Heritage Park Rehabilitation And Skilled Nursing C

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices cleaning the ice machine, cleaning the cooktop range drip pans, utilization of an ice scoop receptacle that was not cracked and broken on the bottom were used. 2. The facility failed to label and date all food items in the kitchen. 3. The facility failed to refrigerate products after opening per the manufacturer label. 4. The facility failed to ensure food items were covered, secured and stored properly. These failures could place residents at risk of foodborne illness. Findings included: Observation on 11/12/2024 at 9:19 AM revealed an ice scoop storage receptacle had cracks and pieces missing from the bottom of the storage receptacle. Observation on 11/12/2024 at 9:20 AM revealed the inside of the ice machine had a brown and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control effectively treat the building for insects. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Observation on 11/12/24 at 9:15 AM, there was a fly, flying around on 300 halls, outside of room [ROOM NUMBER] by the meal service cart. Observation on 11/12/24 at 9:58 AM, revealed 4 gnats flying around the tea urn and landing on the wall and counter in the dining room. Observation on 11/12/2024 at 11:56 AM revealed Resident #142 had visible flies and gnats on cups that were sitting on the bedside table. The cups had coffee and a clear liquid. He had three flies that were flying around the resident's lower extremities above the blanket. Flies were landing on and off his exposed chest. Observation on 11/13/24 at 8:24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 9 of 9 (Resident #292, Resident #12 Residents #6, 17, #22, #27, #60, #93, and 103's) residents reviewed for dignity. 1. The facility failed to ensure Resident #292, and Resident #12 had a privacy cover on their urinary catheter bag. 2. The facility failed to promote Residents #6, 17, #22, #27, 60, #93,103's dignity while dining when staff did not serve the residents their lunch tray at the same time as other residents at the same table for lunch on 11/12/2024 and Resident #6 for lunch on 11/14/2024. These failures could affect the resident's dignity and affect their quality of life and contribute to poor self-esteem and unmet needs. Findings included: Resident #6 Record review of Resident #6's face sheet dated 11/14/2024 revealed a [AGE] year-old female…

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 interviews, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 12 of 12 residents 9 confidential residents and 3 of 3 residents (Residents #128, Resident #140, Resident #101) reviewed for resident rights. 1. The facility failed to ensure the SS did not search residents' wheelchairs and belongings (Resident #128, #101, and #140) for contraband without their permission. 2. The facility failed to ensure an unidentified staff did not conduct random searches on residents' rooms (Residents #128, Resident #140, 9 confidential residents) on undisclosed dates without residents' permission or remove items from their rooms without permission. This failure could place all residents at risk of emotional distress, feelings of disrespect, lack of dignity, and could decrease residents' self-esteem and/or quality of life. Findings included: Resident #128 Record review of Resident #128's face sheet dated 11/14/2024 revealed a [AGE] year-old female…

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, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for the rooms of 4 of 20 residents (Resident room [ROOM NUMBER], #43, #106, and #176) reviewed for cleanliness and sanitization. The facility failed to ensure that the rooms of Residents #12, #43, #106, and #176 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: Resident #12 Review of face sheet dated 11/13/2024 for Resident # 12 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her primary diagnoses were quadriplegia (paralysis of all four limbs and the torso), cerebral palsy (a group of conditions that affect movement and posture), and Cauda equina syndrome (severe type of spinal stenosis where all the nerves in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to 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 for 3 of 9 residents (Residents #33, 151, and 176) reviewed for care plans. The facility failed to ensure Resident # 33's care plan addressed her oxygen orders. The facility failed to ensure Resident # 151's care plan addressed his dental needs and food allergies. The facility failed to ensure Resident # 176's care plan addressed her present on admission diagnosis of PTSD-Post Traumatic Stress Disorder needs. These failures could place residents at risk of not having their care and treatment needs met and a potential diminished quality of life. Findings included: Resident # 33 Review of face sheet dated 11/13/2024 for Resident # 33 reflected a [AGE] year-old…

