Treemont Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation when they failed to: A. Cover opened food items. B. Discard perishable food items past the use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation of the dry storage on 07/21/24 at 10:20 AM revealed a 1-gallon plastic container (approximately ½ full) of opened Teriyaki Sauce dated 05/05/24. Manufacturer instructions on the container stated to refrigerate after opening. 2. Observation of the walk-in refrigerator on 07/21/24 at 10:24 AM revealed a plastic container of approximately 40 ounces of apple sauce covered with clear plastic wrap with an open date of 07/13/24 and a use by date of 07/16/24. 2. Observation of the walk-in refrigerator on 7/21/24 at 10:30 AM revealed a large plastic bag of six boiled eggs that was not sealed and open 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 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 disease for 2 of 2 residents (Resident #75 and Resident #60) reviewed for infection control. The facility failed to ensure: A. CNA E changed soiled gloves during incontinent care to Resident #60. B. CNA D changed soiled gloves during incontinent care to Resident #75. This failure could place residents at risk for cross contamination which could result in infections or illnesses. Findings included: Record review of Resident #75's face sheet dated 7/23/24 revealed Resident #75 was [AGE] years old with diagnoses of moderate protein-calorie malnutrition (malnourished) and urinary tract infection. Record review of Resident #75's MDS dated [DATE] revealed Resident #75 had a BIMS score of 14 (suggests cognition is intact), had a fall within the last month, and…

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

Based on observations, interviews, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen review for equipment safety. In the kitchen walk-in refrigerator and walk-in freezer, the fan cooling units were leaking. These failures could affect all residents that eat meals from the kitchen and pose a possible risk for cross-contamination. Findings included: In an observation on 07/22/24 at 10:20 AM in the kitchen walk-in refrigerator a large, five-gallon, food grade clear plexiglass bucket was observed to be half full of a water-like substance, liquid was observed dripping from a pipe connected to the fan-cooler unit above the bucket. The fan-cooler unit was observed to be making a clanking noise. A further observation in the kitchen walk-in freezer revealed that both fan-cooler units had ice build-up in the form of icicles that had dripped onto food boxes below building up 2-3 inches of ice on top of the food boxes. In an interview on 07/22/24 at 2:05 PM the ADM revealed that the fan-cooler…

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 effective pest control program so that the facility was free of pests for 1 of 1 kitchen areas, 2 of 5 (Resident #40 and Resident #66) resident rooms, and 2 of 3(First and Second Floor Dining Room) dining areas reviewed for environment . The facility failed to ensure the kitchen area was free of roaches before lunch service. The facility failed to ensure dining rooms were free of flies during the resident meal service. The facility failed to ensure resident rooms were free of flies. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live. Findings included: In an observation on 07/21/24 at 10:10 AM in RM [ROOM NUMBER] revealed three live gnats/small flies inside the room, alighting on tables and walls, there were no residents in the room at the time of the observation. In an observation and interview on 07/21/24 at 10:18 AM in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect for 1 (Resident #59) of 7 residents reviewed for dignity. The facility failed to ensure MA K knocked or requested permission before entering Resident #59's room. This failure placed residents at risk of psychosocial harm such as low self-esteem, loss of dignity, and decreased quality of life. Findings included: Record Review of Resident #59's face sheet dated 7/21/24 revealed Resident #59 was [AGE] years old with diagnoses of bipolar disorder, major depressive disorder, and anxiety. Record Review of Resident #59's MDS assessment dated [DATE] revealed a BIMS score of 15 (suggests resident is cognitively intact) and a diagnosis of post-traumatic stress disorder. Observation on 7/21/24 at 1:41 p.m. while Resident #59 was being interviewed, MA K opened Resident #59's door and entered Resident #59's room. Resident #59 yelled Get out of my room! and Why are you in here?. MA K responded,…

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 resident has a right to a safe, clean, comfortable and homelike environment for 2 of 5 resident rooms, observed for environment. In resident rooms #1125 an #1207 tiles around the toilets were loose, missing pieces or otherwise separated. This failure could place residents at risk for living in an unsanitary and uncomfortable environment. Findings included: In an observation on 07/21/24 at 1:33 PM the bathroom floor in room [ROOM NUMBER] was observed to have two pieces of tile directly in front of the toilet that had approximately 2-inch by 2-inch pieces missing exposing the bare concrete below. In an observation on 07/22/24 at 1:29 PM the bathroom floor in room # 1207 was observed to have 5 pieces of tile bordering the toilet to have ¼ inch gaps between the tiles exposing the concrete below. One tile directly to the right of the toilet had a large ½ inch crack directly down the middle of the tile exposing the bare concrete below.…

