Greenville Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. for 3 of 21 (Residents #39, Resident #58, and Resident #33) residents reviewed for psychoactive medications. 1. The facility did not ensure a written consent was obtained for Ativan (antianxiety medication) an ingredient used in her order for ABH(Ativan, Hadol and Benadryl) for Resident #39. 2. The facility failed to ensure Resident #58 had signed a psychotropic consent for Clonazepam (antianxiety). 3. The facility failed to ensure Resident #33's paroxetine (antidepressant medication) was discontinued when he did not consent to the medication on 04/01/25. These failures could place residents at risk for receiving unnecessary antipsychotic medications without informed consent.…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #50) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #50 was given a NOMNC (is a notice that indicates when your care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) when discharged from skilled services prior to his covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: Record review of Resident #50's face sheet, dated 05/09/25, reflected Resident #50 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 of 23 residents (Resident #5) reviewed for privacy and confidentiality. The facility did not ensure RN WW closed Resident #5's EMR before entering his room to administer his medications on 05/06/25. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medical records being accessible to others. Findings included: Record review of Resident #5's face sheet, dated 04/23/25, reflected Resident #5 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnoses which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support), cellulitis (bacterial skin infection) of abdominal wall, GERD (stomach acid repeatedly flows back up), and dysphagia (difficulty of swallowing).…

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, neglect, exploitation, or mistreatment, including misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #9) reviewed for abuse. 1.The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. 2.The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when staff reported allegations of misappropriation. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and further injuries of unknown source. Findings included: Record review of Resident #9's face sheet dated 05/09/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with 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 record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 2 residents (Resident #73) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #73. This failure could place residents at risk of not having complete records after permanent discharge from the facility. Findings included: Record review of Resident #73's face sheet dated 05/09/25, indicated an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia (memory loss), chronic obstructive pulmonary disease (lung disease that block air flow and make it difficult to breathe), hypertension (high blood pressure), and cerebral infarction (stroke). Record review of Resident #73's discharge MDS assessment dated [DATE], indicated discharge assessment-return not anticipated. Resident #73 was discharged to home/community. Resident #73 cognition was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to facilitate resident and family participation in the care planning process for 1 of 23 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7 had a care plan meeting. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care. Findings included: Record review of Resident #7's face sheet dated 05/07/25, indicated an [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses which included end state renal disease (permanent kidney failure that requires dialysis or a kidney transplant), weakness, congestive heart failure (condition in which the heart does not pump blood as well as it should), and diabetes mellitus (disease that results in too much sugar in the blood). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood…

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 unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 23 residents reviewed for ADLs. (Resident #7) The facility failed to ensure Resident #7 received his shower as scheduled. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings included: Record review of Resident #7's face sheet dated 05/07/25, indicated an [AGE] year-old male who readmitted to the facility on [DATE] with diagnoses which included end state renal disease (permanent kidney failure that requires dialysis or a kidney transplant), weakness, congestive heart failure (condition in which the heart does not pump blood as well as it should), and diabetes mellitus (disease that results in too much sugar in the blood). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated he…

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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents reviewed for nutritional status (Resident #5). 1.The facility failed to ensure Resident #5's enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 05/06/25. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life. Findings included: 1. Record review of Resident #5's face sheet dated 05/07/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included dysphagia (difficulty swallowing), gastrostomy status (surgical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #5) reviewed for enteral nutrition. The facility did not ensure RN WW checked Resident #5's G-Tube (a tube directly inserted through the skin to the stomach to deliver nutrition) stomach content residual and placement prior to medication administration. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #5's face sheet, dated 04/23/25, reflected Resident #5 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support), cellulitis (bacterial skin infection) of abdominal wall, GERD (stomach…

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 respiratory care was provided with professional standards of practice for 1 of 3 residents reviewed for quality of care. (Resident #5) The facility failed to ensure Resident #5's had a physician's order to receive oxygen. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: Record review of Resident #5's face sheet dated 05/07/25, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #5 had diagnoses which included respiratory failure (condition where the lungs cannot adequately exchange gasses, leading to insufficient oxygen or excessive carbon dioxide in the blood), dysphagia (difficulty swallowing), gastrostomy status (surgical opening in stomach to provide nutrition and medications), dementia (memory loss), muscle wasting and atrophy (loss of muscle mass). Record review of Resident #5's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that resident who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 had a physician's order for dialysis treatment. The facility failed to ensure there was a physician's order for Resident #7's dialysis catheter and to monitor for complications. These failures could place the residents, who received dialysis, at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #7's face sheet dated 05/07/25, indicated an [AGE] year-old male who readmitted to the facility 03/06/25 with diagnoses which included end state renal disease (permanent kidney failure that requires dialysis or a kidney transplant), weakness, congestive 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 interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 3 residents (Resident # 39 and Resident #34) reviewed for trauma-informed care. 1.The facility did not ensure Resident #39 had the diagnosis of PTSD also known as post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and the triggers listed on his care plan. Resident #39 had a history of trauma. 2. The facility did not ensure Resident #34's trauma screening was completed upon admission to the facility. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: 1.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 interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 1 of 1 nurse (RN WW) reviewed for nursing services. The facility did not ensure RN WW check residual and placement by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia. Findings included: Record review of Resident #5's face sheet, dated 04/23/25, reflected Resident #5 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support), cellulitis (bacterial skin infection) of abdominal wall, GERD (stomach acid repeatedly flows back up), and dysphagia (difficulty of swallowing). Record review of Resident #5's annual MDS assessment, dated…