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, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of ten residents (Resident #142, Resident #54, Resident #39 and Resident #60) reviewed for quality of life. The facility failed to ensure Resident #142, Resident #54, Resident #39 and Resident #60 received regular showers. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Review of Resident #142's Face Sheet reflected he was an [AGE] year-old male with an original admission date of 01/21/2023 and readmitted on [DATE] with diagnoses Unspecified viral hepatitis C (a viral infection that affects the live and can be life-threatening) without hepatic coma ( is a coma-like state that can occur due to liver failure), Schizophrenia ( is a chronic mental disorder that affects a person's ability to think, perceive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 16 residents (Residents #9, 58, and 130) reviewed for activities. The facility failed to ensure Residents #9, 58, and 130 received activities according to their preference on their comprehensive assessments. This failure placed residents at risk of boredom and diminished quality of life. Findings include: Resident #9 Review of Resident #9's face sheet revealed a [AGE] year-old male with admission date of 8/4/2011. Diagnoses include Intellectual disabilities, kidney failure, Alzheimer's disease (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 5 of 15 residents (Resident #6, Resident #48, Resident #64, Resident #108, and Resident #292) reviewed for infection control in that: 1. CNA V did not sanitize or wash hands in between giving Resident # 48, Resident # 64 and Resident #108's meal trays, placing residents at risk of getting sick from food contamination. 2. CNA O failed to perform proper hand hygiene practices during peri care for Resident #6 3. The facility failed to ensure Resident #292 received indwelling urinary catheter care to maintain his catheter free of a moderate build-up of a dark brown colored substance. This failure could place all residents at risk of getting sick and risk of transmission of diseases and infection. The findings were: 1. Observation of lunch trays being passed on 11/12/2024 at 12:33pm revealed that CNA V did not wash 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 observation, interviews, and record review, the facility failed to provide the required 80 square foot per resident in 5 of 5 resident rooms (room numbers 201, 404, 504, 2405, and 2505), reviewed for environment. The facility failed to provide 80 square feet per resident in 5 shared resident rooms. This failure could affect residents who resided in the facility and could result in inadequate space for resident's activities of daily living in their rooms. Findings included: During observations on 11/12/2024 during initial pool screening, rooms 201, 404, 504, 2405, and 2505 were observed to have three beds/three residents in the room. The beds were positioned parallel to each other in a row with one bed near the door, one bed in the middle, and one bed next to the window. The positioning of the beds allowed for Bed B, which was the middle bed, to have significantly smaller living space than the other two beds in the room. During an interview with the ADM on 11/12/2024 at 3:54 PM, the ADM stated he did not have any room waivers nor room variations. The ADM stated this had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility failed to provide personal privacy for of closing privacy curtains during pericare for resident ( Resident # 92) reviewed for privacy. 1 of 1 resident was observed. Resident #92's privacy curtain was not closed all the way while receiving incontinent care. This failure could place residents at risk not having personal privacy. Findings included: Review of Resident #92's Face Sheet dated 11/13/2024 revealed he was a [AGE] year-old male who was admitted to the facility with and initial admission date of 04/06/2018 and an admission date of 10/21/2024. Resident #92's diagnoses included unspecified dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance (, mood disturbance, anxiety, hemiplegia, hemiparesis following nontraumatic subarachnoid are a group of serious mental illnesses that all have signs of psychosis) hemorrhage (term used to describe blood loss)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #6) of 37 residents reviewed for restraints. The facility failed to ensure that wedges (triangle plastic pads used to position residents with pressure ulcers) were not used on the side of Resident # 6's bed without the resident having been evaluated for the medical need. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need. Findings include: Record review of Resident #6's face sheet dated 11/14/2024 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia (memory, thinking, difficulty), bipolar (extreme mood swings), major depressive disorder, , cognitive communication deficit (problems with communication) and muscle wasting. Record…

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 interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #176) reviewed for baseline care plans. The facility failed to ensure Resident #176's baseline care plan dated 10/21//2024 included instructions to address her present on admission diagnosis of PTSD-Post Traumatic Stress Disorder (a mental health condition that can develop after someone experiences or witnesses a traumatic event) within 48 hours of admission. This failure could place the resident at risk of not receiving continuity of care and communication among nursing home staff, reduced resident safety, and reduced safeguards against adverse events that are most likely to occur right after admission. Findings included: Review of face sheet dated 11/13/2024 for Resident # 176 reflected a [AGE]…

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 interview and record review, the facility failed to ensure the residents environment remained as free of accident and hazards as possible for 1 of 3 residents reviewed for accidents and hazards (Resident #13). The facility failed to ensure soap was secured in labeled container in Resident #13's room. This failure could result in residents experiencing accidents and possible illness, injury, and hospitalization by inadvertently consuming unknown substances. Findings included: Review of Resident #13's face sheet revealed an 80-years-old male with admission date of 8/24/24 with a discharge date of 10/18/2024. Diagnosis included: vascular dementia (memory and thought process difficulties related to multiple strokes, or loss of blood circulation to the brain), dysphagia (difficulty swallowing), and cognitive communication deficit (inability to communicate). Review of Resident #13's initial minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 12 which…

