Grace Care Center of Henrietta

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (January 2025, February 2025, and March 2025) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 28 of 47 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings include: In a record review and interview on 02/23/25 at 10:00 am, the Human Resource Director provided the Nurse Staffing Information from January 1, 2025, to February 21, 2025. It revealed there was no RN coverage for dates of 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, 01/20/25,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 12 of 12 residents (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #15, #16) during medication pass. A: Resident #7 and Resident #5 did not receive medications at 8:00 am medication pass. B: CMA F administered Resident's #2, #3, #4, #6, #8, #9, #11, #15, #16 medications greater than one hour after the scheduled administration time on [DATE]. C: CMA F operated outside of her scope of practice by administering an initial dose of a narcotic to Resident #1 and assessed Resident #1's pain. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm. Findings Include: A. Resident #7 Record review of Resident #7's admission Records, dated [DATE], revealed an [AGE] year-old female, 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 residents were free of significant medication errors for 7 (Resident's #2, #3, #5, #6, #7, #8, #9) of 11 residents reviewed for medication errors. 1. CMA F failed to administer Resident #2's 7:30 am blood pressure medications on 03/05/25 of Amlodipine Besylate 10mg, hydrochlorothiazide 50mg, Metoprolol Succinate 25mg, hydralazine HCI 10mg after 11:00 am. 2. CMA F failed to administer Resident #3's 7:00 am blood pressure medications on 03/05/25 of Amlodipine Besylate 5mg, Lisinopril 40mg, Metoprolol Succinate 25mg until after 11:00 am. 3. CMA F failed to administer Resident #5's 8:00 am blood pressure medications on 03/05/25 of Lisinopril 5mg, Carvedilol 6.25mg, Verapamil HCI 180mg, Hydralazine HCI 25mg, clonidine HCI 0.1mg until after 11:00 am. 4. CMA F failed to administer Resident #6's 8:00 am psychotropic medications on 03/05/25 of Depakote ER 240mg, buspirone HCI 5mg, Quetiapine Fumarate 50mg until after 11:00 am. 5. CMA F failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow menus for one of one facility. The facility failed to follow their menus prepared in advance daily for 11 meals dated 2/10/25 -3/13/25. This failure could affect the residents by the menus failing to meet the residents' choices and dietary needs. Findings included: Interview on 2/22/25 at 11:15am with [NAME] B stated the facility got a truck in yesterday but the food supplies remain low. Stated the facility was out of coffee, milk, bread, sweeter. Stated the facility had to substitute meals due to not having the food on the menu. Stated they try to make it as close as possible to the menus to make sure the residents are receiving the correct nutritional value. At times the facility had no bread or milk. [NAME] B stated she purchased food for the residents out of her own pocket without reimbursement, mostly condiments, ketchup, and mustard. Observation on 2/22/25 at 11:15am of food supply closet showed food supplies low. The facility…

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 appropriate plans of action to correct identified quality deficiencies and to regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements for one of one facility. The facility failed to follow their Plan of Correction (POC) dated 1/3/25 in utilizing a pool of RNs from neighboring/sister communities to ensure RN coverage at least 8 consecutive hours/day 7 days/week for 28 days since the dated POC. The facility failed to follow their POC to review weekly RN coverage in SOC (Standard of Care meeting) by the Administrator and DON to ensure appropriate RN coverage is arranged and provided by the facility or services of facilities or RN telehealth audio and visual capabilities were arranged. The facility failed to follow their POC to discuss the quality deficiencies in monthly QAPI meetings for 3 months. This failure placed the residents at risk of oversight and management 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.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024. This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. Findings included: Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days: 1. 10/26/2024 with no RN coverage. 2. 10/27/2024 with no RN coverage.…

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 handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices. The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. This failure could place residents at risk for healthcare associated cross-contamination and infections. The findings include: Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER]. Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport. Interview on 01/02/2025 at 12:10pm the LVN C 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.

Based on interviews and record reviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies and review and update the assessment at least annually for 1 of 1 facility reviewed for facility assessment. The facility failed to update a facility-wide assessment to determine what resources was necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving necessary care and services required. The findings included: During an interview on 10/12/24 at 8:50 PM, the Administrator stated the only form of facility assessment she could find was whatever is in the emergency preparedness book. She further stated that information regarding resident acuity level for evacuation in emergency preparedness book was not accurate. She stated that the facility assessment was the responsibility of the Administrator and she had been working on it. During an interview…