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 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 1 of 6 residents (Residents #5) reviewed for pharmacy services. 1. The facility did not ensure Resident #5 was given Mucinex (expectorant that helps loosen and thin mucus in the airways) DM (cough suppressant) 30-600 mg. This failure could place residents at risk of having an exacerbation of their disease processes. Findings included: 1. Record review of Resident #5's face sheet, dated 04/23/25, reflected Resident #5 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support), cellulitis (bacterial skin infection) of abdominal wall, GERD (stomach acid repeatedly flows back up), 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 interview and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents reviewed for pharmacy services. (Resident #30) The facility failed to reorder Resident #30's lorazepam (antianxiety medication) tablet timely resulting in Resident #30 having 6 missed doses. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: Record review of Resident #30's face sheet dated 05/10/25, indicated a [AGE] year-old female who readmitted to the facility on [DATE] with diagnoses which included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depression, and anxiety. Record review of Resident #30's annual MDS assessment dated [DATE], indicated she was able to make herself understood and understood others. Resident #30 had a BIMS score of 15, which indicated her cognition was intact. The 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 received therapeutic diets that were prescribed by the attending physician for 2 of 21 residents (Resident #10 and Resident #29) reviewed for therapeutic diets. 1. The facility failed to ensure Resident #10 received her fortified food, Ensure Clear, or water on 05/05/25 as indicated on her tray card. 2. The facility failed to ensure Resident #29 received fortified foods with his lunch meal on 05/05/25. The facility did not ensure Resident #29 was given his fortified food on 05/05/25 as indicated on his tray card. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #10's face sheet dated 05/10/25 indicated a [AGE] year-old female who was re-admitted to the facility on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), heart failure,…

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 follow their own established smoking policy for 2 of 4 residents (Resident #35 and Resident #62) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #35 and Resident #62. This failure could place residents at risk of unsafe smoking and injury. Findings included: Record review of Resident #35's face sheet, dated 05/10/25, indicated Resident #35 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugars), Chronic Obstructive Pulmonary Disease, also known as COPD (a long-term lung disease that makes breathing difficult), and depression (sadness). Record review of Resident #35's quarterly MDS assessment, dated 02/04/25, indicated Resident #35 understood and was understood by others. Resident #35's BIMS score was 15, which indicated she was cognitively intact. Resident #35 was independent…

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 establish and 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 6 of 6 residents (Resident #s 1, 2, 3, 5 and 6) and 5 of 5 staff (Staff NA B, NA C, MA D, NA F, and LVN G) reviewed for infection control. The facility failed to follow their policy when they did not ensure the following: -Resident #2 remained on isolation for 10 days and/or wear appropriate PPE when not in his room. -NA B washed or sanitized her hands and donned appropriate personal protective equipment (PPE) when she entered and exited Resident #1 and 2's room. -NA F washed or sanitized her hands and donned appropriate personal protective equipment (PPE) when she entered and exited Resident #5's room. -Staff NA B, NA C, MA D, NA F, and LVN G were aware who were Covid+ -LVN G was aware Resident #s 1, 2, 3, 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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 1 dining room reviewed for resident rights. 1. The facility did not ensure CNA C and MA D treated residents with dignity and respect by referring to them as feeders. 2. The facility failed to ensure LVN A fed Resident #1 while sitting down. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: 1. During a dining observation and interview on 02/25/25 at 11:40 a.m., CNA C stated to MA E, It's goes in the feeding room. CNA C was approximately 3 feet from dining room tables where residents were sitting. CNA C stated the word assisted dining room should be used instead of the word feeder. CNA C stated, I wasn't thinking. CNA C stated referring to residents as a feeder was a dignity issue. During an interview on 02/25/25 at 11:59 a.m., MA D stated he was a feeder when asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review the facility failed to ensure residents were free from abuse for 7 of 13 residents (Residents #3, #4, #5, #6, #7, #8 and #9) reviewed for resident abuse. 1. The facility did not ensure Resident #3 was free from abuse when Resident #9 shoved Resident #3 on 8/19/24. 2. The facility did not ensure Resident #6 was free from abuse when Resident #5 hit Resident #6 with her silverware packet on 8/28/24. 3. The facility did not ensure Resident #3 was free from abuse when Resident #4 hit Resident #3 on the back of the head 10/17/24. 4. The facility did not ensure Resident #7 was from abuse when Resident #8 hit Resident #7 on the head 12/20/24. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Resident #3 Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 4 of 13 (Residents #3, #4, #5, and #6) reviewed for abuse. 1. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 10/17/24 between Resident #3 and Resident #4 2. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 08/28/24 between Resident #3 and Resident #4. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met. Findings included: Record review of the facility policy for Policy and Procedures: Abuse, Neglect and Exploitation revised 09/06/24, reflected . 2. The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect . to the state survey agency and other official in accordance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 13 (Residents #3, #4, #5, and #6) residents reviewed for reporting. 1. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of been notified. 2. The facility did not report the resident-to-resident altercation between Resident #5 and Resident #6 to the State Survey Agency within 2 hours of been notified. These failures to report could place the residents at risk for abuse. Findings included: 1. Resident #3 Record review of Resident #3's face sheet, dated 02/27/25, reflected Resident #3 was a [AGE] year-old male, originally admitted to the facility on [DATE] with a diagnosis which included supraventricular tachycardia (abnormal fast heartbeat).…

