Mt. Tabor Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to provide maintenance to maintain a safe, comfortable and homelike environment for 1 of 1 facility reviewed for physical environment. This placed residents at risk for an unsafe and unkempt interior building. Findings include: 1. An observation on 6/2/25 at 9:39 AM, revealed the wall to the right of room [ROOM NUMBER]'s bed was in disrepair with scratches of paint missing from the wall. On 6/5/25 at 2:02 PM, Staff 8 (Maintenance Director) observed the wall to the right of room [ROOM NUMBER]'s bed which was in disrepair with scratches of paint missing from the wall. Staff 8 stated he was unaware of the scratches of paint missing from the wall and he would expect the wall to be painted. On 6/6/25 at 11:25 AM Staff 1 (Administrator) stated she expected all resident rooms to be in good condition and walls maintained. 2. On 6/2/25 at 10:35 AM four sections of approximately 5 feet long areas of carpet were observed buckled 4 inches high 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 record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#45) reviewed for medications. This placed residents at risk for inaccurate assessment and care. Findings include: Resident 45 was admitted in 2/2025 with diagnoses including major depressive disorder (mood disorder) and schizophrenia (chronic brain disorder characterized by disconnection from reality). On the 2/7/25 Admissions MDS and the 5/13/25 Quarterly MDS, schizophrenia was coded in Section I. On 6/6/25 at 9:05 AM and at 11: 22 AM, Staff 2 (DNS) stated there was no supporting evidence in the medical record regarding Resident 45's diagnosis of schizophrenia and the MDS should not have been coded without supporting evidence of the diagnosis.

Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to professional standards for medication management and licensed nurse oversight of assigned residents. This placed residents at risk for adverse side effects of medication and unmet medical needs. Findings include: The facility initiated an investigation on 3/1/24 regarding Staff 17 for her night shift which started on 2/29/24. Staff 2 (DNS) completed interviews and record reviews for residents which were assigned under Staff 17's supervision. Staff 2 concluded on the evening of 2/29/24 until 3/1/24 at about 6:30 AM, Staff 17 slept in her car in the facility parking lot most of the shift and was not available. Staff 2 concluded seven residents missed ordered medications, opportunities for PRN medications or treatments. On 6/4/25 at 6:39 AM Staff 18 (CNA) confirmed Staff 17 was the charge nurse when she worked in the facility on 3/1/24. Staff 18 stated Staff 17 went missing from the facility and at around 6:00 AM she found Staff 17 asleep in her car and Staff 17…

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 implement fall interventions to reduce hazards and risks for 1 of 3 sampled resident (#3) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 3 was admitted to the facility in 2018 with diagnoses including dementia and diabetes. Fall/Post Fall Assessments reviewed from 11/16/24 to 6/4/25 revealed Resident 3 experienced a fall on the following dates: - 11/16/24; - 11/29/24; - 12/24/24; - 1/4/25; - 2/5/25; - 2/8/25; - 4/23/25; - 5/30/25. Resident 3's 1/14/25 Quarterly MDS was assessed with a BIMS score of three (severely cognitively impaired) and identified over the past quarter she/he experienced two or more falls with no major injury. Resident 3's 6/4/25 at risk for falls care plan directed staff to implement the following: - Make sure the door to the room was opened wide enough so staff could visualize if she/he was attempting to get out of bed; - To keep her/his room door open except when providing care; - Leave wheelchair at bedside at the foot 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 interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency LPN) adhered to medication administration and treatment management for 7 of 7 sampled residents (#s 5, 17, 21, 27, 31, 36, and 155) reviewed for failure to follow physician orders. This placed residents at risk for adverse side effects and unmet medical needs. Findings include: 1. Resident 5 admitted to the facility in 2004 with diagnoses including esophageal reflux (stomach contents leak backwards from the stomach into the food pipe) and Cerebral Palsy (affect ability to move, balance and posture). Review of Resident 5's 3/2024 MAR revealed a physician order which directed staff to administer 20 mg of Omeprazole Suspension 2 MG/ML via G-tube (tube to stomach), and eternal feeding (tube delivers nutrients directly to stomach) water flushes on 3/1/24 at 3:00 AM. Resident 5's 3/1/24 MAR revealed she/he was not administered the medication or treatment on 3/1/24 at 3:00 AM. On 6/5/25 at 9:50 AM Staff 2 (DNS) confirmed Staff 17 did not administer the prescribed medications for…