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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #48) of 1 residents reviewed for catheter care. The facility failed to enssure Resident #48's catheter bag was not leaking urine. This failure affected one of five residents and could place residents with indwelling urinary catheters at risk of infection. Findings include: Record review of Resident #48's admission Record, dated 07/22/2024 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and most recently admitted [DATE] with a diagnosis of Obstructive and Reflux Uropathy (obstructed/blocked urinary flow). Record review of Resident #48's MDS , dated 05/28/2024, revealed a BIMS score of 14 and an active diagnosis of Diabetes Mellitus (a disease of inadequate control of blood glucose levels). His Functional Status assessment indicated he required two-person…

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 received assistance devices to prevent accidents for 1 of 3 residents (Resident #75) reviewed for accidents. PTA G failed to apply a gait belt to Resident #75 prior to ambulating in the hallway. Resident #75 fell and suffered a skin tear to the left elbow and right forearm when PTA G was unable to secure Resident #75 to prevent the fall. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #75's face sheet dated 7/23/24 revealed Resident #75 was [AGE] years old with diagnoses of moderate protein-calorie malnutrition (malnourished) and urinary tract infection. Record review of Resident #75's care plan dated 7/10/24 with a revision date of 7/22/24 states Resident #75 was at risk for falls. Record review of Resident #75's MDS dated [DATE] revealed Resident #75 had a BIMS score of 14 (suggests cognition is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (09/12/23) of one incident reviewed for reporting according to facility policy. The facility failed to follow their policy to report to the State Survey Agency when Resident #1 was missing for approximately 15 hours after leaving the hospital where he went for a doctor's appointment. This failure could place the residents in the facility at risk of lacking timely reporting of incidents. Findings included: Review of the facility's policy titled Abuse/Neglect dated 03/29/18 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by…

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 all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for 1 of 1 incidents reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #1 was missing for about 15 hours after leaving the hospital where he went for a doctor's appointment. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Review of Resident #1's MDS dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypotension (low blood pressure), and muscle weakness. The resident was cognitively intact with a BIMS score of 15, and he had the ability to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 disease and infections for 4 (Residents #2, #3, #4, #7) of 5 residents reviewed for infection control. 1.The facility failed to ensure CMA K sanitized her hands during medication administration on Residents #2, #3, and #4 during morning medication pass. 2.The facility failed to ensure CMA K sanitized the blood pressure cuff between uses on Residents #2, and #3 during morning medication pass. 3.The facility failed to ensure CNA O followed facility protocol for entering and exiting a room with a Resident on droplet precautions (Resident # 7) while passing ice on the hall and CNA O failed to close the ice chest on the hall. These failures could place residents at risk of infectious disease. The findings included: Review of Resident #2's admission 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.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate accountability of controlled drugs for one (First Floor East Wing Cart) of two medication carts reviewed for medication administration. The facility did not obtain nursing staff signatures for the controlled Drug-Count Record for First Floor East Wing medication cart on 01/26/2024 on the 2pm to 10 pm shift and 01/30/2024 on the 6am to 2pm shift. This failure could cause access, loss, and diversion of controlled narcotic medications. Finding included: Records reviewed of narcotic signing sheet on 01/31/2024 at 09:35 AM, revealed on 01/26/2024 NURSE ON 2pm to 10 pm shift and NURSE OFF 2pm to 10pm had no signatures for narcotic signing sheet. On 01/30/2024 NURSE ON 6am to 2pm and NURSE OFF 6am to 2 pm had no signatures on the narcotic signing sheet. Record review of daily staffing schedule for 01/26/24 and 01/30/24 did not specify medication carts assignments. Interview with ADON L on 01/31/2024 at 1:00 PM, revealed that she had done a lot 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, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for 1(Resident #6) of five residents on (Hall 400) second floor reviewed for storage of medications. Resident #6 medications left at bedside unattended. This failure could affect residents by placing residents at risk of consuming unsafe medications. Findings included: Record review of Resident #6's face-sheet revealed a [AGE] year-old male, initially admitted to facility on 03/18/2021, and readmitted on [DATE]. Resident's diagnosis included: Type 2 Diabetes Mellitus without Complications (Managing type 2 diabetes by closely monitoring blood glucose levels), Heart Failure, Unspecified (disorder characterized by the heart to pump blood at an adequate volume to meet tissue metabolic requirements), and Essential (Primary) Hypertension (three or more blood pressure readings taken over three visits separated by weeks whose average exceeds 140/90). Record review of Resident #6's quarterly MDS…

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 reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 (Resident #1) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #1's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs. The findings included: Record review of Resident #1's face sheet, printed on 12/13/23, revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (kidneys do not filter blood like they should), dementia without behavioral disturbances (impaired ability to remember or make decisions), major depressive disorder (persistent feeling of feeling sad). Record review of Resident #1's admission MDS, dated [DATE] revealed the resident had a BIMS score of 08 which indicated the resident was mildly cognitively…