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 treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. The facility failed to ensure LVN A assessed Resident #1 buttocks after CNA B reported that Resident #1 had skin issues. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Findings included: Record review of Resident #1's face sheet dated 05/22/24, indicated a [AGE] year-old female who initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident #1's diagnoses included peripheral vascular disease (narrowing of arteries that supply blood to your legs and feet), Type 2 diabetes mellitus (chronic condition that affects how your body uses sugar for energy), congestive heart failure (impairment in the heart's ability to fill with and pump blood), and protein calorie…

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 each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 4 residents (Resident's #30, 183 and 185) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #30, Resident #183, and Resident #185 were given a Skilled Nursing Facility Advanced Beneficiary notice of non-coverage ({SNF ABN}, which is a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility before covered days were exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings include: 1.Record review of Resident #30's face sheet, indicated he was a [AGE] year-old male who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 24 residents (Resident # 17, Resident #38, Resident #49, and Resident #53) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 17's, Resident #38's, Resident #49's, and Resident #53's anticoagulant (blood thinner) use was accurately coded. These failures could place residents at risk for not receiving care and services to meet their needs. 1. Record review of a face sheet dated 3/27/24 indicated Resident #17 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Parkinson's (brain disorder that causes unintended or uncontrollable movements), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease (stomach acid or bile…

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 15 residents (Resident's #44, #51, #5, and #47 ) reviewed for care plans. 1. The facility failed to care plan Resident #44's Lorazepam (antianxiety medication) and interventions. 2. The facility failed to care plan Resident #51's Eliquis (blood thinner medicine that reduces blood clotting) and interventions. 3. The facility failed to care plan Resident #5's fall and interventions. 4. The facility failed to ensure palliative care was care planned for Resident #47. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. The findings include: 1.Record review of Resident #44's face sheet, dated 03/28/24, indicated a [AGE] year-old female who was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 3 of 8 residents (Resident #1, Resident #34, and Resident #49) reviewed for nutrition. The facility failed to ensure Resident #1 received his magic cup with his meals. The facility failed to ensure Resident #34 received his health shake. The facility failed to ensure Resident #49 received her Nutritious Shake. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life. Findings included: 1. Record review of Resident #1's face sheet dated 03/27/24 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses senile degeneration of the brain (., anxiety, dementia (decline in 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 observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 6 of 14 residents (Residents #44, #51, #17, #60, #47, and #53) who were reviewed for respiratory care. 1.The facility failed to ensure Resident #44 had an oxygen order. 2. The facility failed to ensure Resident #51's oxygen filter on the oxygen concentrator filter was cleaned. 3. The facility failed to ensure Resident #17's oxygen filter on the oxygen concentrator filter was cleaned weekly and Resident #17's oxygen nasal cannula tubing was bagged when not in use. 4. The facility failed to ensure Resident #60's oxygen concentrator filter was cleaned weekly. 5. The facility failed to ensure Resident #47's nebulizer mask was placed in a bag after use. 6. The facility failed to ensure Resident #53's BiPAP (machine that helps a person to regulate their breathing pattern while they are asleep or when respiratory…

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 all drugs were stored in a locked compartment, only accessible by authorized personnel and all drugs and biologicals used in the facility were labeled in accordance with professional standards for 1 of 1 treatment carts, 2 of 5 medication carts (100 Hall Nurse Cart, 300 Hall Nurse Cart and the 400 Hall Nurse cart), 1 of 1 medication storage room reviewed for drugs and biologicals, and 3 of 3 Residents. (Resident #49, Resident #233, Resident #52) The facility failed to ensure the Treatment Cart and the 400 Hall Nurse cart were secured and unable to be accessed by unauthorized personnel. The facility failed to label medications with an open date for Resident #49's insulin pen and Resident #52's and Resident #233's inhalers on the 100 Hall Nurse cart. The facility failed to label with an open date a multidose vial of Lidocaine 1% 200 mg/20 ml on the 300 Hall Nurse cart. The facility failed to discard a vial of Influenza Vaccine…

