Maplewood Nursing And Rehab Center

Based on review of facility provided documentation, interview with staff and review of clinical record, it was determined that facility failed to ensure that require information to obtain an imaging study was submitted for one out of nine residents reviewed. (Resident R4) Findings include: Review of Resident R4's clinical record that the resident was admitted to facility on January 27, 2023 with medical history of left basal ganglia, intraparenchymal hemorrhage (bleeding within brain parenchyma), status post craniectomy, stroke affecting right dominant side, cognitive communication deficit, encounter for surgical aftercare following surgery on the nervous system, depression, aphasia (difficulty speaking), dysphagia (difficulty swallowing),and gastrostomy status. Review of facility provided documentation revealed Resident R4 had left decompressive hemicraniectomy (neurosurgical procedure that removes part of the brain) completed prior to admission to facility, on January 2, 2023. On April 16, 2024, Resident R4 had consult regarding neurosurgery with recommendation for stealth CT…

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, review of facility policies and interviews with staff, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: An initial tour of the main kitchen on November 3, 2024, at 9:45 a.m. with the Food Service Director, Employee E4, revealed the following: Observations revealed boxes of dry cereal placed directly on floor next to tray line while waiting for service to start. Observations in the freezer revealed a tray of premade meatballs that was not sealed, raw burger patties on the shelf not in any packaging, waffles not in their original packaging with no date, open vegetable blend with no date. Observations revealed an industrial fan facing the dish machine where clean dishes come out with a thick layer of dust build-up on the fan. Observations revealed a small red bucket with dirty water/cleanser and a cloth on the shelf beneath the coffee maker. Observations in the dry storage room revealed a plastic bin filled with condiment packets and a red…

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, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans, related to behaviors, nutrition and contractures, for four of 32 residents reviewed (Residents R129, R100, R117 and R38). Findings include: Review of facility policy, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R38's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 16, 2024, revealed the resident had diagnoses of hemiplegia (paralysis of one side of the body), muscle…

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, review of facility policies and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment for three of 32 residents reviewed (Residents R43, R81, and R52) and proper disposal of PPE by staff prior to leaving room for 4 out of 17 rooms observed. Findings include: Review of facility policy titled Isolation Steps Categories of Transmission Based Precautions revised August 1, 2023, revealed the facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections enhanced barrier precautions expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and bodily fluids is anticipated and referred to the use of donning gloves during high contact resident care activities that provide opportunities for the transfer of multi drug resistant organisms (MDRO) to staff hands…

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 reviews, review of facility policies, and staff interviews, it was determined that the PASRR (Preadmission Screen and Resident Review) was not appropriately revised according to the resident assessment for one of three residents reviewed. (Resident R77) Findings include: Review of facility policy titled Pre-admission Screening and Resident Review (PASRR) program dated April 1, 2022, reveled the facility work will coordinate assessments with the preadmission screening and resident review program. The coordination includes incorporating the recommendations from the pass our level to determination and pass our evaluation report into a resident assessment care planning and transition of care also to referring all level two residents and all red and all residents with newly evident or possible serious mental disorder intellectual disability or a relation condition for level two resident review upon a significant change in status assessment. Continued review of this policy revealed a nursing…

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, clinical records reviews, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, ADL (activity of daily living) needs for one of 32 residents reviewed (Resident R362). Findings include: Observation conducted of Resident R362 on November 3, 2024, at 9:10 a.m. revealed that Resident R362's left hand was in a fist. Further, Resident R362 had unkempt facial hair. Review of clinical record revealed that Resident R362 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction (stroke) due to embolism to the right vertebral artery, aphasia (difficulty speaking and trouble understanding), and cerebral atherosclerosis (thinking and hardening of brain arteries). Review of Resident R362's OSA (OSA- Optional State Assessment, a state required MDS-minimum data set assessment containing the activities of daily living (ADL) functional items) MDS (minimum…

