Edenbrook On Second Ave

Based on observation and staff interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and three of five resident pantry areas (Nursing Units Medbridge Hall, A Hall, and B Hall). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean, and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness, according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations on September 25, 2025, at 8:28 AM revealed the kitchen floor…

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 observations, a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for four out of five nursing units (Units Medbridge Hall, A Hall, B Hall, and D Hall), including experiences reported by two out of three residents interviewed (Residents 1 and 2). Findings include:A review of resident council meeting minutes dated August 4, 2025, revealed residents in attendance expressed concerns regarding the housekeeping services. Residents reported that only garbage is emptied, and floors are occasionally mopped. Additional concerns included housekeepers using dirty water to mop floors, particularly in hallways and dining areas; lack of top dusting; dusty surfaces; spider webs; over-bed tables not being cleaned; and bathroom floors uncleaned. Observations on September 25, 2025, at 8:26 AM revealed a black mat with multiple pieces of white debris, a wet paper towel, 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 a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 29 residents sampled (Residents 2, 3, and 5) and four out of five residents interviewed during a resident group interview (Residents 4, 61, 77, and 112). Findings include: During a resident council meeting on June 4, 2025, at 10:00 AM, Residents 4, 61, 77, and 112 voiced concerns about the timeliness of staff response to activated call bell lights. Resident 112 stated he rang his call bell for assistance the night before but did not receive help for over one hour. He needed assistance with toileting. He reported that he has waited at least 30 minutes anytime he utilized the call bell. Resident 4 stated that he frequently waited over an hour for staff to answer his call bell. He stated that staff often enter…

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 a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for one residents out of 29 sampled residents (Resident 3) and failed to provide nursing care consistent with professional standards of practice in accordance with physician orders for one resident out of 29 sampled residents (Resident 93). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure…

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 a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to properly store resident personal care equipment on one of five nursing units (A wing) and failed to store a urinary catheter drainage bag in a manner to limit the potential for infection for one of three sampled residents (Resident 29). Findings include: A review of the facility Infection Control Program Policy last reviewed May 5, 2025, indicated the infection control program exists to assure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. An observation on June 3, 2025, at 11:58 AM in the bathroom of resident room A 05 revealed a grey bedpan on the floor under the sink, wedged between the garbage can and the wall. The bedpan was not enclosed in a plastic bag and was in direct contact with the floor, wall, and garbage can. A pink wash basin was also observed…

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 clinical record review and resident and staff interviews, it was determined that the facility failed to conduct a care plan conference and failed to ensure that the resident was invited to participate in the care planning process for one of 29 residents reviewed (Resident 112). Findings include: A clinical record review revealed Resident 112 was admitted to the facility on [DATE], with diagnosis to include a below the knee amputation of the left lower extremity (leg), and end stage renal disease (final, permanent stage of chronic kidney disease, where the kidneys can no longer function on their own). A review of the quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 12, 2025, revealed that Resident 112 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, 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 a review of clinical records, facility investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement a planned intervention to prevent intrusive wandering by a cognitively impaired resident (Resident 103) which resulted in a resident-to-resident altercation for two of 29 sampled residents (Residents 91 and 103). Findings include: A clinical record review revealed that Resident 91 was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and hypertension (blood pressure that is higher than normal). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated April 4, 2025, revealed that Resident 91 is cognitively intact with a BIMS score of 15 (Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility policy and clinical record, the facility failed to ensure respiratory equipment was maintained in a sanitary and functional condition for one resident (Resident 40) out of 29 sampled residents. Findings include: A review of facility policy entitled Oxygen Administration and Storage last reviewed on May 5,2025, revealed a nebulizer mouthpiece (a piece of medical equipment that a person with asthma or other respiratory conditions use to administer medication directly and quickly to the lungs) and tubing should be labeled with the date and changed weekly. A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD a disease that restricts airflow to the lungs and causes breathing problems). A review of the Resident 40's clinical record revealed a physician's order dated May 5,2025, for Ipratropium 0.5mg- Albuterol Sulfate Inhalation…

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 clinical record review, payor source data, resident and staff interview, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident 110) out of 29 residents reviewed. Findings included: Review of the clinical record indicated Resident 110 was admitted to the facility on [DATE], with diagnoses to include unspecified dementia (the loss of cognitive functioning that affects a person's ability to perform everyday activities). Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated May 5, 2025, revealed Resident 110 was cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). The resident's care plan, initiated…