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

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 1 of 3 sampled residents (#202) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 202 was admitted to the facility in 4/2024 with diagnoses including hemiplegia (paralysis that affects only one side of the body). Resident 202's 4/5/24 admission: Social Services Assessment indicated the resident was cognitively intact. Resident 201 was admitted to the facility in 2/2024 with diagnoses including unspecified psychosis (a collection of symptoms that affect the mind where there has been some loss of contact with reality). Resident 201's 2/21/24 Socially Inappropriate Sexual Behavior Care Plan revealed the following: -The resident's socially inappropriate sexual behaviors included showing photos of her/his private parts and exposing her/himself to staff. -The resident masturbated in her/his room with the door open. Resident 201's 2/23/24 admission MDS indicated the resident was moderately cognitively impaired. 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 timely report allegations of abuse to the State Survey Agency for 2 of 3 sampled residents (#s 201 and 202) reviewed for abuse. This placed residents at risk for delayed and incomplete investigations. Findings include: The facility's 10/2022 Reporting Abuse to Facility Management Policy directed the following: -Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator. -When an alleged or suspected case of abuse is reported, the facility Administrator or her/his designee will notify the State licensing/certification agency responsible for surveying/licensing the facility within two hours of the allegation being made. Resident 202 was admitted to the facility in 4/2024 with diagnoses including hemiplegia (paralysis that affects only one side of the body). Resident 202's 4/5/24 admission: Social Services Assessment indicated the resident was cognitively intact. Resident 201 was admitted to the facility in 2/2024 with…

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 maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and resident rooms from 2/20/24 through 2/23/24 identified the following issues: -Floor 2 on the north side near the elevators had a large area of cracked paint that was peeling. -Floor 4 had nine missing wall guard endcaps. -room [ROOM NUMBER] had a baseboard peeling off the wall near the resident bathroom. -room [ROOM NUMBER] had a privacy curtain with several brown spots and smudges that appeared to be blood. -The wall outside room [ROOM NUMBER] had two quarter-sized patches that were not painted. -room [ROOM NUMBER] had three large areas of ceiling damage between the south wall and resident bed. -room [ROOM NUMBER] had a large unpainted patch on the north wall. -The wall outside room [ROOM NUMBER] had a softball-sized…

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 timely call light responses on 2 of 2 sampled units and for 1 of 3 sampled residents (#15) reviewed for sufficient staffing. This placed residents at risk for delayed and unmet needs. Findings include: 1. Resident 15 was admitted to the facility in 11/2023 with diagnoses including chronic pain and hemiplegia (weakness of one side of the body). On 2/20/24 at 12:52 PM Resident 15 stated call light response times were often 30 minutes or more, depending on the time of day. Review of Resident 15's 1/1/24 through 1/13/24 Call Light Tracking Logs revealed the following call light response times: -1/1/24 at 3:03 AM: call light response time was 26 minutes. -1/1/24 at 6:46 AM: call light response time was 25 minutes. -1/1/24 at 7:26 AM: call light response time was 24 minutes. -1/1/24 at 5:47 PM: call light response time was 22 minutes. -1/2/24 at 1:08 PM: call light response time was 47 minutes. -1/2/24 at 3:02 PM: call light response time was 30 minutes. -1/3/24 at 3:33 AM: call light response time was 18…

