Gardens At Millville, The

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. 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). Observation during the initial tour of the food and nutrition services department with the foodservice director (FSD) conducted on February 11, 2025, at 9:20 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne…

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 investigative reports, select facility policies, and staff interview, it was determined the facility failed to provide meal tray set-up assistance to ensure food was cut in bite size pieces to promote safe swallowing for one of 23 residents sampled (Resident 76). Findings include: Review of the facility Assistance with Meals Policy dated November 1, 2024, indicated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. Facility staff will serve resident trays and will help residents who require assistance with eating. Review of the facility LifeVac Policy (non-powered, non-invasive, single use only airway clearing device developed for resuscitating a victim with an airway obstruction) dated November 1, 2024, indicated the LifeVac can be utilized when traditional basic life-saving methods, such as the Heimlich maneuver (first-aid technique…

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 clinical records and the facility's activity calendar, and interviews with staff, it was determined the facility failed to provide an individualized activities program designed to meet the specific functional needs, abilities, and preferences for residents with dementia and/or sensory deficits for five residents (Residents 15, 46, 96, 65, and 51) out of 23 sampled residents. Findings include: On February 13, 2025, at 10:35 AM, an observation was conducted in the day room across from the C/D nurses' station. Five residents (Residents 15, 46, 96, 65, and 51) were seated in the room. The television was on; however, none of the residents appeared to be watching or engaged with the program. No staff member was present, and none of the residents were conversing or otherwise engaged in meaningful activities. According to the February 2025 activities calendar, a scheduled Ladies Group was taking place in the main dining room; however, the female residents in the day room were not participating in the scheduled activity. A review of Resident 15's clinical…

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, test tray results, and resident and staff interviews, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for 7 out of 23 residents sampled (Residents 44, 201, 38, 16, 88, 54 and 34). Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility Temperatures Policy dated November 1, 2024, indicated that all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. Take temperatures often to monitor for safe temperature ranges at or below 41 degrees Fahrenheit for cold foods and at or above 135 degrees Fahrenheit for hot foods. During a group interview with six alert and oriented residents…

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 staff interview and review of professional literature, the facility's assessment, facility provided documentation, and review of the medical, psychiatric, and mental health conditions of the resident census, it was determined the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, the assessment of the resident population should…

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

Based on observation, review of select facility policy, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility and further failed to ensure that staff followed proper infection control techniques while passing medications to three of three residents (Residents 6, 22, and 32) on the A Hall nursing unit. Findings included: A review of facility policy titled Infection Prevention and Control Program last reviewed by the facility on November 1, 2024, indicated the Infection Prevention and Control Program (IPCP) is established and maintained to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. An observation on February 12, 2025, at 8:22 AM revealed…

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 the facility's abuse prohibition policy, clinical records, select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 40) was free from physical abuse perpetrated by another resident (Resident 81) out of 23 sampled residents. Findings include: A review of facility policy titled Abuse Policy, last reviewed by the facility on November 1, 2024, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A review of Resident 40's clinical record revealed the resident was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure a physician-ordered fluid restriction was maintained for one resident receiving dialysis (Resident 13) out of 23 sampled. Findings include: A review of a facility policy titled Encouraging and Restricting Fluids last reviewed by the facility on November 1, 2024, revealed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. The policy stated, Verify that there is a physician's order for this procedure and review the resident's care plan and/or assignment sheets to assess for any special needs of the resident. The procedure stated to follow the specific amount of fluids ordered by the physician concerning for fluid intake or restrictions. A review of the clinical record revealed that Resident 13 was admitted to the facility on [DATE], with diagnoses that included…

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 interview, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for one resident out of 23 sampled (Resident 46). Findings include: A review of the clinical record revealed that Resident 46 was admitted to the facility on [DATE], with diagnoses to include early onset Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions), and cerebrovascular disease (or stroke - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel). Review of Resident 46's plan of care dated November 17, 2021, indicated that the resident had a nutritional problem or a potential nutritional problem due to gastroesophageal reflux (a chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach. Foods containing tomato, such as spaghetti sauce, salsa, or pizza, spicy…