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 a review of clinical records, select facility policy, documentation provided by the facility, and staff and resident family interviews, it was determined the facility failed to ensure residents have the right to personal privacy for one resident out of eight sampled (Resident 1). Findings include: A review of facility policy titled Photographing, Video and Audio Recording, and Other Imaging of Residents, Visitors, and Associates, dated April 1, 2022, revealed it is the facility's policy to take reasonable steps to protect residents, visitors, and associates from unauthorized photography, video or audio recordings, or other images. The policy indicates photography and audio recording of residents within the facility by associates for personal use is prohibited. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include down syndrome (a genetic condition that causes physical and intellectual disabilities) and dementia (a condition characterized by 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 review of clinical records and staff interview it was determined the facility failed to ensure that a resident's room change was not completed for the purpose of staff convenience for one resident out of 8 sampled residents. (Resident 1) Findings include: A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and type 2 diabetes (disease that occurs when your body doesn't produce enough insulin or doesn't use it properly, resulting in high blood sugar levels). Further review of the resident's clinical revealed the resident resided in Room A6 from June 2, 2024, until December 24, 2024, when he was moved to room B 11. A social service progress note dated December 24, 2024, at 12:00 PM indicated that staff attempted to notify Resident 1 of the room change by calling his phone three times while the resident was at the hospital. Messages were left on his voicemail. A subsequent progress note dated…

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 review of facility investigative reports, clinical records, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 8 sampled residents (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49,…

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 clinical record review, observation, and staff and resident interviews, it was determined the facility failed to reasonably accommodate a request and need for more frequent bed linen changes for one resident out of eight residents sampled (Resident 2). Findings incudes: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include morbid obesity (complex chronic disease in which a person has a body mass index of 40 or higher) and lymphedema (chronic condition that causes tissue swelling usually in the arms or legs in which accumulated fluid could break the skin resulting in leakage). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 31, 2024, revealed the resident had a BIMS (brief interview for mental status- tool to screen and identify the cognitive condition of long-term care residents) score of 15 (a score of 13-15 indicates…

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 clinical record and facility policy review and staff interview, it was determined the facility failed to ensure that in preparation for a room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for two of 15 room changes completed by the facility from October 30, 2024, through November 4, 2024 (Resident 1 and Resident 2). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A review of the facility Room Change/Roommate Assignment Policy, last reviewed July 2024, indicated that changes in room…

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 a review of clinical records and resident and staff interview, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by seven residents out of the 29 residents sampled (Residents 3, 34, 85, 66, 57, 6, and 38). Findings include: A clinical record review revealed that Resident 3 was admitted to the facility on [DATE]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 5, 2024 revealed that Resident 3 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 34…

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, review of select facility policy, clinical record review, and resident and staff interviews, it was determined the facility failed to provide housekeeping services to maintain a clean and safe resident environment in two resident rooms and the A unit. (Resident 68 and Resident 39) Findings include: Review of facility policy titled Shower/Bath last reviewed by the facility on July 18, 2024, indicated that staff will change a resident's bed linens on shower days or when visible soilage is observed. An observation on August 20, 2024, at 11:44 AM , in resident room A06, bed A, revealed soiled bed linens on Resident 68's bed. The resident's pillowcase contained multiple reddish-brown stains, the fitted sheet had a large yellow stain in the middle of the mattress, and there were multiple light brown stains at the foot of the bed. Interview with Resident 68, a cognitively intact resident with a BIMS score of 15 (BIMS-brief interview to assess cognitive status. A score of 13-15 indicates intact cognitive responses), indicated he has not had his sheets changed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for three residents out of 29 sampled (Residents 9, 22, and 135). Findings include: Review of facility policy titled Oxygen Administration last reviewed by the facility on July 18, 2024, revealed when oxygen is not in use, the oxygen tubing, nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) or mask is to be stored separately in a labeled plastic bag. Review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe), and atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls which causes obstruction of blood flow). 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, select facility policy review and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. (Medication Storage Room B). Findings include: A review of facility policy titled Disposition of Discontinued Medications, last reviewed by the facility on July 18, 2024, revealed the facility will destroy or return medication in accordance with the facility policy. The discontinued medication procedure includes four steps: 1. Obtain order for discontinued medications 2. Timely remove medication from medication cart 3. Follow pharmacy/facility policy specific to a. controlled substances b. fentanyl patches c. medication returns 4. Medication awaiting final disposition will be locked in the medication room once removed from the medication cart. A review of facility policy titled 3.0 Returned Medications to the Pharmacy & Credits last reviewed by the facility on July 18, 2024, revealed the procedure of returning medication from the facility to the pharmacy indicated, if…