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

Based on observations, interviews, and record review, the facility failed to ensure that menus were followed for the noon time (lunch) meal to meet the nutritional needs for the residents on a pureed food consistency diet ( 5 of 5) residents were reviewed for puree food consistency diet. 1. The facility served the residents on a pureed food consistency diet the wrong scoop size servings on the macaroni and cheese for the noon time (lunch) meal on 3/25/24. 2) The facility failed to follow puree recipe for lunch meal served on 3/26/24. 3) The Dietary Staff failed to serve the puree residents puree bread on the 3/25/24. This failure affected all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: 1. Record review of the facility diet and nourishment roster on 03/25/2024 indicated there were 5 residents in the facility on pureed food consistency diet. Record Review of the week 1 menu dated 3/24/24, indicated the lunch meal items included glazed ham,…

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 provide food that was palatable, attractive, and at a safe and appetizing temperature for 4 of 4 residents (Resident #23, Resident #49, Resident #47 and Resident #17), 1 of 3 meals were reviewed for palatability, attractiveness, and appetizing. 1) The dietary staff failed to provide food that was palatable and appetizing temperature for Resident #23, Resident #49, Resident #47 and Resident #17. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the week 1 menu dated 3/24/24, indicated the lunch meal items included glazed ham, mixed vegetables, macaroni and cheese, breadstick, citrus gelatin, choice of beverage: (Substitute) Chicken soup, grilled cheese. During an interview on 03/24/2024 at 10:46 AM, Resident #23 said the food was terrible and that it was really bland. During an interview on 03/24/2024 at 3:05 p.m., Resident # 49 said the food was over seasoned, and it tasted awful. During an interview on 03/24/24…

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

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 in (1 of 1) kitchen reviewed for dietary services. 1) The Dietary staff failed to date all food items. 2) The Dietary staff failed to dispose of expired food items in the refrigerator. 3) The Dietary staff failed to effectively seal, label, and date refrigerated food items. 4) The Dietary staff failed to to repair a leak in the kitchen ceiling. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation on 03/24/24 at 10:37 a.m., of Refrigerator #1, the following was indicated: -(1) 5-pound block of sliced cheese had no open date and no received date. -(1) 5 slices of cheese in saran wrap and not bagged, had no open date, no expiration date, and no received date. -(1) 8 quarts of lettuce in a container had a preparation date of 3/2/24 and had no expiration. (expired) -(1) 5 slices of bologna opened and not bagged, had no open…

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 establish and 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 4 of 4 reviewed (Resident #38 and Resident #47, Resident #14, and Resident #66 ) for infection control practices. 1. The failed to ensure CNA X performed hand hygiene or change gloves while providing incontinent care for Resident #38. 2.The facility staff failed to properly dispose of used PPE in the biohazard bin. 3.The facility failed to ensure CNA D did not leave trash and a sheet in Resident #14's room after providing care to her. 4.The facility failed to ensure Treatment Nurse H performed hand hygiene after glove removal and performed proper glove changes while providing wound care to Resident #66 . These failures could place any resident at the facility requiring incontinent care, wound care, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #55) reviewed for resident rights. The facility failed to ensure CNA O knocked on Resident #55's door prior to entering his room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of Resident # 55's face sheet dated 03/27/24 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of lumbar spina bifida (a congenital disease that affects the spinal cord and causes problems with walking and bladder control), neuromuscular dysfunction of the bladder, high blood pressure, and major depression. Record review of Resident #55's annual MDS dated [DATE] indicated he had a BIMS score of 15 which indicated he was cognitively intact. 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 residents had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #38) reviewed for right to be informed The facility failed to obtain an informed consent based on the information of the benefits and risks for Resident #38 before administering Bupropion, an antidepressant medication, used to treat depression. This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status. Findings included: Record review of Resident #38's face sheet, dated 03/28/24, indicated a [AGE] year-old male who was admitted 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 interviews and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 24 residents (Resident #23) reviewed for self-determination. The facility failed to ensure Resident #23 was provided showers instead of bed baths per her request. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of a face sheet dated 03/27/2024 indicated Resident #23 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and chronic diastolic congestive heart failure (condition in which the heart cannot fill up with blood properly). 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 immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #62) of 18 residents reviewed for changes in condition, in that: The facility failed to notify Resident #62's RP after she had abnormal hemoglobin lab values and required a blood transfusion. This failure placed residents at risk of a delay in treatment and their responsible party not being informed and involved in care decisions. Findings included: Record review of Resident #62's face sheet dated 03/27/24 indicate she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Dementia (decline in cognitive abilities that impacts everyday activities), Type 2 Diabetes (blood sugar regulation disorder), and Hypertension (high blood pressure), and anxiety. Resident #62's face sheet also indicated she had 3 family members listed for emergency contact. Record review of Resident #62's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 24 residents (Resident #36) reviewed for privacy. The facility failed to ensure LVN F provided privacy for Resident #36 while she administered his g-tube medications (gastrostomy tube is a tube that gives direct access to the stomach for administration of medications and feedings). This failure could place residents at risk of having their bodies exposed to the public, low self-esteem, and a diminished quality of life. Findings included: Record review of a face sheet dated 03/27/2024, indicated Resident #36 was a [AGE] year-old male originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination) and autistic disorder (developmental disabilities that can cause significant social,…

