Brookhaven Nursing and Rehabilitation Center

Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for one (Hospitality Aide A) of three employees reviewed for staff qualifications. 1. The facility failed to ensure Hospitality Aide A had a current nurse aide certification while employed at the facility while actively providing care for residents on 02/12/25: 6:00 AM - 2:00 PM shift, 02/10/25: 6:00 AM - 2:00 PM shift, 02/08/25: 6:00 AM - 2:00 PM shift, 02/07/25: 6:00 AM - 2:00 PM shift. This failure could result in residents being provided care by staff who do not have the training and competency needed for providing care. Findings include: Record review of Hospitality Aide A's personnel file revealed her date of hire was not listed. She did not have a CNA license. Record review of the facility's schedule revealed Hospitality Aide A was listed as a CNA and counted as a CNA in the numbers for the schedule on dates: 02/12/25: 6:00 AM - 2:00 PM shift 02/10/25: 6:00 AM - 2:00 PM shift 02/08/25: 6:00 AM - 2:00…

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 supervision to prevent accidents for 2 of 10 residents (Resident # 55 and Resident #12) reviewed for Accidents and Supervision. The facility did not provide supervision for Resident #55 and Resident #12 while smoking on 08/30/24. This failure could place residents at the facility at risk of injuries related to burns. The findings included: Record review of Resident #55's Face Sheet, dated 08/30/24, revealed that he was a [AGE] year old male with an initial admission date to the facility of 02/07/24. Resident #55's active diagnoses included: dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), major depressive disorder, seizures, hemiplegia (paralysis that affects one side of the body), unspecified affecting right dominant side, aphasia (loss of ability to understand or express speech, caused by brain damage) chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing…

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 that the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of 1 (Resident #44) of 5 residents reviewed for accommodation of needs. 1. The facility failed to ensure that Resident #44 had a mobility device that was operable and comfortable to her that promoted independence, safety, and psychosocial need. This failure could place residents at risk of increased isolation, depression and increased risk of injury. Findings Include: Record Review of Resident #44's Quarterly MDS with an ARD of 07/13/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #44's active diagnoses included: Unspecified Dementia, Unsteadiness on feet, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening) and unspecified glaucoma (progressive eye condition that can cause blindness). Resident #55 had a BIMS score of 9, indicating 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 observation, interviews, and record review, the facility failed to resolve a grievance in a timely manner for 1 of 5 (Resident #44) residents reviewed for grievances. 1.The facility failed to make prompt efforts to ensure Resident #44's grievance was initiated, reported, and resolved in a timely manner. These failures could affect the Resident's ability to file a grievance without the fear of discrimination, reprisal or retribution and their right to have their grievances resolved in a timely manner. Findings Included: Record Review of Resident #44's Quarterly MDS with an ARD of 07/13/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Resident #44's active diagnoses included: Unspecified Dementia, Unsteadiness on feet, muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening) and unspecified glaucoma (progressive eye condition that can cause blindness). Resident #55 had a BIMS score of 9, indicating a moderately impaired cognition. Record Review of 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 interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (Resident #55) of 5 resident's reviewed for MDS assessment accuracy. The facility failed to ensure Resident #55's Quarterly MDS assessment with an ARD (assessment reference date) of 05/14/2024, reflected his current diagnosis of Major Depressive Disorder (clinical depression). This failure could place residents at risk of not receiving care and services to meet their needs. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Record Review of the MDS Section I, Active Diagnoses revealed 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 interview and record review the facility failed to submit an accurate PL1 (PASARR Level 1) screening when residents admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 (Resident #55) out of 5 residents reviewed for PASARR screenings. The facility failed to submit a new PL1 screening when Resident #55 was diagnosed with Major Depressive Disorder after admission to the facility. These failures could affect residents by not receiving a Level II PASARR Evaluation to access for needed services. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) out of 5 residents reviewed for care plans. The facility failed to ensure that Resident #55's comprehensive care plan included his diagnosis of Major Depressive Disorder. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body…

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 facility residents received proper treatment and care to maintain mobility and proper foot health for 1 (Resident #11) of 1 residents reviewed for foot care services. The facility failed to provide podiatry services for Residents (Resident #11). This failure could lead to increased potential negative outcomes related to foot health including development of sores, infections, amputation and death for a resident with diabetes. Findings included: Record review of Resident #11's Face Sheet, dated 08/30/24, revealed that he was a [AGE] year-old male with an initial admission date to the facility of 04/14/24. Resident #11's active diagnoses included: Type 3 Diabetes with mellitus without complications, hyperosmolality (occurs when very high blood sugar leads to severe dehydration, highly concentrated blood and mental status changes) and hypernatremia (a rise in serum sodium concentration), phosphorus metabolism (is a complex…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. RN B and LVN C failed to document the administration of Ipratropium-Albuterol Inhalation Solution (inhaled treatment used to prevent difficulty breathing and coughing) to Resident #1 as ordered. LVN C failed to document the administration of Robitussin Mucus+Chest Congest Oral Liquid (used for cough and congestion) to Resident #1 as ordered. This failure placed residents at risk of not receiving their medications as ordered by a physician and worsening of their condition. Findings included: Record review of Resident #1's admission Record dated 8/30/24 revealed he was an [AGE] year-old male admitted to the facility on [DATE] from an acute care hospital. Record review of Resident #1's 5-Day…

