15 PM, Resident 17 was evaluated by physical therapy and had goals developed to improve her/his independence with mobility. Resident 17 requested to receive physical therapy services twice a week to assist with her/his recovery. Review of physical therapy treatment encounter notes from 6/24/22 through 8/6/22 revealed Resident 17 was only provided physical therapy once a week from 7/17/22 through 7/30/22 and not provided any physical therapy from 7/31/22 through 8/6/22. On 8/8/22 at 11:08 AM Resident 17 stated she/he did not receive therapy as scheduled during the prior three weeks. On 8/10/22 at 4:07 PM Staff 7 (Rehab Director) stated the…

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