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 interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 20 staff (Dietician) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource Manager implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check and Criminal History check for the dietician upon hire. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the Dietician's personnel file on 03/27/24, indicated she was hired on 07/17/23. The Dietician's employee misconduct registry nor Criminal History check was not completed upon hire. During an interview on 03/27/24 7:16 PM the Human Resources Manager said the Criminal history check and the EMR were completed on the day of hire and then annually. She said the corporate office was responsible for completing Criminal History check and the EMR upon hire. The Human…

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 review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #44) residents reviewed for care plan revisions. The facility failed to update Resident #44's care plan for her Bipap (a machine that helps you breathe) being discontinued. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. 1.Record review of Resident #44's face sheet, dated 03/28/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), diabetes, chronic obstructive pulmonary disease (no airflow for breathing), and stroke. Record review of Resident #44's change in condition MDS assessment, dated 03/11/24, indicated Resident #44 was understood and understood by others. Resident #44's BIMS score was 12, which indicated she was…

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

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 unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 24 residents (Residents #23) reviewed for ADL care. The facility failed to ensure Resident #23 was routinely showered/bathed. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. Findings included: Record review of a face sheet dated 03/27/2024 indicated Resident #23 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and chronic diastolic congestive heart failure (condition in which the heart cannot fill up with blood properly). Record review of the Comprehensive MDS assessment 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 interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 24 residents (Resident #66) reviewed for the use of outside resources. The facility failed to ensure Resident #66's appointments with nephrology (specialty for kidneys/kidney disease, function) and with hematology (specialty for blood and blood diseases) were scheduled after she discharged from the hospital on [DATE]. This failure could place residents at risk of not receiving needed medical care. Findings included: Record review of a face sheet dated 03/27/2024 indicated Resident #66 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar which leads to high blood sugars), thrombocytopenia (low blood…

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 medical record was complete and accurately documented for 1 of 24 residents (Resident #66) reviewed for resident records. The facility failed to ensure Resident #66's allergy to Zyvox (antibiotic) and Heparin (anticoagulant medication) were added to her list of allergies after she re-admitted from the hospital on [DATE]. This failure could place residents at risk of receiving medications they are allergic to and inaccurate medical records. Findings included: Record review of a face sheet dated 03/27/2024 indicated Resident #66 was a [AGE] year old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), type 2 diabetes mellitus with hyperglycemia (chronic condition that affects the way the body processes blood sugar which leads to high blood sugars), thrombocytopenia…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to obtain Resident #1's physician's order for hospice services, most recent physician order, and the most recent hospice plan of care. The facility failed to obtain the most recent hospice certification. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #1's face sheet dated 03/27/24 indicated he was an [AGE] year-old male who admitted to the…

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

Based on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 20 employees (Dietician) reviewed for required annual trainings. The facility failed to ensure the Dietician received required dementia training upon hire 07/17/23. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files on 03/27/24 indicated the dietician was hired on 07/17/23 and had no dementia training upon hire. During an interview on 03/27/24 at 06:17 PM the Human Resources Manager said the corporate office was responsible for the training required upon hire for the dietician. She said she had reached out to the corporate office by email, and they refused to send the information needed. The Human Resources Manager said the failure placed staff at risk for not knowing how to correctly care for a resident with dementia. During an interview on 03/27/24 at 06:27 PM the Administrator said the corporate office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan for Resident #1's wound care to the left breast. This failure could place residents at risk of not having individual needs met and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 03/07/2024, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy (a problem in the brain caused by chemical imbalance in the blood), Cellulitis of Left Lower Limb…

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 all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 12 (Resident #1) residents reviewed for medication storage. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #1 had a medication cup with 1 tablet and 1 capsule sitting on top of his bedside table on 02/15/2024. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: During an observation on 02/15/2024 at 12:29 PM revealed Resident #1 had a clear plastic medication cup with 1 tablet and 1 capsule sitting in a clear plastic medication cup on the bedside table. Resident #1 stated the medication belonged to him. Resident #1 stated the medication was to make his leg feel better. Record review of face sheet, dated 02/20/2024, revealed Resident #1 was…