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 assist in obtaining routine and emergency dental care for 1 out of 5 residents (Resident #55) reviewed for dental services. The facility failed to complete and submit a dental referral for Resident #55 This failure could place Resident's at risk for oral complications, dental pain and diminished quality of life. Findings Included: Record Review of Resident #55's Quarterly MDS with an ARD (Assessment Reference Date) of 05/14/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #55's active diagnoses included: Aphasia (brain disorder that affects the ability to speak or understand language), Hemiplegia following cerebral infarction (weakness on one side of the body following a stroke) and muscle weakness. Resident #55 had a BIMS score of 1 indicating a severe cognitive impairment. Review of the assessment revealed that Resident #55 had no dental issues identified and he required setup or clean-up assistance…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for three of five residents (Resident #52, Resident #70, and Resident #85) reviewed for catheter care. 1. The facility failed to ensure CNA D and CNA E maintained the foley catheter drainage bag below Resident #52's bladder during a mechanical lift transfer. 2. The facility failed to ensure RN P maintained Resident #70's foley catheter drainage bag below the bladder level during wound care on 06/03/24. 3. The facility failed to ensure Resident #85's catheter bag did not had contact with the floor. This failure placed residents at risk for not receiving care appropriate to address their incontinence. Findings included: 1. Record review of Resident #52's face sheet dated 06//06/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included obstructive and reflux uropathy (a disorder 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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 medication cart (Nurses cart hall 300) of 3 medication carts reviewed for pharmacy services. The facility failed remove damaged medications from the Nurses Cart hall 300 timely for disposition. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: Record review and observation on 06/04/24 at 12:17 PM of Nurses Cart Hall 300, with LVN N revealed: - the blister pack for Resident #39's tramadol 50 mg tablet (controlled medication used for pain) had 2 blister seals broken and the pills still inside the broken blisters and taped over. - the blister pack for Resident #50's tramadol 50 mg tablet (controlled medication used for pain) had 6 blister seals broken…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility refrigerator and freezer had a visible use-by date and covered. 2. The facility failed to discard food stored in the refrigerator that should no longer be consumed. 3. The facility failed to ensure staff were only using clean utensils when accessing bulk foods. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation in facility's walk-in freezer on 06/04/24 at 09:36 AM revealed beef patties were not covered appropriately. Observation in Facility's refrigerator on 06/04/24 at 09:42 AM revealed a bunch of cilantro was rotten and a box of diced potato did not have a visible use-by date on it. Observation in facility's kitchen's prep area on 06/04/24 at 09:51 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of sixteen residents (Resident #78, Resident #13, and Resident #51) observed for infection control. 1. The facility failed to ensure that CNA D performed hand hygiene while providing incontinence care to Resident #78 on 06/04/24. 2. The facility failed to ensure that CNA F changed his gloves and performed hand hygiene while providing incontinence care to Resident #13 on 06/04/24. 3. The facility failed to ensure that CNA L changed her gloves and performed hand hygiene while providing incontinence care to Resident #51 on 06/04/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #78's Face sheet dated 06/06/24 reflected 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 ensure the right to reside and receive services in the facility with reasonable accommodation of the resident needs for 2 (Resident #6, and Resident #83) of 5 residents reviewed for resident rights. The facility failed to ensure Resident #6 and Resident #83's call light was placed within reach. These failures could place residents at risk of injuries and unmet needs. Findings included: Review of Resident #6 Quarterly MDS assessment dated [DATE] revealed resident was admitted on [DATE] with readmission on [DATE], diagnoses of cerebral infarction (stroke), dementia (loss of cognition cognitive communication deficit), unsteadiness on feet, difficulty in walking, generalized muscle weakness, and a BIMS score of 7 (severely impaired cognition). Review of Resident #6 Care Plan dated initiated 04/04/2023 and revised 05/03/2024 reflected resident had a history of falls and had a fall with injury to his forehead on 04/04/2024 due to an unsteady…