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, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of five residents reviewed with limited range of motion (Resident R38). Findings Include: Review of Resident R38's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 16, 2024, revealed the resident was cognitively intact and had diagnoses of hemiplegia (paralysis of one side of the body), muscle wasting, and muscle weakness. Further review of Resident R38's quarterly MDS dated [DATE], revealed the resident had impairment in range of motion on one side of the upper extremity. Observations on November 3, 2024, at 12:50 p.m. revealed Resident R38 had a contracture (shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) of the left-hand and had no splint.…

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, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residents reviewed on renal dialysis (Resident R22) Findings include: Review of facility policy title Dialysis dated April 1, 2022, revealed that the facility shall provide adequate management of dialysis services to ensure that residents attained or maintain the highest practicable physical mental and psychosocial wellbeing. Further review of this policy reveal the facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice the comprehensive standard care plan and residence goals and preferences. The nursing facility will collaborate with the dialysis facility and assure that residents needs related to dialysis or met. That documentation requirements are met to assure that treatments are provided as ordered and nephrologist attending practitioners and dialysis team. That there is an ongoing communication and collaboration…

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, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure a medication error rate of less than five percent for two of four residents observed during medication administration (Residents R43 and R108). Findings include: The facility's medication error rate was 20.69 percent based on observation of 29 medication administration opportunities with six medication errors observed. Review of facility policy, Administering Medication dated April 17, 2024, revealed, Medications shall be administered in a safe and timely manner, and as prescribed. Review of facility policy, Enteral Feeding dated April 15, 2024, revealed, Prior to crushing tablets for administration through the enteral tube, the Medication Crushing General Guidelines should be reviewed. Continued review revealed, Each medication is administered separately followed by a 5cc [milliliter] flush of water between medications to avoid physical interactions of the medications. Observation of the morning medication pass on November 3,…

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, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were properly labeled and dated for two of three medication carts reviewed (fourth floor A and B carts), and failed to ensure that a medication cart was kept locked when not in use during medication administration for one of three nursing units observed (third floor nursing unit). Findings include: Review of facility policy, Administering Medication dated April 17, 2024, revealed, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. Continued review revealed, Medications must be stored per manufacturer/labeled. Review of facility policy, Medication Storage dated April 1, 2022, revealed, Medications will be stored in the original, labeled containers received from the pharmacy. Review of facility policy, Expiration Dates for Open Injectable Diabetes Medications dated July 12, 2023, revealed that…

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 personnel files, review of facility documentation, and staff interviews, it was determined that the facility failed to employ a qualified Registered Dietitian and Director of Food and Nutrition Services. Findings Include: Review of the job description for the Director of Food and Nutrition Services revealed that job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Interview on November 4, 2024, at 11:45 a.m. with Registered Dietitian, Employee E8, confirmed the Registered Dietitian only worked at the facility part time. Review of Food Service Directors, Employee E4, personnel file revealed the employee held the position of Dietary Director with a start date of July 17, 2023. Review of the Food Service Directors, Employee E4, personnel file confirmed the employee was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service…

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 and staff interviews, it was determined that the facility failed to employ sufficient dietary personnel to carry out the functions of the food and nutrition service for one of one meal observed (Breakfast November 3, 2024). Findings Include: Observation on November 3, 2024, revealed that the posted mealtimes on the fourth-floor nursing unit were: Breakfast 7:40 a.m. to 8:40 a.m. Observations in the main kitchen on November 3, 2024, at 9:00 a.m. revealed dietary staff were preparing for the breakfast meal service and cooking food. Observations revealed there was one dietary personnel cooking the breakfast and three dietary aides preparing the resident beverages and meal trays for service. Interview on November 3, 2024, at 9:00 a.m. with the Assistant Food Service Director, Employee E24, revealed the cook did not show for the breakfast shift. Observations revealed breakfast was still being prepared by the Assistant Food Service Director, Employee E24, at 9:15 a.m. Further observations on November 3, 2024, revealed breakfast tray line (when resident trays began 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, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure menus were followed for three of three nursing units observed (second, third and fourth floor nursing units). Findings include: Review of the facility menu revealed the planned menu for lunch on November 3, 2024, was crispy ranch chicken, oven browned potatoes, and parslied carrots. The alternate planned lunch items were roast pork, rice pilaf, and brussels sprouts. Observations on November 3, 2024, at 2:00 p.m. in the main kitchen revealed dietary staff was serving beef stew over rice. Interview on November 3, 2024, at 2:00 p.m. with the Food Service Director, Employee E4, confirmed the planned menu was not followed because there was not sufficient time to prepare the meal due to breakfast running so late. Review of the facility menu revealed the planned menu for lunch on November 4, 2024, was fish, orzo, and sauteed mushrooms. The alternate planned lunch items were…