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 CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 7, 13, 28, 29 and 30) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: A review of personnel records on 2/21/24 at 2:19 PM with Staff 15 (Human Resources) indicated the following employees had not received their annual performance evaluations: -Staff 7 (CNA), hire date 11/23/22: no annual performance review was completed. -Staff 13 (CNA), hire date 10/18/19: no annual performance review was completed. -Staff 28 (CNA), hire date 12/5/19: no annual performance review was completed. -Staff 29 (CNA), hire date 10/6/06: no annual performance review was completed. -Staff 30 (CNA), hire date 12/21/22: no annual performance review was completed. On 2/21/24 at 2:19 PM Staff 15 confirmed annual performance reviews for Staff 7, Staff 13, Staff 28, Staff 29 and Staff 30 were not completed. On 2/23/24 at 11:41 AM Staff 2 (DNS) stated her expectation was annual 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 observation, interview, and record review it was determined the facility failed to ensure medications were secured, maintain and log appropriate medication storage temperatures and ensure proper labeling of biologicals for 3 of 3 floors reviewed for safe medication storage. This placed residents at risk for receiving medications with reduced efficacy and access to potentially harmful medications. Findings include: 1. On 2/22/24 at 10:09 AM the medication room door on the fourth floor by the nurse's station was observed to be open with no staff present nearby. The medication room contained resident medications that were sitting on the counter. Continuous observations from 10:09 AM through 10:15 AM revealed staff were walking by or at the nurse's station while the door remained open. On 2/22/24 at 10:15 AM Staff 20 (LPN) stated she was the nurse for the fourth floor medication room and acknowledged it was left open and contained resident medications. 2. On 2/22/24 at 9:56 AM the medication refrigerator on the fifth floor was observed with Staff 16 (CMA) and contained 2 open…

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 prepare and serve food in a safe and sanitary environment for 1 of 1 kitchen observed for food service. This placed residents at risk for foodborne illness. Findings include: On 2/20/24 at 9:10 AM the kitchen was toured and the following was observed: -The backsplash in the dishwashing area had a black substance extending up the wall approximately 8-12 inches. -Multiple light fixture covers were dirty where food was prepared and one had a dead spider dangling 12 inches from the light fixture. -Multiple ceiling tiles in the main kitchen area were damaged or missing. On 2/21/24 at 11:23 AM Staff 18 (Dietary Manager) acknowledged the black substance on the wall, dirty light covers and missing tiles. On 2/21/24 at 12:10 PM Staff 1 (Administrator) stated the mentioned areas in the kitchen needed to be cleaned and repaired.

Based on observation, interview and record review it was determined the facility failed to provide a restorative program to maintain or improve ROM for 1 of 2 sampled residents (#14) reviewed for ROM. This placed residents at risk for decline in ROM. Findings include: Resident 14 was admitted to the facility in 2010 with diagnoses including heart failure and anxiety. The 12/19/23 Annual MDS indicated Resident 14 had lower extremity impairment on both sides, muscle weakness, and impaired balance. Resident 14 required assistance with ADLs and mobility. Resident 14's 2/2024 restorative care plan indicated Resident 14 had weak ankles. Resident 14's goal was to strengthen her/his ankles and improve her/his ability to self-transfer. Staff were to assist Resident 14 to complete daily exercises consisting of eight to twelve repeated exercises with an exercise band. The care plan indicated staff were to refer to signage posted in the resident's room. Task sheets reviewed from 1/2/24 through 2/22/24 revealed Resident 14 received exercise support on four out of 29 days. On 2/20/24 at 12:00 PM…

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 assess for care plan effectiveness, identify and implement new fall interventions or provide adequate supervision needed to prevent falls for 1 of 3 sampled residents (#36) reviewed for falls. This placed residents at risk for avoidable falls. Findings include: Resident 36 was admitted to the facility in 7/2023 with diagnoses including cognitive deficit, osteoporosis and fracture of the left femur (thigh). Resident 36's 7/19/23 admission MDS indicated the resident had severe cognitive impairments. The resident required the extensive assistance of two staff for bed mobility, limited assistance of two staff for transfers and the extensive assistance of one staff for toileting and personal hygiene. The resident was not steady moving from a seated to standing position and was only able to stabilize herself/himself with staff assistance. Resident 36 was incontinent of bowel and bladder and was not on a toileting program. Resident 36's 7/19/23 ADL, Cognition and Fall CAAs indicated the resident had…