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 the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #53, Resident #74) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #53 had her fingernails cleaned and trimmed. 2- Resident #74 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1-Record review of Resident #53's Quarterly MDS assessment dated [DATE] reflected Resident #53 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia (paralysis that affects only one side of the body) affecting right side, and dementia.…

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 based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 21 residents (Resident #44) reviewed for quality of care. The facility staff failed to ensure Resident #44's splint was placed on his right arm and hand on 06/04/24 and 06/05/24 per physician orders. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in decreased Range of Motion and worsening of contractures. Findings included: Record review of Resident #44's face sheet dated 06/06/24 reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of aphasia (loss of ability to understand or express speech caused by brain damage), hemiplegia right side (paralysis), and cerebral vascular accident (stroke). Record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #51) of three residents reviewed for supervision. The facility failed to ensure Resident #51 received two-person assist when providing incontinent care. This failure could place residents at risk for accidents and injury. The findings were: Record review of Resident #51's Face sheet dated 06/06/24 reflected Resident #51 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included paraplegia (paralysis that affects legs, but not arms) and chronic respiratory failure. Record review of Resident #51's Comprehensive MDS assessment, dated 04/05/24, reflected Resident #51's cognition was severely impaired. The MDS assessment indicated Resident #51 was dependent of care for all ADLs. He requires 2 persons assist with roll left and right. He was always incontinent of urine and bowel. Record review of Resident #51's Care Plan initiated 04/21/20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #26) reviewed for feeding tubes. The facility failed to ensure Resident #26's hydration bag for the tube feeding pump was labeled and dated. This failure could result in complications of enteral feedings such as receiving incorrect hydration or elevated risk of infection with using the same hydration bag over multiple days. The findings were: Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed that Resident #26 was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Cancer (abnormal proliferation of cells), Hypertension (high blood pressure) and Heart Failure (insufficient pumping of the heart) and unspecified Neurological conditions (disease that affects the nervous system). Resident #26 had a feeding tube.…

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 the resident environment remained as free of accident hazards as was possible for contaminated sharps disposal bins, attached to one (300 Hall MA Medication Cart) of one 300 Hall MA Medication Cart and one (300 Hall Nurse Medication Cart) of one 300 Hall Nurse Medication Cart reviewed for hazards. MA B failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall MA Medication Cart, were below the full line. MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. RN C failed to ensure contaminated sharps in the sharps bin attached to the 300 Hall Nurse Medication Cart, were below the full line. These failures placed residents at risk of being exposed to contaminated sharps, possible bloodborne pathogens, and access to unprescribed medications. Findings included: An observation on 01/30/2024 at 10:07 AM, revealed the plastic insert contained inside the sharps bin attached to MA B's 300 Hall MA Medication Cart…

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 pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 15 and #20) of 3 residents reviewed for pharmacy services. MA B failed to administer medications timely as ordered by physician to Resident # 20 LVN D failed to administer medications timely as ordered by physician to Resident # 15 The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order. The findings included: Record review of Resident #15's face sheet dated 01/30/24 revealed an [AGE] years old female, admitted to the facility on [DATE] with diagnoses that included hypertension (blood pressure that is higher than normal), hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone) and malignant neoplasm of unspecified site…

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 all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (300 Hall MA Medication Cart) of six of six medication carts reviewed for medication storage. MA B failed to ensure medications found on the sharps bin insert lid on the 300 Hall MA Medication Cart, were disposed of properly. This failure placed residents at risk for unauthorized access to the medication cart and a harmful medication can be consumed placing residents at risk for administration of harmful medication. Findings included: An observation on 01/30/2024 at 10:07 AM revealed, MA B's 300 Hall MA Medication Cart, had eight pills stuck between the plastic insert of the sharps (needles, blades [such as scalpels] and other medical instruments that are necessary for carrying out healthcare work and could cause an injury by cutting or pricking the skin) container and the lid, which prevented the lid from closing properly. Residents were observed self-ambulating through the hall in thier…

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 all residents had a means to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 (Residents #3 and #4) of 9 residents reviewed for resident call systems. Residents #3 and #4 were moved to the same room on a covid unit for quarantine after testing positive for the virus. The room did not contain a call system for use at the bedside. This failure could place residents at risk of not being able to notify staff when care was needed. Findings included: Resident #3 Record review of Resident #3's admission Record dated 12/28/23 revealed he was a [AGE] year-old ma major depressive disorder, le admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pain in unspecified joints, acute pancreatitis, primary hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular heartbeat), 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 ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of three residents reviewed for comprehensive care plans. Resident #1's care plan failed to address interventions to prevent complications related to her PICC line. This failure placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns. Findings included: Record review of Resident #1's admission MDS assessment, dated 08/05/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's brief interview for mental status was cognitively intact by staff assessment. The resident had IV medications. Her diagnoses included acute and subacute endocarditis (inflammation of heart…