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 interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment in two units out of four units observed. (A and C units) Findings include: An observation on August 27, 2024, at approximately 9:50 AM of the A hall nursing unit revealed the following: room [ROOM NUMBER] was noted to have a plastic three drawer bin covered with dried brown spots. The bathroom in this room had a plastic garbage bag tied to the grab bar by the toilet containing a soiled urinal with urine collected in the bottom of the plastic garbage bag. Another plastic garbage bag tied to the grab bar by the toilet contained a soiled foley catheter bag (urine drainage bag) with a brown substance observed in the bag. A toilet brush encrusted with a yellow substance was present in a plastic container once used for cottage cheese, on the floor in the bathroom. room [ROOM NUMBER] was noted to have a plastic garbage bag tied to the grab…

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 and staff interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and comfortable environment for residents. Findings include: Observations of resident room [ROOM NUMBER] during an environmental tour of the facility on May 21, 2024, at 10 AM revealed the floor surrounding and beneath the resident's bed was littered with dirt, paper debris and a brown sticky substance. Observation of resident room [ROOM NUMBER] D, revealed a large amount of dirt, paper debris and a brown sticky substance on the floor, under the bed and around the bedside table. The hot water temperature in the 200 hallway resident shower room on May 21, 2024 at 10 AM was 100 degrees Farenheit. The hot water temperatures in the locked dementia care unit shower room was only 98 degrees Farenheit. The hot water temperatures in the 100 hallway shower rooms May 21, 2024, at 10 A.M. ranged from 90 degrees and 98 degrees Farenheit. The facility failed 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, select facility policy and investigative reports and staff and resident interviews it was determined that the facility failed to consistently implement sufficient measures to protect a resident (Resident A3 ) out of 16 sampled from sexual verbal abuse perpetrated by another resident (Resident A2 ). Findings included: A review of a facility policy for Abuse last reviewed by the facility on June 21, 2023, indicated that residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians friends or other individuals. Clinical record review revealed that Resident A2 was admitted to the facility on [DATE], with diagnosis to include dementia, alcohol abuse 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.

Based on observation and staff interview, it was determined that the facility failed to maintain an environment free from accident hazards on one of two resident hallways. Findings include: Observations of the east hallway May 21, 2024 at 9 AM, 11 AM. and again at 1 PM on the upper end of the 100 hallway revealed 7 wheelchairs. a straight back chair, a large linen cart, dirty linen carts, a trash bin and a wheelchair charger plugged into a hallway outlet lining the left side of the hallway, obstructing access to the handrails on the wall on that side of the corridor. Observations of the east hallway, May 21, 2024, at 9:10 AM and again at 1:10 PM on the lower end of the 100 hallway revealed 5 wheelchairs, a large linen cart, trash container and a double dirty linen cart, lining the left side of the hallway, obstructing access to the handrails on the wall on that side of the corridor. Residents were observed to be out and about on the unit at those times, self-propelling in wheelchairs and/or ambulating with walkers. During an interview May 21, 2024 at 2 P.M.,the Nursing Home…

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 and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication for one of 16 residents reviewed (Resident B1). Findings include: A review of facility policy titled Administering Medications, provided by the facility on May 21, 2024, indicated it is the policy that medications shall be administered to in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Team (IDT) had determined that they have the decision-making capacity to do so safely. A review of the facility policy titled Self-Administration of Medications, provided by the facility on May 21, 2024, indicated it is the policy to promote the right of the resident to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe. The staff and practitioner will assess each resident's mental and physical…

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 and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection including for one of 16 sampled residents (Resident A1). Findings include: Observations on May 21, 2024 at 9 AM, 11 AM and 1 PM revealed Resident A1 was his bed, and upon each observation his urinary foley catheter collection bag was observed directly on the floor. The collection bag was not in a privacy bag at the time of these observations. There were multiple uncovered, clean dressings, a opened box of clean dressings an open tube of Hydrocortisone cream (with the cap off), an open tube of Triamcinolone ( a topical steroid cream) with the cap off and an open bottle of sodium chloride solution (used for irrigation) with no open date on the bedside table in Resident A1's room. On top of these resident care and treatment supplies was an uncovered, clean incontinence brief. On the resident's dresser was a wash basin containing multiple used hand towels,…