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 and interviews with residents and staff, it was determined that the facility failed to ensure that food was palatable and served at appetizing temperatures. Findings include: Review of facility food council minutes dated September 25, 2024, revealed old business that was reviewed included cold food temperatures. Further review of the food council minutes revealed 9 out of 11 residents reported the temperature of hot and cold foods at breakfast were not appropriate. Review of facility food council minutes dated October 30, 2024, revealed food temperatures are still served cold for breakfast. Further review of the food council minutes revealed 7 out of 7 residents reported breakfast is served cold. Observation of the breakfast meal served on the fourth floor nursing unit on November 3, 2024, at 10:58 a.m. revealed that residents were served pancakes with syrup, scrambled eggs, trix cereal, coffee, sugar, nondairy creamer and milk. Interview on November 3, 2024, at 10:58 a.m. Resident R63 stated that the pancake was cold, that the coffee was cold, that the eggs…

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, review of facility documentation, and staff interviews, it was determined that the facility failed to prepared foods in a form that meet resident needs for 8 of 8 residents on a pureed diet (Resident R100, R124, R21, R148, R8, R138, R81, R53). Findings Include: Review of facility diet manual signed by the Medical Director on January 1, 2023, and signed by the Food Service Director on September 1, 2023, revealed the facility follows the International Dysphagia Diet Standardization Initiative (IDDSI - provides a common terminology to describe food textures and drink thickness) Framework for food and beverage consistencies. Continued review of the facility diet manual revealed IDDSI Level 4 -Pureed Diet are foods pureed which are of a smooth, homogenous, and cohesive consistency and keep their shape when on a spoon. Review of a physician diet order report provided by the Food Service Director, Employee E4, on November 3, 2024, at 9:50 a.m. revealed Resident R100, R124, R21, R148, R8, R138, R81, and R53 were ordered a pureed diet. Interview on November 3, 2024, at…

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

Based on observations, review of clinical record, and staff interview, it was determined that the facility failed to provide beverages consistent with resident needs for two of twenty-seven residents reviewed for dining (Resident R152 and R145). Findings include: Observation of breakfast meal service conducted on November 3, 2024, at 10:20 am revealed that Resident R152 was in the dining room. Further observation revealed that Resident R152's meal ticket indicated No Dairy Products. Observation of Resident R152's breakfast tray revealed that the breakfast tray contained a carton of whole milk. Interview with Resident R152 conducted at the time of the observation revealed that she is lactose intolerant and that she had requested for almond milk or other non-dairy products but has not received any. Observations and review of Resident R145's meal ticket on November 4, 2024, revealed the meal ticket specified to provide the resident with thickened beverages. Review of Resident R145's physician order summary revealed a diet order dated August 6, 2024, which indicated the resident was…

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

Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely on three of three nursing units observed (second, third and fourth floor nursing units) and failed to ensure that residents were provided snacks for two of 32 residents reviewed (Residents R68 and R34) Findings include: Observation on November 3, 2024, at 9:11 a.m. revealed that posted meal times on the fourth floor nursing unit were: Breakfast 7:40 a.m. to 8:40 a.m.; Lunch 12:15 p.m. to 1:15 p.m.; Dinner 5:50 p.m. to 6:50 p.m. Review of facility food council minutes dated September 25, 2024, revealed 11 out of 11 residents reported breakfast is usually served late. Review of facility food council minutes dated October 30, 2024, revealed 7 out of 7 residents reported breakfast is usually served late. Observations in the main kitchen on November 3, 2024, at 9:00 a.m. revealed dietary staff were preparing for the breakfast meal service and cooking food. Observations revealed there was one dietary personnel…