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 interviews and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #176) of 3 resident reviewed for quality of care. The facility failed to ensure that Resident #176's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of face sheet dated 11/13/2024 for Resident # 176 reflected a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis of PTSD (a mental health condition that can develop after someone experiences or witnesses a traumatic event) Review of Resident # 176's Comprehensive MDS assessment dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Resident # 176 had a diagnosis…

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, interviews, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 7.69 % based on 2 errors out of 26 opportunities, which involved 2 of 4 residents (Resident #1 & #156) and 2 of 2 staff (MA R and MA T) reviewed for medication errors, in that: MA R administered a whole Metroprolol ER (Extended release or slow release) gel pill and the Resident #1 had orders to crush all medications. MA T administered 1 medication (Metroprolol) which was ordered to be given if blood pressure reading was within the parameters. Orders indicated to hold (do not give to resident) if blood pressure reading is outside of the parameters. The blood pressure was outside of the parameters. These failures could place residents at risk of medication errors that could cause a decline in health. Findings included: During an observation on 11/12/2024 at 03:29 p.m., MA R was observed passing medications to Resident #1 which included 5 medications (Dicyclomine 10MG, Acidophilus Probiotic, Fish Oil…

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 interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident#156) of 4 resident reviewed for pharmaceutical services. The facility failed to follow prescriber's orders and professional standards and principles which apply to professionals providing services for Resident #156's scheduled medications. MA T administered 1 medication (Metroprolol) which was ordered to be given if blood pressure reading was within the parameters. Orders indicated to hold (do not give to resident) if blood pressure reading is outside of the parameters. The blood pressure was outside of the parameters. This failure could place residents at risk of discomfort or jeopardizes his or her health and safety. Findings included: Record Review on 11/14/2024 of Resident #156's face sheet reflected Resident #156 was a [AGE] year-old male with an original admission date of 05/06/2024 and admission date of 09/17/2024. Resident #156 had a diagnoses of Essential (primary)…

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.

In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. 2 of 4 medication carts reviewed in that: The medication cart for the 2400 hall and one cart by the front entrance on the lower level were not locked. During a medication review, MA T walked away and left the medications out with the surveyor, instead of locking the medications back up. These deficient practices could affect residents and result in a drug diversion due to medications not being properly disposed and secured. The findings were: Observation on 11/13/2024 at 7:13 a.m., of the medication cart for the 2400 was not locked when MA T, was administering medications. Observation on 11/13/2024 at 7:40 a.m., MA T, walked away from cart and left medications with the surveyor, during a medication pass inspection. The medications were not in sight of MA T view. MA T walked down the hall to ask the charge nurse for clarification on a medication order. Observation 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 interviews and record review the facility failed to provide diagnostic services to meet the needs of its residents in a timely manner for 1 of 9 (Resident # 153) residents reviewed for radiology services. The facility failed to ensure Resident # 153 was taken to their imaging appointment in a timely manner to ensure their appointment was not canceled due to being late for the appointment. This failure could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries. Findings included: Resident # 153 Review of face sheet dated 11/13/2024 for Resident # 153 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), epilepsy (a seizure disorder), pain in right hip, altered mental status, chronic pain, depression, insomnia, , and pelvis fracture. Review of Quarterly MDS assessment dated [DATE] for Resident # 153 reflected a BIMS…

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 interviews and record review the facility failed to assist residents in arranging transportation to and from dental services location to meet the needs of 1 of 6 (Resident # 151) reviewed for dental services. The facility failed to assist Resident # 151 with arranging transportation to and from dental services location to complete his dental appointment for castings to be made for dentures. This deficient practice could affect residents by placing them at risk of not receiving dental care. Findings included: Review of face sheet dated 11/13/2024 for Resident # 151 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of the bladder (bladder cancer), muscle wasting and atrophy, malaise, , and vitamin D deficiency. Review of the Quarterly MDS assessment dated [DATE] for Resident # 151 reflected a BIMS score of 15 indicating intact cognition. MDS oral/dental status section did not have any documentation recorded. Review of Resident # 151's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for one (1) of ten (10) residents (Resident # 151) reviewed for food allergies. The facility kitchen failed to honor Resident # 151 food allergies according to his meal ticket and served him beets which his meal ticket stated he had an allergy to. This failure placed the resident at risk of consuming a food allergen. Findings included: Review of face sheet dated 11/13/2024 for Resident # 151 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included anemia, type 2 diabetes with foot ulcer, and vitamin D deficiency. Listed under allergies it reads beets. Review of the Quarterly MDS assessment dated [DATE] for Resident # 151 reflected a BIMS score of 15 indicating intact cognition. Review of the care plan for Resident # 151 dated 05/22/2024 reflected the following resident was on an RCS (Reduced Concentrated Sweets) diet…