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 staff interview, it was determined that 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 dietary department, and Alzheimer's dementia care unit kitchenette/pantry area, and East and [NAME] medication rooms. 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). A review of a facility policies entitled Storage Areas and Handling Clean Equipment 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 review of clinical records, the facility's infection control data, and infection control program and policies and staff interview, it was determined that the facility failed to maintain a comprehensive program to monitor and prevent infections in the facility. Findings include: A review of the facility's current infection control policy provided during the survey ending April 12, 2024, revealed that it is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan. A review of the facility's compiled infection data since the last standard survey ending May 12, 2023, revealed that during the months from August 2023 through March 2024 multiple resident infections were identified each month. However, there was no documented evidence that the infection preventionist/designee had evaluated potential causative…

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 and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of the four nursing units (Nursing [NAME] A, [NAME] B, East C, and East D Hall). Findings include: An observation on April 9, 2024, at 10:24 AM revealed the window blinds in resident room [ROOM NUMBER] were broken or missing slats. Pieces of the slats were observed on the floor of the resident's room. A film of dust, black debris, and white paint chips were observed on the window sill. A build-up of dust and debris was observed on the radiator cover extending along the floor on the window-side wall. An observation on April 9, 2024, at 11:15 AM in the [NAME] A Hall exit, near resident rooms [ROOM NUMBERS],2 revealed a black substance debris on the floor to the left of the exit doors. The bottom corner of the exit door was observed to have a dirt buildup of approximately 0.25 inches thick. An observation on April 9, 2024, at 12:02 PM in the…

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

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 provide restorative nursing services planned to maintain the mobility and functional abilities of one of the 20 residents sampled (Resident 16). Findings included: A clinical record review revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses that included end-stage renal disease (final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 28, 2024, revealed that Resident 16 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…

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 review of controlled drug records and staff interview, it was determined that the facility failed to implement pharmacy procedures for reconciling controlled drugs and records accounting for their administration for one of 20 residents sampled (Resident 36) . Finding include: A review of the clinical record revealed that Resident 36 had a physician order dated January 18, 2024, for Oxycodone (a narcotic opioid pain medication) 10 mg Tablet, one tablet every 6 hours as needed for severe pain 7-10 (a pain scale, 1-10, 1 least pain, 10 most pain). A review of the controlled substance record accounting for the above narcotic medication revealed that on April 1, 2024, at 12:00 AM, April 1, 2024 at 11:45 AM, April 2, 2024, at 8:30 PM, April 4, 2024 at 11:40 PM, April 5, 2024 at 5:30 PM, April 6, 2024, at 5:30 AM, April 7, 2024, at 5:37 AM, April 8, 2024, at 11:30 AM, and April 8, 2024, at 12:30 PM, nursing staff signed out a dose of the resident's supply of Oxycodone 10 mg . However, the administration of the controlled drug to the resident was not recorded on the resident'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, a review of facility's planned menus and resident and staff interview it was determined that the facility failed to serve menus that accommodated, to the extent possible, the food preferences of the resident population, to promote acceptance and satisfaction with meals, including three residents of 20 residents reviewed (Resident 69, 80, and 91). Findings included: During an interview with Resident 69 on April 9, 2024, at 1:00 p.m., the resident stated that that the food served lacks flavor and the facility menu lacks variety. He reported that he regularly attends food committee meetings and voices his concerns regarding the lack of a varied menu, such as repetitive menu options. Resident 69 stated that the Certified Dietary Manager (CDM) was very understanding and did a good job, but he feels that her hands are tied due to budgetary restraints from the facility's corporate staff. Resident 69 stated that the facility's CDM and Registered Dietitian (RD) weren't involved in the development of the menu and that the corporate dietitian develops the menu 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 observations, resident and staff interviews and a review of clinical records and water temperature logs it was determined that the facility was not administered in a manner to effectively use its resources to promote safety and physical well-being of residents by failing to ensure safe hot water temperatures on the [NAME] Hall A and B unit. Findings included: A review of clinical records and water temperature logs, observations, and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to maintain hot water temperatures within a safe range for residents, including Resident 12, 13, and 69, residing on the [NAME] Hall A and B unit, placing these 27 residents out of 97 residents residing in the facility in immediate jeopardy due to the potential for serious burns. According to the U.S. Consumer Product Safety Commission, most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns…