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 maintain a medication error rate of less than 5%. There were 2 errors with 35 opportunities resulting in an 5.71% medication error rate. This placed residents at risk for adverse drug reactions. Findings include: Resident 305 admitted to the facility in 2024 with diagnoses including chronic obstructive pulmonary disease (COPD). The 2/12/24 physician order indicated Resident 305 was to receive the following medications: -fluticasone-salmeterol (Wixela inhaler) one inhalation twice daily for COPD. -pantoprazole 20 mg before breakfast for indigestion. On 2/22/24 at 9:18 AM Staff 16 (CMA) was observed to administer pantoprazole. Resident 305 stated she/he already ate breakfast. Staff 16 was observed to administer the Wixela inhaler. Staff 16 did not instruct the resident to rinse her/his mouth after using the inhaler and the resident was not observed to rinse her/his mouth after using the inhaler. On 2/22/22 at 9:18 AM and 9:51 AM Staff 16 acknowledged the pantoprazole was not given prior 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 consent was obtained prior to administering psychotropic medications to residents for 1 of 5 sampled residents (#305) reviewed for unnecessary medications. This placed residents at risk for being uninformed about their medications. Findings include: Resident 305 was admitted to the facility in 1/2024 with diagnoses including congestive heart failure. Resident 305's 1/31/24 Physician Order indicated the resident was prescribed lorazapam for anxiety disorder. Resident 305's 1/2024 and 2/2024 MARs revealed the resident received lorazapam PRN starting on 1/31/24. Review of Resident 305's health record revealed no documentation to indicate the resident was informed in advance of the risks and benefits of lorazapam. On 2/23/24 at 9:25 AM Staff 2 (DNS) reviewed Resident 305's health record, acknowledged there was no documentation to indicate the resident was informed of the risks and benefits of lorazapam and confirmed consent was not obtained from Resident 305 prior to the resident starting the medication.

Based on interview and record review it was determined the facility failed to notify the physician and the resident's responsible party of a change of condition for 1 of 1 sampled resident (#153) reviewed for change of condition. This placed residents at risk for delayed treatment and uniformed responsible parties. Findings include: The facility's 10/2016 Lab and Diagnostic Test Results - Clinical Protocol stated: If the resident has signs and symptoms of acute illness or condition change and he/she is not stable or improving, or there are no previous results for comparison, then the nurse will notify the Medical practitioner promptly to discuss the situation, including a description of relevant clinical findings as well as the test results. Resident 153 admitted to the facility in 12/2023 with diagnoses including spinal stenosis (narrowing of spaces within spinal canal). Resident 153's clinical record indicated Witness 1 (Family Member) was Resident 153's responsible party, POA (Power of Attorney) and Emergency Contact #1. A physician order dated 1/21/24 indicated Resident 153 had…

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 properly secure controlled medications for 1 of 1 sampled resident (#11) reviewed for misappropriation. This placed residents at risk for loss of medications. Findings include: Resident 11 admitted to the facility in 2023 with diagnoses including chronic pain. The 11/27/23 physician order indicated Resident 11 was to receive oxycodone (narcotic pain medication) 5 mg BID PRN. The Controlled Substance Record Book #113, page 82 indicated the following: -On 12/5/23 the oxycodone 5 mg medication card had 13 doses remaining on 12/5/23 and no additional doses signed out. -On 12/8/23 it was noted this oxycodone medication card was missing. On 2/23/24 at 1:01 PM Staff 2 (DNS) stated she completed the facility investigation and Resident 11's oxycodone was missing on 12/5/23 but was not discovered until 12/8/23 due to staff not counting narcotic medication correctly in between shifts. Staff 2 acknowledged Resident 11's 13 doses of oxycodone were missing and the facility was unable to determine what happened 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.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner and ensure dietary staff wore facial hair restraints for 1 of 1 kitchen staff serving all residents within the facility and 1 of 1 steam carts. This placed residents at risk for food borne illness and contaminated food. Findings include: 1. On 11/14/22 at 9:15 AM during the initial tour of the facility's kitchen, packaged food items were observed stored directly on the floor in the hallway outside of the kitchen and directly on the floor of the dry storage room. Items stored on the floor in the hallway outside of the kitchen included: *A box of scone and shortcake mix; *A box of pasta; *Six cans of three bean salad; *A box of cranberry juice; *A box of white and wheat bread; *A box of white tea rolls; and *A case of V8 juice (one six-pack was removed). Items stored on the floor of the dry storage room included: *A flat of cans of pumpkin; *A flat of cans of red beans (one can was removed); and *A flat of cans of crushed tomatoes (one can was removed). On 11/14/22 at 9:30 AM…