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 a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for personal privacy. CNA B failed to ensure the door to Resident #1's room was closed behind her while she left to retrieve supplies for Resident #1. Resident#1 was on the floor naked when CNA B left the door to the room open. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care. Findings included: Record review of Resident #1's face sheet, printed on 12/13/23, revealed Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (kidneys do not filter blood like they should), dementia without behavioral disturbances (impaired ability to remember or make decisions), major depressive disorder (persistent feeling of feeling sad). Record review of Resident #1's admission MDS, dated [DATE]…

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 biologicals) for 1(Resident #3) of eight reviewed for pharmaceutical services The facility failed to ensure Residents #3's medication administration log was completed accurately. Resident #3's medication administration log reflected no documentation that Resident#3 was given humanLOG injection solution 100 units per sliding scale for diabetes on 12/03/2023 and lidocaine external patch 4% at 7:00 AM as directed on 12/03/2023 This failure placed residents at risk of not having accurate clinical records completed to indicate if a medication was administered, resulting in potential medical errors and a decline in health. Findings included: Review of Resident #3's electronic face sheet printed 12/14/2023 revealed a 61- year -old male admitted to the facility 06/26/2023 and re admitted on [DATE]…

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 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 1 (Resident #1 reviewed for infection control practices and transmission-based precautions. The facility failed to ensure LVN G performed hand hygiene and glove change while providing wound care for Resident #1 on 11/28/2023. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: Review of Resident #1's electronic face sheet undated revealed a 60- year- old male admitted to the facility on [DATE] with diagnoses that include chronic viral hepatitis C (a viral infection that causes liver swelling), and high blood pressure. Review of the Resident #1's care plan dated 11/23/23 revealed Resident #1 had reopened scab to calf region, interventions included treat…

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 conduct an inspection of all bed frames, mattresses, and bed rails for 1 (Resident#1) of five residents reviewed for bedrails in that: On 11/27/23 Resident #1's mattress was to long for his bed and Resident #1 did not have a foot board. This deficient practice could place residents at risk for accidents such as sliding out of the bed. The findings included: Review of Resident #1's electronic face sheet undated revealed a 60- year- old male admitted to the facility on [DATE] with diagnoses that include chronic viral hepatitis C (a viral infection that causes liver swelling), and high blood pressure. Review of the Resident #1's care plan dated 11/23/23 revealed Resident #1 used grab/assist bar to assist himself with adl's. Resident #1's bed rails should have been assessed every quarter. Review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. 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 interviews and record review, the facility failed to maintain clinical records, in accordance with accepted professional standards and practices that contain sufficient information that includes a history of the resident's assessments, care, and services provided, were accurately documented for one (Resident #1) of one resident reviewed for complete and accurate clinical records. On 09/03/23 Resident #1 had an unwitnessed fall and sustained a raised area on the top left side of the head. The facility failed to document ongoing neuro assessments per facility protocol after the initial Q15 minutes x 4 were completed. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and inaccurate documentation. The findings included: A record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses of T2DM, muscle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the right, right to make choices about aspects of his or her life in the facility that are significant to the resident, for 5 (Resident #2, Resident #3, Resident #38, Resident # 76 , and Resident #85 ) of 9 residents reviewed for self-determination. 1.The facility failed to promote Resident #2's self-determination by not allowing her to participate in smoke break, then return to dinner. 2.The facility failed to promote Resident #3's self-determination by assessment for an outside podiatrist. 3.The facility failed to promote Resident #38 choices to receive scheduled ADL care task for 9:00 am therapy and 2:00 p.m. showers as scheduled. 4. The facility failed to promote Resident #76's self-determination by restricting the time he watched television, prhibiting him from visiting another resident , 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 residents were free from abuse, neglect, misappropriation of resident property and exploitation for 3 (Resident #51, Resident # 76, Resident #85) of 6 residents reviewed for abuse. 1. The facility failed to protect Resident #51 from abuse when staff yelled at him when asking for assistance via call light. 2. The facility failed to protect Resident # 76 from abuse when he was not permitted to participate activities he chose, and visitation with other residents, and by misrepresenting agency policies, rules, and guidelines to meet the staff's preference. 3. The facility failed to protect Resident #85 form abuse when CNA-E mocked her walking down the hall in the presence of other residents. These failures placed residents at risk of experiencing and enduring abuse by facility staff causing decreased quality of life. Findings Included: Resident #51- In an interview with resident #51 on 5/32/23 at 10:00 a.m. in a resident group…