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 staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to conduct a facility wide assessment that accurately reflected the personnel and specific resources presently available and to identify those that are necessary to care for its current resident population. Findings include: At the time of the survey ending April 12, 2024, the facility had reviewed its facility assessment on June 3, 2023, to determine the specific and unique needs of its resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations. The facility provided a facility assessment tool to the survey team on April 11, 2024. There was no documentation on the form that identified and addressed the needs of the locked B unit, Dementia/Memory care unit. The form did not include any focus on the care and needs of the 48 residents with documented diagnosis of Dementia/Alzheimers disease, including the 27 residents residing on the locked dementia unit. There was no addressed dementia care…

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 policies and staff interviews, it was determined that the facility failed to thoroughly investigate injuries of unknown origin, bruising, to rule out abuse, neglect or mistreatment as the potential cause for one out of 20 sampled residents (Resident 90). Findings included: A review of the facility's policy Abuse Policy that was last reviewed by the facility on June 21, 2023, indicated that a timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources, misappropriation of resident property) and reasonable suspicion of a crime resulting in bodily injury will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) if the alleged does not involve abuse AND has not resulted in serious bodily injury.…

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 staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 20 sampled (Resident 299). Findings include: Review of Resident 299's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include ischemic cardiomyopathy (the hearts decreased ability to pump blood properly due to heart damage), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), and the presence of an automatic implantable cardiac defibrillator (AICD- is a microcomputer that is implanted under the skin of the upper chest area. It monitors heart rate and delivers therapy in the form of small electrical pulses. An AICD is a permanent device inserted into the right ventricle and typically placed near the collarbone under the skin of the chest). There was no documented…

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 select facility policy and staff interviews, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia-related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for one resident out of 20 sampled (Resident 14). Findings include: A review of facility policy titled Alzheimer/Dementia Disease, last reviewed by the facility on June 21, 2023, indicated that Dementia care requires constant adjustments. New challenges arise, meaning that a caregiver must be constantly observant to behavioral changes. A clinical record review revealed Resident 14 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified psychosis (a disturbance in thought and perception disrupting a person's ability…

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 ensure that the resident's drug regimen was free of unnecessary antibiotic drugs for one out of 20 residents sampled (Resident 15). Findings included: Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include dementia, chronic kidney disease stage 3 and was severely, cognitively impaired. A review of an RN Practitioner assessment of the resident dated March 15, 2024, revealed that a Chart review indicates {Resident 15} with multiple UTIs in the past, asked nursing to collect urine and dip is suspicious for UTI sent for U/A C&S (urinalysis and culture and sensitivity), initial urine appears suspicious for infection, collect U/A C&S via straight cath. The noted plan included Elevated white blood cell count, no clinical signs of infection, vital signs stable, collect U/A C&S (urinalysis and culture and sensitivity). The RN practitioner ordered a urinalysis…

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, a review of select facility policy 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 one of two medication storage rooms (Med Room West). Findings include: A review of the facility policy titled Vials and Ampules of Injectable Medications, last reviewed by the facility June 21, 2023, indicate that the purpose is to ensure medications are used in accordance with the manufacturer's recommendations or the provider pharmacy directions for storage, use, and disposal. The beyond use date and initials of the first person to use the vial are recorded on the multidose vials. Medication in multidose vials may be used for twenty-eight days if inspection reveals no problems during that time. An observation of the medication room on the [NAME] Wing on April 10, 2024, at 9:05 AM, in the presence of Employee 6 (RN Supervisor), of medication stored in the medication refrigerator revealed a multi-dose bottle of Aplisol (solution used for screening for tuberculosis)…