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 facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to submit complete records related to rehabilitation services for three of 32 residents reviewed (Resident R110, R113, R38). Findings include: Request for rehab documents for Resident R113 on November 6, 2024, at 1:10 pm for Resident R113 revealed that the facility was not able to provide surveyors with rehab notes as requested for Residents Resident R133. Request for rehab documents for Resident R110 on November 6, 2024, at 1:10pm for Resident R110 revealed that the facility was not able to provide surveyors with rehab notes as requested for Residents Resident R110. Interview with Employee E1 conducted on November 6, 2024, at 1:11pm revealed that the facility changed rehab company and that they were not able to access the rehab therapy notes from the previous company. A request for Resident R38's most recent physical and occupational therapy notes and discharge summary was made to the Nursing Home Administrator, Employee E1, on November 6, 2024, at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility documents and resident clinical records and interviews with staff, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for one of nine residents reviewed (Resident R259). Findings include: Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of admission record indicated Resident R259 was admitted to the facility on [DATE]. Review of Resident R259's Minimum Data Set (MDS - a periodic assessment of care needs) dated January 17, 2021, indicated the diagnoses of cognitive communication deficit (problem with one or more cognitive skills involved in communication, such as attention, memory, 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.

Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential dining equipment in the kitchen and essential resident equipment was maintained in proper working order for two of 32 residents reviewed (Residents R26 and R38). Findings include: Interview on November 3, 2024, at 12:50 a.m. with Resident R38 revealed the head rest of the wheelchair fell off and now there is no where to put his head when leaning back. Interview on November 5, 2024, at 12:45 a.m. with Physical Therapist, Employee E21, confirmed Resident R38's head rest fell off the wheelchair and a maintenance request was sent to the Nursing Home Administrator, Employee E1, on November 1, 2024. Interview on November 6, 2024, at 9:47 a.m. with the Nursing Home Administrator, Employee E1, confirmed Resident R38's headrest on the wheelchair was broken and that maintenance has not yet looked at the wheelchair for repair. Observations on November 3, 2024, at 10:45 a.m. revealed dietary staff utilized a tray line system to plate resident meals in the kitchen…

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 of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand at the facility in the event that there was a loss of normal water supply. Findings Include: Interview on November 6, 2024, at 11:15 a.m. with the Food Service Director, Employee E4, revealed based on a census of 156 residents, the facility should have 3-gallons of water per resident for emergency purposes. Further interview revealed based on the above information the facility should have a total of 468 gallons of emergency water. Observations of the emergency water storage on November 6, 2024, at 11:30 a.m. with the Food Service Director, Employee E4, revealed the facility only had 294 gallons of emergency water on hand. Interview with the Food Service Director, Employee E4, confirmed the facility did not have sufficient emergency water to meet the needs of the residents in case of an emergency. 28 Pa. Code 201.18(b)(3) Management

Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective pest control program in the kitchen and for two of 32 residents reviewed (Resident R81 and R309). Findings include: Review of the facility pest control report dated October 28, 2024, revealed the pest control company Observed live roach activity in the dishwasher area coming out of wheel carts that carry dishes after they are done being washed. Observed carts with old food on them as well. Subsequently the pest control company recommended for better sanitation practices throughout the kitchen, especially behind the cooking area such as stoves, and for trash to be thrown out in a timely manner. The pest control company also recommend for leaks under dishwasher area to be fixed as the water washes away chemicals after being treated. Review of the facility pest control report dated November 4, 2024, revealed the pest control copy observed positive roach acceptance on monitor placed under dishwasher area in the main kitchen. The pest…