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

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases or infections and the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 3 of 4 halls (100 hall, 200 hall, and 400 hall), and 3 out of 79 employees (CNA C, CNA D, CNA E) reviewed for infection control practices. 1. The facility did not ensure the clean linen carts (on 100 hall, 200 hall, and 400 hall) were completely covered on 02/15/2024 while not being used. 2. The facility did not ensure CNA E placed soiled linen and trash in the appropriate barrels after providing care on 02/21/2024. These failures could place residents at increased risk for infection or cross-contamination that could diminish the resident's quality of life. The findings included: During an observation 02/15/2024 between 01:15 - 02:30PM, the clean linen cart on 100…

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 not employee and individual that was found guilty of mistreatment in a court of law for 1 of 6 employees reviewed (Kitchen Staff A) The facility allowed Kitchen Staff A to work at the facility for about 18 months without accurate criminal history check. Kitchen Staff A had a conviction with an absolute bar to employment. This facility failure put residents at risk for mistreatment. Finding included: Record review of employee records for Kitchen Staff A indicated she was hired on 7/11/22. Her initial criminal history check was done on 7/11/22 and indicated no criminal issues. She had a second criminal history check completed on 2/7/23 that indicated no criminal issues. Review of Kitchen Staff A driver's license indicated those criminal history checks were completed with the wrong birthday. Review of a criminal history check dated 1/7/24 with the correct birthdate indicated she had a charge of abandoning or endangering a child. During an interview on 1/10/23 at 5:50 a.m. the HR Manager said she worked at the facility for 8…

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 resident environment remained free of accident and hazards for 2 of 5 residents (Resident #1 and #2) reviewed for accident hazards. NA B did not obtain the assistance of certified or licensed personnel before using the mechanical lift ( a is used by caregivers to safely transfer patients) to transfer Resident #1 to her bed. CNA C and CNA H did not ensure the brakes were locked on Resident #2's bed before lowering him into the bed with the Mechanical lift. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life. Findings included: Record review of the face sheet for Resident #1 indicated she was [AGE] years old admitted to facility on 3/14/23 with diagnoses including, history of stroke, hemiplegia (Muscle weakness or partial paralysis on one side of the body) affecting the dominant right side of the body, aphasia (affects a person's ability to express and understand…

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 treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 2 residents (Resident #2) reviewed for resident rights. The facility did not ensure Resident #2's door was closed while performing a mechanical lift transfer. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: Record review of Resident #2's face sheet indicated he was [AGE] years old re-admitted to the facility on [DATE] with diagnoses including history of stroke, hemiplegia ( (muscle weakness or partial paralysis on one side of the body) affecting the dominant right side of the body, heart disease, high blood pressure, type 2 diabetes, peripheral vascular disease, anxiety and morbid obesity. Record review of the MDS dated [DATE] indicated Resident #2 made himself understood and understood others. The 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 that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility did not report Resident #1's elopement incident on 7/4/23 to the State Agency. This failure could place residents at risk of neglect.…

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 to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed for care plans. (Resident #1) The facility did not update Resident #1's care plan to reflect her history of elopement and wander guard system intervention. This failure could place residents at risk of not having individual needs met, and cause residents not to receive needed services. Findings include: Record review of Resident #1's face sheet indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, dementia, anxiety, depression, heart disease, type II diabetes, high blood pressure, muscle weakness and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #1 had the behavior of wandering that occurred 1 to 3 days during the 7 days look back period. Record review of the MDS dated [DATE] indicated Resident #1 usually made…

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 treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 20 residents (Residents #26, #14 and #1) reviewed for resident rights. 1. The facility failed to ensure RN F and CNA Z treated residents with dignity and respect by referring to them as feeders. 2. The facility failed to ensure the Environmental Service Manager knocked prior to entering Resident #26 room. 3. The facility failed to ensure LVN E provided privacy for Resident #14 while administering his insulin injection. 4. The facility failed to ensure Resident #1 had a privacy bag for his catheter drainage bag. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. The findings included: 1. During an observation on 02/06/2023 at 11:52 a.m., RN F stated where's the feeders in the dining hall while passing out food trays 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 interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 4 of 20 residents (Resident #'s 49, 130, 182, and 188) reviewed for baseline care plans. Resident #'s 49, 130, 182, and 188 did not have a baseline care plan completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: 1. Record review of Resident #49's face sheet (undated) revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of end stage renal disease (occurs when chronic kidney disease - the gradual loss of kidney function - reaches an advanced state), dependence of renal dialysis (clinical way of purifying the blood by removing unwanted substances and extra water - a function that kidneys normal do), and surgical aftercare following…