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 interview and record review, the facility failed to ensure the resident's medical records are accurately documented for 1 of 5 residents (Resident #13) reviewed for clinical records. The facility failed to ensure Resident #13's admission Agreement dated 8/26/24 signed electronically after consent received during phone conversation was witnessed by 2 people. These failures could result in inaccurate records, errors in care, decline in health and quality of life. Findings Include: Review of Resident #13's face sheet revealed an 80-years-old male with admission date of 8/24/24 with a discharge date of 10/18/2024. Diagnoses included: Hyperlipidemia (high level of lipids or fats in the blood), vascular dementia (memory and thought process difficulties related to multiple strokes, or loss of blood circulation to the brain), hypertension (high blood pressure), dysphagia (difficulty swallowing), and cognitive communication deficit (inability to communicate). Review of Resident #13's initial minimum data set…

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 interviews and record reviews, the facility failed to ensure that all alleged violations were reported immediately or not later than 24 hours for 1 (Resident #1) of 6 residents reviewed for elopement. The facility failed to report to the SA an incident where Resident #1 eloped from the facility on 11/01/24. This deficient practice could place residents at risk of abuse, neglect, elopement, injury, and death. Findings included: Review of Resident #1's admission record, dated 11/06/24, reflected she was a [AGE] year old female who initially admitted to the facility on [DATE], readmitted on [DATE], was discharged to the hospital on [DATE], had an RP, and had diagnoses including cerebral infarction due to embolism of left middle cerebral artery (a medical condition that occurs when an embolism blocks blood flow to the middle cerebral artery, resulting in an ischemic stroke), essential (primary) hypertension (a common condition that occurs when the pressure of your blood is consistently too high), aphasia (a…

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

Based on observation, interviews and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 facilities reviewed for pests control The facility failed to ensure the facility was free from pests/insects in multiple areas including resident rooms, shower room, dining room and kitchen. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable and non-homelike environment free of pests. Findings include: At 10:39 AM on 08/06/2024, a cricket was observed to be in a resident room on the floor. At 10:43 AM on 08/06/2024, an insect wing was observed on the floor of the kitchen and was light brown color. At 10:49 AM on 08/06/2024, a small bug was observed on the floor of the kitchen. At 11:22 AM on 08/06/2024, a small bug was observed crawling under freezer 1 in the kitchen. At 11:24 AM on 08/06/2024, a small bug was observed crawling on the floor in the dry storage area of the kitchen. At 11:31 AM on 08/06/2024, a small bug was observed on the wall near the…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service in that: The facility failed to label and date items in the freezer. This failure could put residents at risk of foodborne illness. Findings included: Observation on 08/06/2024 at 10:49 AM, revealed torn bag with exposed food in the freezer. Further observation revealed that there was no date or label of what the food was. Observation on 08/06/2024 at 10:50 AM, revealed bag of food dated 07/29/2024 with no label of the contents. Observation on 08/06/2024 at 10:51 AM revealed FSS instructed staff to put the food that had the torn bag into another bag and date it. During an interview on 08/06/2024 at 10:51 AM, the FSS stated that food was supposed to be labeled with the contents of the bag. She stated that the staff was aware of what was in the bag and that it was okay for the food to be exposed and put in another bag. During an interview on 08/06/2024 at 2:10 PM, FSS stated that all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 8 residents reviewed for resident rights and dignity. CNA B failed to provide privacy and dignity to Resident #1 by closing the door and/or privacy curtain leaving the resident exposed during incontinent care. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. Finding included: Record review of Resident #1's face sheet dated 07/17/24 revealed a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of conversion disorder with seizures or convulsions (a mental condition in which a person experiences blindness, paralysis, or other nervous system neurologic symptoms that cannot be explained by illness or injury), cerebral palsy-unspecified (a group of disorders 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 observation, interview, and record review, the facility failed to ensure all drugs were stored in locked compartments with access by authorized personnel only for 1 of 3 medication carts (300 hall cart) reviewed for storage of drugs and biologicals. RN A failed to secure the 300 hall medication cart leaving it unlocked and unsupervised. This failure could result in staff, visitors, or residents accessing medications not prescribed to them. Findings included: An observation on 07/17/24 at 10:06 AM, a medication cart was observed halfway down the 300-hall unsupervised and unlocked with 3 compartments that were able to be opened and accessed. An interview and observation on 07/17/24 at 10:10 AM, RN A stated that all medication carts are to be locked and secured before leaving them unattended. RN A stated the medication cart that was unlocked was her assigned cart at the time and she had stepped away to attend to a residents' needs away from the 300 hall completely. RN A said that she was supposed to lock the cart and take the keys with her to ensure nobody could access 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 observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for 3 (Resident #20, #65, and #395) of 169 residents reviewed for resident rights and ensure each resident was provided a safe, clean, comfortable, and homelike environment in that: 1. Staff did not check on and make sure Resident #20 was fully clothed. 2. Resident #395's urinal was out in plain sight, emptied, and cleaned. 3. Resident #65 repeatedly urinated in resident common areas, threw, and damaged facility property placing residents in an uncomfortable, unsanitary, and non-homelike environment. These deficient practices placed residents at risk of a decline in their sense of dignity and self-worth and diminished their right to feel safe, secure, and live in a clean homelike environment. Findings included: Review of Resident #20's face sheet, dated 09/20/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including…