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 medications were labeled and stored in accordance with currently accepted professional principles for one of six medication carts reviewed for medication storage; the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for one (Resident #75) of four residents reviewed for medication storage; the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to keys for two (300-hall) of three medication and treatment carts. 1. The 300 and 400 Hall medication cart had 2 insulin pens that had no resident listed or open/expiration dates. 2. The facility failed to ensure Resident #75's medications were secured inside of the medication cart on 04/25/23. 3. The facility failed…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings included: Observation of the facility's refrigerator on 04/23/23 at 9:21 AM revealed: - 1 roll of meat thawing directly on the 2nd shelf rack from the top and above a box of potatoes; - 1 carton of milk dated best by 04/20/23; - 1 orange with white fuzzy spots; and - 4 green bell peppers with white spots. Observation of the facility's freeze on 04/23/23 at 9:27 AM revealed: - plastic wrap and strips of tape left on shelf rack and floor; - pieces of corn, green beans, and sherbet cup on the floor; - red spill on a shelf rack; - 1 box of beef patties open and exposed to air; - 1 box of white ranch dinner roll dough open and exposed to air; - 1 box of chocolate chip cookie dough open and exposed 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 observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #57) of three residents reviewed for environment. The facility failed to ensure Resident #57 bedside commode was clean and sanitary. This failure could place residents at risk for a diminished quality of life due to the lack of a clean and sanitary homelike environment. Findings included: Review of Resident #57's face sheet, dated 04/25/23, reflected he was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction (stroke), abnormal posture, and end stage renal disease. Review of Resident #57's care plan did not address his use of a bedside commode. Review of Resident #57's quarterly MDS, dated [DATE], reflected he had a BIMS score of 15. Further review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #75) of five residents reviewed for foot care. The facility failed to ensure Resident #75 received foot care. This failure could place residents at risk of diminished quality of life by not receiving care and services to meet their needs. Findings included: Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. She required extensive assistance with one-person physical assistance regarding personal hygiene. She required total dependence with one-person physical assistance regarding bathing. Review of Resident #75'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, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #75) of three residents observed for indwelling urinary catheters. The facility failed to ensure Resident #75's catheter bag was changed as ordered by the physician. These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Record review of Resident #75's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included anemia, hypertension, renal failure, neurogenic bladder, Non-Alzheimer's Dementia, malnutrition, anxiety, depression, and insomnia. Her BIMS score was 10 out of 15, which revealed she was moderately impaired. Her appliances used was an indwelling catheter and she was always incontinent. Review of Resident #75's care plan, undated, reflected her…

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 are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #24) reviewed for gastrostomy tube management. The facility failed to ensure Resident #24's head of bed was elevated at a minimum of 30-degree angle during medication administration and bolus feeding (a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). The facility failed to check the Resident #24's residual before administering medications This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health. Findings include: Record review of Resident #24's face sheet dated 4/25/23 revealed a 49- year-old-male…

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 who needs respiratory care is provided such care, consistent with professional standards of practice, the resident's care plan, and the resident's goal and preferences for one (Resident #26) of two residents reviewed for tracheostomy care. The facility failed to dispose of Resident #26's suction catheter after use. These failures placed the residents at risk of respiratory infections. Findings included: Record review of Resident #26's Quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included hypertension, diabetes mellitus, hyperlipidemia, aphasia, seizure disorder, anxiety disorder, and respiratory failure. Her BIMS score was 0 out of 15, which revealed she was severely impaired. She required total dependence with one-to-two-person physical assistance regarding ADLs. She received oxygen therapy, suctioning, and tracheostomy care. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological's) to meet the needs of each resident, for 2 of 5 residents (Residents #50 and # 78) observed during medication administration. The facility failed to ensure Resident #50's and Resident #78's medications were administered at the scheduled time per the physician orders. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #78's face sheet, dated 5/2/23, revealed an admission date of 11/22/22, with diagnoses which included hypertensive urgency, obesity, dehydration, acute kidney failure, muscle weakness, cognitive communication problem and Type 2 diabetes. A record review of Resident #78's quarterly MDS, dated [DATE], revealed Resident #78 was 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.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #50 and #23) of four residents reviewed for infection control. MA X failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50 and #23. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 04/23/23 at 9:25 AM of MA X using a wrist blood pressure monitor for Resident #50. At 9:27 AM MA X took the same wrist blood pressure monitor to Resident #23. MA X did not sanitize or clean the wrist blood pressure monitor between the two residents. In an interview on 04/23/23 at 9:32 AM with MA X revealed she did use the wrist blood pressure monitor on Resident #50 and Resident #23 without cleaning or sanitizing it in between the residents. MA X said she knew she should…

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