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 necessary services to maintain grooming and personal hygiene were provided for 3 of 20 residents reviewed for ADLs (Residents #24, Resident #25, and Resident #182). The facility failed to ensure Resident #24, and Resident #182 received showers or bed baths as scheduled. The facility failed to provide assistance with facial hair removal for Resident #25. These failures could place residents at risk of not receiving services and care, and a decreased quality of life. Findings included: 1. Record review of Resident #24's face sheet dated 02/08/23 revealed an [AGE] year old male initially admitted on [DATE] with diagnoses of pneumonia, unspecified organism (an infection of the lungs), chronic combined systolic (congestive) and diastolic (congestive) heart failure (heart does not pump blood well enough to meet the body's demand for blood and oxygen), and unspecified dementia, unspecified severity, without behavioral disturbance,…

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 respiratory care was provided with professional standards of practice for 3 of 16 residents (Residents #26, #47, and #61) reviewed for respiratory care and services. 1. The facility failed to administer oxygen at 2 via nasal cannula as prescribed by the physician for Resident #26. 2. The facility failed to properly store Resident #26's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. 3. The facility failed to ensure Resident #47's nasal cannula tubing was changed weekly. 4. The facility failed to ensure Resident #61's oxygen concentrator had a filter in place. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. Findings include: 1. Record review of Resident #26's order summary report, dated 02/08/2023, indicated Resident #26 was a [AGE] 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.

Based on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 6 out of 10 dietary staff. (Cook T, DW U, [NAME] V, DA W, [NAME] S, and DW X) The facility failed to ensure [NAME] T, DW U, [NAME] V, DA W, [NAME] S, and DW X had appropriate food handlers permit by the 60th day from hire. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness. The findings included: Review of the food handler's certificates of completion provided by the facility on 02/07/2023 at 10:45 AM, revealed the following: 1. [NAME] T had a food handler certificate that expired on 01/29/2023. 2. DW U, hired on 08/30/2021, had no food handler certificate. 3. [NAME] V, hired on 06/28/2022, had no food handler certificate. 4. DA W, hired on 08/03/2022, had no food handler certificate. 5. [NAME] S, hired on 08/09/2021, had no food handler certificate. 6. DW X, hired on 03/21/2022, had no food handler certificate. During an…

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 ensure the meals served to residents met the nutritional needs of residents for 1 of 1 meal (the lunch meal), as evidenced by: The facility failed to ensure [NAME] S followed the recipe for pureeing the honey glazed ham and cabbage during the lunch meal. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life. The findings included: During an observation and interview on 02/07/2023 at 10:25 AM, [NAME] S was preparing to puree the residents' meals. [NAME] S stated she normally followed a recipe while pureeing the food. [NAME] S had a prefilled metal measuring container filled with cabbage. [NAME] S stated she guessed on how much food was needed for the 6 pureed residents. [NAME] S placed the pre-measured, cooked cabbage into the blender and proceeded to puree. [NAME] S took the empty measuring container and placed a small amount of water into the blender. [NAME] S stated she used water to blend her pureed meals daily. [NAME] S…

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

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 20 residents (Resident #20, Resident #35, and Resident #69) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #20, Resident #35, and Resident #69 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: Record review of the Grievance/Complaint Report, dated 12/30/2022, revealed Resident #36, Resident #47, and Resident #56 complained the food was cold. During an interview on 02/06/2023 at 10:02 AM, Resident #69 stated the food was never seasoned. During an interview on 02/06/2023 at 10:38 AM, Resident #35 stated the meat was tough and the food was not seasoned. During an interview on 02/06/2023 at 11:30 AM, Resident #20 stated the food was bland. During and observation 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 observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. An open bag of dinner rolls and cookie dough, in a box dated 1/30/23, was stored properly. 2. A container cooked of ham, dated 1/23/2023, was discarded after 7 days. 3. A container of cheese, dated 1/4/23, was discarded after 7 days. 4. An expired container of chocolate pudding, good by date of 1/25/2023, was discarded. 5. A container of pears was labeled and dated. 6. The deep fryer was clean and had clear grease. 7. The ice scoop was stored appropriately when not in use. These failures could place residents at risk for food-borne illness. The findings included: Observation and interview during the brief initial kitchen tour on 02/06/2023 at 9:22 AM, the following was revealed: 1. An open bag of dinner rolls in a box dated 1/30/2023 was observed in the freezer. 2. Two open bags of cookie dough in a box dated 1/30/2023 was observed 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 each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 20 residents (Resident #73) reviewed for self-determination. The facility failed to ensure RN M and CNA N assisted Resident #73 to the toilet when she requested to be put on the toilet. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of Resident #73's face sheet, dated 02/08/23, revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood…