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, and record reviews, the facility failed to ensure each resident had a right to a safe, clean, comfortable and homelike environment for 4 (Resident #41, #129, #141, and #395) of 169 residents reviewed for environment. 1. Resident #41, #129, #141, and #395's rooms had a urine odor. 2. The facility's memory care unit had a urine odor and sticky floors. These deficient practices placed residents at risk of discomfort and diminished quality of life. Findings included: Review of Resident #41's face sheet, dated 09/20/2023, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including late onset Alzheimer's disease, vascular age-related physical debility, dementia, paranoid schizophrenia, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and muscle wasting and atrophy. Review of Resident #41's annual MDS assessment, dated 09/20/2023, reflected she did not have a BIMS conducted because she was rarely/never…

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, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control treat the building for insects. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Review of Resident #4's face sheet, dated 9/20/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizophreniform disorder, essential (primary) hypertension, and other visual disturbances. Review of Resident #4's quarterly MDS assessment, dated 07/11/2023, reflected a BIMS of 00, indicating severe cognitive impairment. Review of Resident #4's quarterly care plan, dated 09/14/2023, reflected he had modified independence, poor decision making skills at times, required cues/supervision for ADLs, and at risk for needs not being met and at risk for decline, high risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside the facility for one (Resident #103) of seven reviewed, in that: The facility failed to provide a communication aide (examples being paper and writing implement or white board) for Resident #103 after a diagnosis of hearing loss. This failure placed residents at risk of a lack of a dignified existence, self-determination, and quality of life. Findings included: Review of Resident #103's undated face sheet reflected a [AGE] year-old woman facility admitted date 01/04/22 with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), unspecified, unspecified hearing loss, left ear, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect one (Residents #78) of one of one reviewed, from verbal abuse, in that: The facility failed to ensure Resident #78 was not verbally abused by Resident #90. This failure could most likely place residents at risk of fear, depression, intimidation, and a diminished quality of life due to verbal abuse. Findings included: Review of face sheet for Resident #78 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, mild, with mood disturbance, schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior), depressive type, major depressive disorder, recurrent extrapyramidal (movement dysfunction such as continuous spasms and muscle contractions) and movement disorder and need for assistance with personal care. Review of quarterly minimum data set (MDS) for Resident #78 conducted on 09/06/23 reflected a brief interview for mental status (BIMS) score of 12,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Resident #102 and Resident #182) of eight residents reviewed for activities of daily living. The facility failed to ensure Resident #102 received nail care. The facility failed to ensure Resident #182 received shaving care. These failures placed residents at risk of diminished support with activities of daily living. Findings included: A record review of Resident #102's face sheet dated 9/20/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of schizophrenia (mental disorder), unspecified dementia (cognitive decline), and major depressive disorder (depression). A record review of Resident #102's quarterly MDS assessment dated 7/3122023 reflected a BIMS score of 9, which indicated moderate cognitive impairment. A record review of Resident #102's care plan last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide or obtain routine dental services to meet the needs of each resident for one (Resident #36) of eight residents reviewed for dental services. SW A failed to obtain financial consent or declination for recommended dental services for Resident #36. This failure placed residents with dental issues at risk of diminished ability to chew, decreased intake and weight loss. Findings included: A record review of Resident #36's face sheet dated 9/20/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of vascular dementia (cognitive decline), iron deficiency anemia, dysphagia (difficulty swallowing), major depressive disorder (depression), cerebrovascular disease (condition affecting blood flow through the brain), schizoaffective disorder (mental disorder), and bipolar disorder (mental illness causing extreme mood swings). A record review of Resident #36's annual MDS assessment dated [DATE] reflected a BIMS score of 9,…

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.