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

Based on observation, interview and record review it was determined the facility failed to ensure a common-use glucometer (a device used to obtain blood glucose levels) was appropriately disinfected between uses for 3 of 3 sampled residents (#s 10, 24 and 29) reviewed for CBG monitoring. This placed residents at risk for bloodborne infections. Findings include: The facility's 4/2019 Obtaining a Fingerstick Glucose Level Policy and Procedure directed to ensure the glucometer was disinfected before use according to the manufacturer's instructions. The 3/2020 ForaCare GD20 Blood Glucose Monitoring System Owner's Manual specified the following safety precautions: - Users need to adhere to standard precautions when handling or using this device. - All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. - The meter should be disinfected after use on each patient. - This Blood Glucose Monitoring System may only be used for testing multiple patients when…

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

Based on observation and interview it was determined the facility failed to ensure residents received reasonable accommodation of needs for 1 of 1 sampled resident (#10) reviewed for accommodation of needs. This placed residents at risk for not meeting resident's individualized needs. Findings include: Resident 10 was admitted in 10/2022 with diagnoses including surgical aftercare for digestive surgery and hematuria (blood in the urine). On 11/14/22 at 1:30 PM Resident 10 reported she/he was unable to access her/his belongings stored on the bookshelf due to the bookshelf being blocked by the resident's TV and TV stand. Resident 10 stated she/he wished they had access to the bookshelf as it contained several personal items the resident wanted. On 11/17/22 at 9:45 AM Resident 10's bookshelf was observed blocked by the resident's TV and TV stand, which made it inaccessible to the resident. On 11/17/22 at 9:46 AM Staff 13 (CNA) stated due to the location of the TV and TV stand, Resident 10 was unable to access items from the bookshelf. Staff 13 stated Resident 10 had to rely on staff 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 and interview it was determined the facility failed to ensure resident privacy was provided for 1 of 1 sampled resident (#10) reviewed for dignity. This placed residents at risk for lack of privacy. Findings include: Resident 10 was admitted in 10/2022 with diagnoses including surgical aftercare for digestive surgery and hematuria (blood in the urine). On 11/14/22 at 1:30 PM Resident 10 reported her/his roommate's head of the bed extended beyond the privacy curtain towards Resident 10's side of the room. Resident 10 reported the privacy curtain was unable to fully close due to the location of the roommate's bed. Resident 10 stated the roommate had the ability to view her/his care or when she/he slept. On 11/15/22 at 10:05 AM and on 11/17/22 at 9:45 AM observations of Resident 10's room revealed the head of the roommate's bed was positioned on Resident 10's side of the room which prevented the privacy curtain from being fully closed. On 11/17/22 at 9:52 AM Staff 13 (CNA) stated Resident 10's privacy curtain was obstructed and did not provide full privacy. 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 ensure residents were free from physical restraints for 1 of 1 sampled resident (#15) reviewed for restraints. This placed residents at risk for being physically restrained. Findings include: Resident 15 was admitted in 10/2022 with diagnoses including dementia and anxiety. On 11/16/22 at 8:32 AM Resident 15 was observed in bed with bilateral padded bed rails installed on each side of the bed. During the observation, it was determined the resident was unable to be interviewed. A review of Resident 15's clinical record revealed no physician orders or assessments in the resident's record regarding the use of padded bed rails. On 11/16/22 at 8:41 AM Staff 5 (CNA) stated the padded bed rails on Resident 15's bed were used to keep Resident 15 from getting out of bed as she/he was a high fall risk. Staff 5 stated she was unaware of how long the padded bed rails had been there. On 11/16/22 at 8:51 AM Staff 15 (LPN) stated Resident 15's padded bed rails prevented her/him from getting out of bed 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 interview and record review it was determined the facility failed to comprehensively assess restraints for 1 of 1 sampled resident (#15) reviewed for physical restraints. This placed residents at risk for unassessed physical restraints. Findings include: Resident 15 was admitted in 10/2022 with diagnoses including dementia and anxiety. A review of Resident 15's 11/11/21 and 10/12/22 Annual MDS Assessment for Restraints and Alarms indicated no padded bed rails were used in conjunction with Resident 15's care. On 11/16/22 at 8:32 AM Resident 15 was observed in bed with padded bed rails installed on each side of the bed. On 11/16/22 at 9:10 AM Staff 16 (RNCM) stated upon review of the MDS Assessment for Restraints and Alarms, no assessment was obtained for the use of padded bed rails.