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 review of the facility's abuse policy, clinical records, facility investigations, information submitted by the facility to the state agency, and staff interview it was determined the facility failed to timely report an alleged violation of misappropriation of resident property for one resident out of 26 reviewed (Resident 42). Findings include: Review of the facility's Abuse Policy reviewed by the facility July 18, 2024, indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property (deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent) and exploitation. It is the policy of the facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined the facility failed to develop and implement a person-centered care plan to meet the specific needs of two residents out of 29 sampled (Residents 63 and 87). Findings including: A clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that include hemiplegia (paralysis on one side of the body) and cerebral infarction (brain damage that results from a lack of blood). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 4, 2024, revealed that Resident 63 is severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment). A care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interviews, it was determined the facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, by failing to provide showers/bed bath as scheduled and personal grooming for two of 26 residents sampled (Residents 42 and 138). Findings include: Review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses to end stage renal disease with hemodialysis (a treatment that filters waste, salts, and fluids form the blood when the kidneys are no longer able to do so) and a right femur (thigh bone) fracture. An admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 4, 2024, indicated the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and resident and staff interview, it was determined the facility failed to provide person-centered quality care by failing to follow physician orders for NPO (nothing by mouth) in preparation for an abdominal ultrasound for one resident (Resident 133) and failed to follow physician orders for the consistent application of a prescribed therapeutic measure, ace wraps, for one resident of 29 sampled (Resident 87). Findings include: A review of the clinical record revealed that Resident 133 was admitted to the facility on [DATE], with diagnoses to include hepatic encephalopathy (loss of brain function when a damaged liver does not remove toxins from the blood), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and gastro-esophageal reflux disease (stomach acid or bile irritates the food pipe lining). A review of a physician's order dated August 20,…

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 a review of clinical records, select facility policy, and staff interview it was determined the facility failed to ensure that physician ordered intravenous (IV- medication is administered through needle or tube inserted into a vein) medications, an antibiotic, were administered as prescribed for one resident out of 26 sampled (Resident 67). Findings include: Review of the facility Medication Administration Policy last reviewed by the facility on July 18, 2024, indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with orders, including any required time frame. Review of Resident 67 clinical record revealed the resident was readmitted to the facility from the hospital on July 30, 2024, with a PICC line (peripherally inserted central catheter- thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart and used to administer fluid and medications) and diagnoses to include osteomyelitis (bone infection that causes inflammation 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 review of clinical records and staff interview, it was determined the facility failed to maintain complete and accurate records of treatment administration to one resident of 29 sampled (Resident 87). Findings included: A review of the clinical records revealed Resident 87 was admitted to the facility on [DATE], with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and fracture of the neck of the left femur (hip fracture). A physician's order dated June 17, 2024, revealed an order for ace wraps to his bilateral legs, on in the AM and off at HS (hours of sleep). Two times a day check skin integrity with application and removal. Observation of Resident 87 sitting in his Broda chair (specialty chair used for positioning and pressure reducing) in the B Hall dining room on August 20, 2024, revealed that the resident was not wearing ace wraps on his bilateral lower extremities (legs) as ordered. However, a review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, CDC infection control guidance, and staff interview it was determined the facility failed to implement transmission-based precaution control practices to mitigate the risk of COVID-19 infections in the facility for four out of five residents sampled for transmission-based precautions (Residents 2, 63, 66, and 121) and failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one out of 29 residents sampled (Resident 49). Findings include: A review of The Centers for Disease Control and Prevention 2007 Guideline for Isolation Precautions: Preventing Transmission of Infection Agents in Healthcare Settings, last updated July 2023, Section II.E. Personal Protective Equipment (PPE) for Healthcare Personnel, revealed that designated containers for used disposable or reusable PPE should be placed in a location that is convenient to the site of removal to facilitate…