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, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1.The facility failed to maintain the kitchen floor and baseboards in the dishwashing room, manual dish room (3 sink compartment), and clean pan storage rack located kitchen in a sanitary condition. 2.The facility failed to maintain kitchen appliances, equipment, and utensils in sanitary condition. 3.The facility failed to monitor and test temperatures on dishwasher. 4.The facility failed to maintain 2 deep fryers in sanitary conditions. 5.The facility failed to date and label food items located in the food pantry. 6. the facility failed to clean and sanitize ice chest used for resident hydration on the hall. These failures placed residents at risk for cross-contamination and food borne illness. Findings included: Observation on 05/30/23 at 9:30 a.m. revealed large amounts of black grime under the dishwashing food…

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 interview and record review, the facility failed to employ a qualified social worker on a full-time basis for one of one facility. A qualified social worker is an individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology. The facility of more than 120 beds, failed to employ a qualified Social Worker on a Full-time basis for all residents residing at the facility. This failure placed residents at risk of not receiving services the individual needs of the residents whenever needed. Findings included: Record Review of facility's Leadership credentials on 05/31/23 revealed the facility did not have a qualified Social Worker on record. Record Review of the faciltiy's census report on 05/31/23 revealed an in house census of 130 residents. Interview with Administrator on 06/01/23 at 11:30 AM revealed the previous Social Worker had resigned nearly 3 weeks ago and they were still searching for one. She stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 (Resident #11, Resident #21, Resident #65) of five residents observed for infection control. The facility failed to ensure MA A sanitized blood pressure equipment between use of Resident #11, Resident #21, and Resident #65. This failure placed residents at risk of cross-contamination and infections. Findings included: Review of Resident #11's Face Sheet, dated 06/01/23 revealed she was a [AGE] year-old female re-admitted to the facility on [DATE] from the hospital. Relevant diagnoses included respiratory (lung) failure, dementia, type 2 diabetes, and urinary tract infection. Review of Resident #21's Face Sheet, dated 06/01/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE] from the hospital.…

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 essential mechanical and electrical equipment in safe operating condition for the facility's only kitchen reviewed for essential equipment. 1.The facility failed to provide necessary repairs for 1 stove missing 2 knobs. 2.The facility failed to provide necessary repairs to the tilt skill power control knob that was missing. These failures could place residents who had their meals prepared in the facility kitchen at risk of having delayed meals due to equipment improperly functioning during meal preparation. maintain all mechanical, electrical, and in the only kitchen used to prepare and serve resident meals in safe operating condition. Findings included: Observation on 05/30/23 at 9:30 a.m. during the initial kitchen tour in the facility kitchen, revealed the kitchen stove had 2 missing knobs used to control the burners gas levels while cooking, and a tilt skillet next to the stove missing a control knob used to control temperatures during meal preparation. 05/30/2023 at 6:16 AM of the kitchen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews 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 1 (Resident #47) of 6 residetns reviewed for home-like environment. The facility failed to ensure a dialysis machine, located in a resident's room, was thoroughly cleaned. This failure placed residents at risk of acquiring an infection or loss of dignity due to an unclean room. Findings included: Record review of Resident #47's Face Sheet, dated 06/01/23, revealed she was a 55 -year-old female admitted on [DATE]. Relevant diagnoses included End Stage Renal Disease (kidney failure), and Infection and Inflammatory Reaction Due to Internal left Hip Prosthesis (prosthetic infection). Record review of Resident #47's Minimum Data Set (MDS) on dated 10/18/22 revealed she had a Brief Interview for Mental Status (BIMS) score of 00 (mentally impaired). Resident #47 was Totally dependent upon staff…

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 comprehensive person-centered care plans were developed and implemented 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 1 of 6 residents (Resident #47) reviewed for Care Plans. The facility failed to ensure Resident #47's Care Plan included goals and interventions for her In-house hemodialysis ( process of purifying the blood of a person whose kidneys are not working normally) treatments. This failure could place Resident #47 at risk of not receiving the appropriate Dialysis care at the facility. Findings included: Record review of Resident #47's Face Sheet, dated 06/01/23, revealed she was a 55 -year-old female admitted on [DATE]. Relevant diagnoses included End Stage Renal Disease (kidney failure), and Infection and Inflammatory Reaction Due to Internal…

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 provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This included identifying hazard(s) and risk(s), for 1 of 6 resident rooms (Rm 1125) reviewed for area free of hazards. The facility failed to ensure personal extensions cords were not being used in Resident RM [ROOM NUMBER]. This failure placed resident at risk of hazards that could result in injury and be a fire hazard. Findings included: Observation on 05/30/23 at 10:14 AM in room [ROOM NUMBER] revealed an extension cord in a resident's room, that was connected to at least three different devices to including a Continuous Positive Airway Pressure (CPAP) machine, and cell phone. Interview with Maintenance Director on 05/30/23 at 10:20 AM revealed the Maintenance Director being shown the devices plugged into the utility extension cord in room [ROOM…

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