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 have physician orders for the resident's immediate care for 1 of 1 residents (Resident #182) reviewed for admission physician orders. The facility failed to ensure Resident #182 had a physician order for dressing change to suprapubic catheter. This failure could place residents at risk for not receiving appropriate care, treatment services, and at risk for infection. Findings included: Record review of a face sheet dated 02/08/23 revealed Resident #182 was a [AGE] year-old male admitted on [DATE] with diagnoses of quadriplegia (paralysis of all four extremities), paroxysmal atrial fibrillation (rapid, erratic heart rate), and neurogenic bladder (bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves). Record review of the order summary report dated 02/08/32, revealed Resident #182 had an order to cleanse supra pubic catheter site with normal saline, pat dry, apply T-drain dressing and secure with tape…

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 complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 2 of 20 residents (Resident #73 and Resident #183) reviewed for accuracy of assessments. The facility failed to complete Resident #73 and Resident #183's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their needs met. Findings included: 1. Record review of Resident #73's face sheet, dated 02/08/23, revealed a [AGE] year-old female initially admitted on [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough…

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 implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 20 residents (Resident #44) reviewed for care plans. The facility did not implement Resident #44's fall management care plan to ensure she always wore non-skid footwear and have a fall mat at bedside. This failure could place residents at risk of not having their individual needs met. Findings include: Record review of Resident #44's order summary report, dated 02/08/2023, indicated Resident #44 was a [AGE] year-old female, originally admitted on [DATE] with a diagnosis which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), essential hypertension (high blood pressure), and history of falling. Record review of Resident #44's significant change in status MDS assessment,…

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 that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 20 (Resident #4 and Resident #59) residents reviewed for accidents and hazards. The facility failed to ensure the Maintenance Supervisor fixed the exposed wires on Resident #4 and Resident #59's bed remotes. These failures could place residents at an increased risk for injury, electrocution, or fire. The findings included: 1. Record review of Resident #4's face sheet (undated) revealed she was [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset (type of brain disorder that causes problems with memory, thinking and behavior and is a gradually progressive condition), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with damaged nerves to hands and feet), and bradycardia (slow heartbeat). Record review of the MDS assessment, dated…

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 act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #68) reviewed for (DRR) Drug Regimen Review. The facility failed to implement Resident #68's signed Note to Attending Physician/Prescriber which agreed with pharmacist recommendation for a gradual dose reduction for an antidepressant medication. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Record review of Resident #68's face sheet (undated) revealed he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of peripheral vascular disease (condition or disease affecting the blood vessels), hemiplegia and hemiparesis following a stroke affecting right dominant side (conditions that cause weakness on one side of the body), and type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with nerve damage to hands and feet). Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 20 residents (Resident #47) reviewed for medication storage and 1 of 8 medication carts (Hall 200) reviewed for drugs and biologicals. 1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #47 had 1 bottle of Fluticasone Propionate nasal spray (allergies) and 1 bottle of Azelastine nasal spray (allergies) on her bedside table. 2. The facility failed to date insulin pens and vials on the hall 200 medication cart. These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication. Findings included: 1. Record review of Resident #47's order summary report, dated…

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 medical record was complete and accurately documented for 1 of 20 residents (Resident #187) reviewed for resident records. The facility failed to ensure Resident #187 had a physician order for contact precautions. This failure could place residents at risk of infections and not receiving individualized care and services to meet their needs. Findings included: Record review of a face sheet dated 02/08/23, revealed Resident #187 was a [AGE] year-old male initially admitted [DATE] with diagnoses of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), type 2 diabetes mellitus with diabetic neuropathy (high blood sugars with nerve damage), and chronic kidney disease stage 4 (severe kidney damage). Record review of Resident #187's Care Plan date initiated 02/03/23 did not indicate Resident #187 was on contact precautions. 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 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 3 of 3 staff (RN M, CNA N, and Treatment Nurse) viewed for infection control. 1. The facility failed to ensure RN M performed hand hygiene after removing his gloves and before putting on clean gloves during tracheostomy care for Resident #62 2. The facility failed to ensure RN M changed gloves and performed hand hygiene after picking up a nebulizer machine off the ground and before performing oral care and washing Resident #62's face. 3. The facility failed to ensure the treatment nurse and CNA N changed gloves when providing incontinent care for Resident #182. 4. The facility failed to ensure the treatment nurse performed hand hygiene between glove changes. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others…

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 follow their own established smoking policy for 1 of 1 resident (Resident #188) reviewed for smoking. The facility failed to ensure Resident #188's smoking evaluation tool was completed upon admission. This failure could place residents at risk of an unsafe smoking environment. Finding included: Record review of a Face Sheet dated 02/08/23 revealed Resident #188 was a [AGE] year-old male admitted on [DATE] with diagnoses of neoplasm of uncertain behavior of bladder (bladder cancer), essential (primary) hypertension (high blood pressure), nicotine dependence, unspecified, uncomplicated (dependence on nicotine a substance found in tobacco products), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of the electronic health record on 02/07/23 revealed no care plan, and MDS assessment was not yet completed. Review of the electronic health record on 02/07/23 did…

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.