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 the statement of deficiencies from the survey ending February 15, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to ensuring that the facility environment was maintained in a safe, clean, comfortable, and homelike environment. Findings included: During an abbreviated complaint survey completed on February 15, 2024, deficient facility practice was identified under the requirement of safe, clean, comfortable, and homelike environment whereas the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of four nursing units (Nursing Hall A, B, C and D). In response to the deficiency cited during the survey of February 15, 2024, the facility developed a plan of correction to include a quality assurance monitoring component to ensure that solutions were sustained. This plan was to be completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and the facility's infection control policies and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by one of 20 sampled residents (Resident 15). Findings include: A review of the facility policy for Antibiotic Stewardship, dated as reviewed June 21, 2023, revealed that the plan was designed to facilitate compliance with state and federal regulations relating to infection control and antibiotic stewardship. It is the purpose of the facility Infection Prevention and Control Program is to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections and to improve antibiotic use. The facility adheres to the mission and goals set forth in the infection control plan. Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses 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 observations and staff interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on four of four nursing units (Nursing Hall A, B, C and D). Findings include: An observation on February 15, 2024, at 11:47 AM in the resident TV room lounge revealed two dead bugs, approximately an inch in length, behind a red recliner. Cobwebs, dust, and debris were observed on the floor near the bugs. Multiple white stains and discolorations were observed on the arm rest and seat cushion. Dust, debris, peeling paint, and black scuff marks extending the length of the heating unit. [NAME] stains were observed on wall below the center window. An observation on February 15, 2024, at 12:08 PM in the C Hall shower room revealed small live black ants on the floor. A bathtub was observed with black pieces of debris on the base of the white tub near the drain. Hair and a rubber band were stuck in the metal strainer in the drain. Cobwebs were observed near…

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 the facility's abuse policy, select investigative reports, and clinical records, and staff interview, it was determined that the facility failed to ensure four residents out of 11 sampled was free from misappropriation of resident property, medications (Resident 7, 9, 10, and 11). Findings included: A review of the facility policy entitled Abuse Policy revealed that the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy noted that misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a residence belongings or money without the resident's consent. A review of the clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses which include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change,…

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 facility provided documents, and resident and staff interviews, it was determined that the facility failed to maintain an effective pest control program, including observations made on two of the four nursing units (Nursing Halls A and C). Findings include: A review of the facility's Pest Sighting Log revealed an entry dated November 27, 2023, indicating that live ants were observed in resident room [ROOM NUMBER]. The number of ants was listed as a lot. A pest sighting entry dated December 10, 2023, indicated that residents reported killing three brown bugs in resident room [ROOM NUMBER]. A pest sighting entry dated December 14, 2023, indicated that black bugs were observed in the bathroom in resident room [ROOM NUMBER]. A review of the facility's pest control service inspection report dated December 15, 2023 revealed two services were provided, drain service and pest management. The service inspection report indicated that no conditions were added for this service and no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement an individualized plan to meet the resident's toileting needs, including timely staff assistance with toileting and incontinence management for one out of six sampled residents (Resident A1 ). Findings include: A review of facility policy titled Urinary Continence and Incontinence - Assessment and Management revealed the staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence, manage incontinence following relevant clinical guidelines, provide appropriate services and treatment to help residents restore or improve bladder function, and prevent urinary tract infections to the extent possible. Residents will be assessed for information related to urinary incontinence with staff defining each individual's level of continence, referring to the criteria in the Minimum Data Set. Nursing staff will seek and document…

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 observations, a review of clinical records, and select incident reports and staff interview it was determined that the facility failed to ensure that one resident out of six sampled were free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident B1). Findings include: A review of Resident B1's clinical record revealed admission to the facility on November 5, 2021, with a history of alcohol abuse, adult failure to thrive (a syndrome of decline in older adults that affects their physical, mental, and social well-being) and major depressive disorder (can be more severe than some other types of depression, requires different treatments, and shares some symptoms). A Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated November 14, 2023, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 12 (8 to 12 points: suggests moderate cognitive…

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 that the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized needs of one resident out of six sampled (Resident B1). Findings included: A review of Resident B1's clinical record revealed that the resident was admitted to the facility on [DATE], with a history of alcohol abuse, adult failure to thrive and major depressive disorder. A review of Resident B1's plan of care initiated May 17, 2022, for the problem of behaviors indicated that the resident had behaviors related to alteration in neurological status due to dementia with specified behaviors that included sexual behaviors, touching female resident, verbally abusive toward staff, exposing his penis dated 1/5/23, and sexually inappropriate behavior dated 1/7/23. Planned interventions to manage Resident B1's behaviors included frequent visual checks as ordered, cueing and reorientation as ordered, and to remove resident from…

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.