Based on observation, interview and record review it was determined the facility failed to provide nail care for 1 of 3 sampled residents (#17) reviewed for ADL care. This placed residents at risk for unmet care needs. Findings include: Resident 17 was admitted to the facility in 8/2019 with diagnoses including type 2 diabetes. The 8/16/22 Annual MDS revealed Resident 17 had a BIMS score of 13 indicating cognitively intact, was bedbound and required extensive assistance of one person for personal hygiene. Resident's 17's 8/22/22 Comprehensive Care Plan for ADLs indicated Resident 17 required physical assistance for most of her/his ADLs due to impaired mobility and physical limitations. No reference to nail care was made in the resident's care plan. Resident 17's fingernails were noted to be long and dirty during observations made from 11/14/22 to 11/16/22 between the hours of 10:00 AM to 2:00 PM. On 11/16/22 at 3:24 PM and 3:40 PM Staff 5 (CNA) and Staff 10 (CNA) stated it was the responsibility of the nurse to provide diabetic nail care. On 11/16/22 at 4:04 PM Staff 7 (RN) stated…

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

Based on observation, interview and record review it was determined the facility failed to implement interventions to prevent pressure ulcers and skin breakdown for 1 of 1 sampled resident (#17) reviewed for positioning. This placed residents at risk for the development of pressure ulcers and skin breakdown. Findings include: Resident 17 was admitted to the facility in 8/2019 with diagnoses including type 2 diabetes and a history of skin and subcutaneous tissue (the deepest layer of skin) disease. Resident 17's 8/16/22 Annual MDS revealed the resident was at risk for developing pressure ulcers/injuries, was bedbound and required extensive assistance for bed mobility with two person physical assist. The 11/2022 signed physician orders directed staff to off-load pressure to Resident 17's right lateral ankle each shift and to notify her/his physician if a pressure ulcer or skin breakdown was observed. Multiple observations of Resident 17 between 11/14/22 to 11/18/22 from 10:00 AM to 3:330 PM noted the resident lying in bed with her/his right ankle flat on the mattress. On 11/16/22 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 observation, interview and record review it was determined the facility failed to provide routine diabetic foot care for 1 of 1 sampled resident (#17) reviewed for foot care. This placed residents at risk for infection and pain. Findings include: Resident 17 was admitted to the facility in 8/2019 with diagnoses including type 2 diabetes. A 1/31/20 podiatry (foot care) appointment progress note indicated the resident received debridement (procedure to remove debris or infected/dead tissue from a wound) of her/his toenails and return in about 10 weeks. No documentation in Resident 17's clinical record indicated she/he received foot care services post her/his 1/31/20 appointment. On 11/16/22 at 3:22 PM Resident 17's toenails were observed to be thick, yellow and long. The nail on her/his left big toe measured approximately 1.5 inches. Resident 17 confirmed her/his toenails caused her/him pain on a daily basis. On 11/16/22 at 4:04 PM Staff 7 (RN) stated licensed nurses were responsible for the nail care of all diabetic residents. Staff 7 observed Resident 17's toenails 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.

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 safety interventions were in place to prevent elopement for 1 of 2 sampled residents (#23) reviewed for elopement. This put residents at risk for potentially avoidable accidents. Findings include: Resident 23 was admitted in 1/2021 with diagnoses including stage 4 pressure ulcers of the sacral region (bottom), chronic obstructive pulmonary disease (a condition that restricts lung capacity) and paralytic syndrome (a condition that causes paralysis in the legs and lower torso). A 5/14/21 physician's order stated Resident 23 may go out of the facility with a responsible individual and appropriate medications. Review of Resident 23's clinical record revealed no assessment was completed that determined the resident's safety or capabilities regarding ambulation to and from the facility. On 11/17/22 at 12:40 PM Resident 23 was observed outside of the facility unsupervised in her/his wheelchair. Resident 23 self ambulated…

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.