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 a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for one out of the 29 residents sampled (Resident 107). Findings include: A clinical record review revealed Resident 107 was admitted to the facility on [DATE], with diagnoses that include acute kidney failure (a sudden loss of kidney function) and intellectual disabilities (significant deficits in general cognitive abilities such as reasoning, planning, and problem solving). A review of an admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 22, 2024, revealed that Resident 107 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new…

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 review of the facility's abuse prohibition policy, clinical records, and select investigative reports and staff interview it was determined that the facility failed to ensure that one resident out of 10 sampled was free from verbal abuse (Resident 2). Findings include: A review of the facility's Abuse policy last reviewed by the facility on March 2024, indicated that the objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detention and prevention. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. A review of the clinical record revealed that Resident 2, was admitted to the facility on [DATE], with diagnoses, which included dementia. Review of Resident 2's quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted…

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 review of clinical records, the facility's abuse prohibition policy and staff witness statements, and staff and family interview, it was determined that the facility failed to timely and thoroughly investigate an allegation of resident abuse and prevent the potential for further abuse during the course of the investigation for one resident out of 10 resident sampled (Resident 2). Findings include: A review of the facility's Abuse prohibition policy last reviewed by the facility on March 2024, indicated that the objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detention and prevention. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within hearing distance, regardless of their age, ability to comprehend, or disability. It is the policy of this facility that reports of abuse are promptly and thoroughly investigated. The designated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and select facility policy and resident and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 10 sampled residents Findings include: A review of a select facility policy for Leave of Absence (LOA), reviewed April 1, 2024 revealed It is the policy of the facility to coordinate, when appropriate, the preparation for nd return from a leave of absence but not limited to physical, medical and medication needs. The purpose of the policy is to ensure resident's are met during their absence from the facility and to ensure sfety of the wheelchair user and other individuals while out in the community. Procedures to include: - the licensed nurse will ensure that there is a physician's order and perform any needed education. -having a personal cell phone to use during LOA is recommended -when the resident is ready to leave the facility, the nurse will…

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, select facility policy review and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on two of four medication carts observed (B hall and C hall). Findings include: A review of facility policy titled Administering Medications last reviewed by the facility November 2023, revealed the procedure for staff to check the expiration date on the medication label. When opening a multi-dose container, place the date on the container. Observation of the B Hall medication cart on May 15, 2024, at 9:40 AM in the presence of Employee 1 (licensed practical nurse), revealed a vial of Lantus injectable 100 ml (a medication used to treat diabetes), a vial of Novolog injectable 100 ml (a medication used to treat diabetes), and a vial of Levemir injectable (a medication used to treat diabetes) opened and used, but not dated when initially opened. Observation of the C Hall medication cart on May 15, 2024, at 9:55 AM in the presence of Employee 2 (licensed practical nurse),…

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 clinical record, select facility policy and incident report reviews and staff interviews it was determined that the facility failed to provide individualized services necessary to maintain continence and prevent continued decline and assure the resident received the necessary staff assistance to meet the resident's toileting needs in an attempt to decrease incontinency for one resident out of 25 sampled (Resident 27). Findings included: A review of the current facility policy for urinary and bowel incontinence revealed, it is the policy of the facility to identify, assess and provide the appropriate treatment and service to achieve or maintain as much normal urinary and bowel function as possible. Residents shall have their continence status assessed upon admission, re-admission and after identified decline/change in condition. Once an incontinent resident is identified, the staff will develop a plan of care to manage issues with incontinence, allowing them to reach their highest level of function. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for diabetes management for one resident (Resident 7) out of 25 sampled. Findings included: A clinical records review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that include diabetes mellitus (a disease of inadequate control of blood glucose levels). A physician order initially dated March 10, 2023, indicated that staff were to administer HumaLOG Solution 100 units/milliliter (Insulin) with instructions for the dose to be based on a sliding scale depending on the resident's blood sugar reading; inject as per the sliding scale: if the resident's blood sugar was between 151-200, administer 2 units; if 201-250, administer 4 units; if 251-300 administer 6 units; if 301-350 administer 8 units; if 351-400, administer 10 units; if 401-999, administer 12 units. 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.