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, review of facility menus and interviews with residents and staff, it was determined that the facility failed to ensure that menus were posted and followed as required on one of four floors observed (third floor). Findings include: Interview on September 12, 2024, at 10: 28 a.m. Resident R2 stated that food is cold, food ticket is blank, and resident don't offer food choices per resident's preferences. Menus were not posted or provided to residents. Interview on September 12, 2024, at 10: 35 a.m. Resident R3 stated no menu provided to residents who are bedbound, and food is disgusting and gross. Never know what you going to get, not following the resident food ticket. Interview on September 12, 2024, at 10: 30 a.m. Resident R1 stated that resident don't offer food choices per resident's preferences. Interview on September 12, 2024, at 10:54 a.m. with Assistant Director of Nursing Employee E2, confirmed that menus are only posted in the nursing station and not sure how bedbound residents know what's on the menus. Observation on the third-floor nursing unit on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for one of eight residents reviewed (Residents R4). Findings include: Review of facility policy, ADL (Activities of Daily Living) Policy, dated December 4, 2023, indicated that the facility will provide care and services for the following activities of daily living: including Hygiene- bathing, dressing, grooming, and oral care. Further review revealed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain goof nutrition, grooming, and personal and oral hygiene. Interview with Resident R4, on April 17, 2024, at 11:27 a.m. revealed that the resident had not received a shower for the last three weeks. Resident R4 stated I did not know I can receive a shower with my condition and that he was never offered a shower. Review of R4's clinical record revealed that 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 observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to hot water temperatures in three of three nursing units (Second, Third and Fourth floor) which resulted in an immediate jeopardy situation. Findings Include: Review of the job description for the Nursing Home Administrator (NHA) revealed the Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of Management and allocates…

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 of the operations of the Food and Nutrition Services Department and interviews with staff, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: Observations of the dish room area of the main kitchen at 10:00 a.m., on January 9, 2024, noted dietary staff working to clear soiled food service equipment, after the breakfast meal service, revealed that everyday resident equipment for meal services were not thoroughly cleaned and sanitized. Dishes (dome lids, meal trays, bowls, cups and mugs) had been serviced by the dish machine or three compartment sink; however the dishes were not clear of debris. Further observations revealed a white film, brown and black staining that was adherent to the dome lids, meal trays, bowls, cups and mugs. Dietary staff were observed putting the meal trays through the dish machine to clean and sanitize the foodservice equipment. After the wet meal trays were observed being placed one on top of each other on a counter top…

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 of care and services, reviews of policies and procedures, interviews with residents, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that each resident's needs and preferences were reasonably accommodated to create an individualized home-like environment for one of six residents reviewed. (Resident R143). Findings include: A review of the facility policy titled Activities of Daily Living dated April 1, 2022 revealed that the facility staff was responsible for creating and sustaining an environment that humanizes and individualizes each resident's quality of life. The policy said that the care and services provided by staff were to be person-centered and honor and support each resident's preferences, choices, values and beliefs. Observations of Resident R143 at 9:30 a.m., on Janaury 9, 2024 revealed that this resident was dressed in soiled sweat pants and shirt. The clothing was visibly soiled with food spillage and bodily fluids. Observations of Resident R143 at 11:00 a.m., on Janaury 10, 2024 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.

Based on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to implement a plan of care to address the dementia needs of one of 32 residents reviewed. (Resident R96 ) Findings include: A review of the policy titled Comprehensive Care Plan dated April 1, 2022 revealed that it was the responsibility of the facility to develop and implement a comprehensive person-centered care plan for each resident that meets professional standards for quality of care. The policy also said that the care plan would be consistent with resident rights, and include measurable goals, objectives and timeframes for meeting the goals. Care plan are to be implemented to meet each resident's medical, nursing, mental and psychosocial needs. The care plan services are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review Resident R96's admission Minimum Data Set (MDS- assessment of resident's care needs) dated July 27, 2023…

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 review of clinical records, it was determined that the faciltiy failed to ensure that range of motion exercises were inititated and that the use of a sit and stand lift was maintained for one of two residents reviewed (Resident R70) Findings include: Review of Resident R70's quarterly Minimun Data Set (MDS-an assessment of care needs) dated October 28, 2023 indicated that the resident was cognitively intact. The resident had functional impairement on one side of the upper body and that the lower body had no functional impairments. This assessment revealed that the resident could wheel 50 feet with staff supervision and touch assistance. Review of physical therapy note dated December 1, 2023 indicated that Resident R70 was able to sit to stand/stand to sit transfers with a front wheeled walker. Clinical record review revealed an occupational therapy progress note dated December 5, 2024 indicated that Resident R70 had the ability improve his left hand grip and strength with the use of nine pound weights, provided with supervision and assist of care giver.…

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, review of facility policy, interviews with staff, and review of facility documentation, it was determined the facility failed to ensure that weights were monitored for three of 32 residents reviewed (R36, R97, R106) Findings Include: Review of Weight Assessment and Intervention Policy dated February 15, 2020 states, The nursing staff and the Dietician will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents. Further review of the facility policy states, 4. The Dietician will also review monthly weights to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietician whether or not the definition of Significant Weight Change is met. Review of Resident R36's Minimum Data Set(MDS- assessment of resident's care needs) revealed an admission date of February 22, 2021. The resident had the diagnoses of Anemia, Mild protein-calorie malnutrition, and muscle wasting and atrophy. Review of Resident R36's weight records revealed that the last weight was taken on November 2, 2023. Review of…

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

Based on observations, clinical record review and resident interview, it was determined that routine dental care was not provided for one of six residents reviewed with dental, chewing and swallowing needs. (Resident R121) Findings include: Clinical record review for Resident R121 revealed comprehensive Minimum Data Set (MDS- assessment of resident's care needs) dated September 28, 2023 that indicated that this resident was cognitively intact. Review of January 2024 physician orders revealed an ordered for a regular soft bite sized foods with thin liquids. Observations of Resident R121 at 9:30 a.m., on January 12, 2024 with a nursing assistant, Employee E16, that was familiar with the resident's dental status revealed that this resident had a full oral cavity of teeth. Interview with Resident R121 at 9:15 a.m., on January 12, 2024 revealed that the resident was interested for the consulting dental group to evaluate her mouth. The resident recalled that it had been awhile since she received a dental hygienist examination and cleaning or dentist evaluation of her oral cavity for…

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

Based on observation, interviews with staff and review of facility policy and procedure, it was determined that the facility did not maintain an effective infection control program related to hand hygiene and medication administration for one resident (Resident R53) of four residents observed and glucometer handling and testing for one resident (Resident R19) of one resident observed. Findings include: Review of facility policy, Hand Hygiene, published 12/04/2023, revealed, Purpose: to prevent and to control the spread of infectious disease. When: 1. Employees must perform at least appropriate twenty second hand washing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions. 2. If hands are not visibly dirty or soiled, use an alcohol-based rub for the following situations: a. before direct contact with residents; b. before donning gloves; before preparing or handling medications; g. after the removal of gloves including between glove changes during procedures. 3. The use of gloves does not replace or eliminate the need for handwashing /hand…

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, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were with in reach for 17 of 24 residents reviewed. (Resident R1, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24). Findings include: The policy of the facility on Call Bells dated, April 1, 2022, states; it is the policy of the facility that all residents always have access to call bells. The call system must be accessible to residents, while in their bed, other sleeping accommodations within the resident's room. On October 12, 2023, at 1:36 p.m., during observations of the nursing units, it was detected that the call bell was not available for Resident R1, room [ROOM NUMBER]-B, as the call bell was tangled with the adjacent resident-bed. The finding was confirmed with Employee E3, a Licensed Nurse, at the time of the finding. On October 12, 2023, at 2:05 p.m., it was observed in room [ROOM NUMBER]-B, that the call bell…

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.