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 develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 4 of 5 (LVN A, CNA E, CNA F, and CNA G) employee's files reviewed for abuse protocol. A. The facility failed to complete criminal background, EMR and NAR check on CNA E before her employment date of 10/12/24. B. The facility failed to complete criminal background, EMR and NAR checks on CNA F before his employment date. C. The facility failed to complete criminal background, EMR and NAR checks on CNA G before her employment date. D. The facility failed to complete criminal background and EMR checks on LVN A before her employment date. This failure could place residents at risk for abuse, neglect, and exploitation. Findings included: Observation on 10/12/24 at 6:20 PM revealed CNA E was in possession of new hire paperwork; it was completely blank except for her name on the first page. Observation on 10/12/24 at 9:44 PM revealed CNA E working on…

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

Based on interview and record review, the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention for 5 of 5 (DON, LVN A, CNA E, CNA F, and CNA G) employees reviewed. The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention was provided to the DON, LVN A, CNA E, CNA F, and CNA G. This failure could negatively affect resident care and place residents at risk of abuse due to lack of staff training. The findings included: Review of Personnel Files on 10/11/24 revealed Record review of DON employment file revealed no record of trainings for 2023 or 2024. 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 manage the personal funds of the residents deposited with the facility for 1 of 3 (Resident #6) residents reviewed for personal funds. The facility failed to ensure Resident #6's personal funds were properly managed. This failure could place residents whose funds were managed by the facility at risk of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: Record review of Resident #6's Facesheet dated 10/25/24 revealed a [AGE] year-old female with a readmission date of 08/23/24. Resident #6 had a diagnosis list that included Bipolar Disorder mixed, severe, with psychotic features. Resident #6 was her own responsible party. Record review of Resident #6's MDS assessment dated [DATE] revealed a BIMS of 3 meaning severe cognitive impairment. Record review of Resident #6's Trust Statement dated 10/14/24 at 11:00 AM revealed a negative balance of $369.63. The month of September 2024 had credit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards. 1. The facility failed to maintain proper functioning of sit-to-stand mechanical lift. This failure could place residents at risk of accidents when using mechanical lift for transfers. Findings include: Record review of face sheet revealed Resident # 3 is a [AGE] year-old male diagnosed with type 2 diabetes, chronic kidney disease, cerebral infarction (previous blocked blood flow to brain), and muscle weakness. Record review of Resident #3's Careplan revised 10/10/24 revealed, Requires Max Assist X 2 staff with [mechanical] Lift for transfers. Record review of Resident #3's MDS assessment dated [DATE] Section C revealed BIMS of 15 meaning resident had no cognitive impairment; Section GG revealed maximum to moderate assistance (meaning 2-person physical assistance) with all ADL's; Section H revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to consult with the resident's physician, or the resident's representatives regarding a change in condition for one Resident (Resident #1) of 3 residents reviewed for notification of changes. The facility did not notify or consult with Resident #1's Physician , or resident representative regarding a burn incident on May 10, 2024, due to spilling coffee on herself. Physician was notified on May 13, 2024 and resident representative was notified on May 14, 2024. This failure could affect residents by causing their physician and representative to be unaware of changes in residents' condition. Findings were: Record review of Resident #1's electronic face sheet dated 06/04/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of lower lobe (lung cancer), Alzheimer's Disease (disease that destroys memory and other important mental functions) and senile degeneration of brain…

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 clinical records that were complete and/or accurate for 1 of 3 (Resident #1) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes on 5/10/24, 5/11/24, 5/12/24, and 5/13/24 related to an incident that occurred to Resident #1 on 05/10/2024 regarding a coffee burn. This failure could place residents at risk for improper documentation. The findings were: Record review of Resident #1's electronic face sheet dated 06/04/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of lower lobe (lung cancer), Alzheimer's Disease (disease that destroys memory and other important mental functions) and senile degeneration of brain (cognitive deficits that impair the memory and judgement). Record review of Resident #1's Significant Change MDS dated [DATE] revealed the following: *Section C- Cognitive Patterns…

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

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses or the facility's resident population in accordance with the facility assessment for 1 of 1 (the Dietary Supervisor) reviewed for dietary manager The facility failed to ensure the Dietary Supervisor completed an approved dietary manager training course. This failure could place the residents at risk for compromised nutritional status, weight loss, and compromised health conditions and not being accurately assessed for nutritional status, needs, and preferences. The findings include: Record review of the dietary employee safe food handling training certificates revealed the Dietary Supervisor had a food handler's certificate but did not have manager's safe food handling training. There was no documented evidence the Dietary Supervisor had a certificate for completing a certified…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The facility failed to store foods in the nonperishable food storage room that were sealed and labeled with an opened date. The facility failed to store foods in the refrigerator and freezer that were sealed and labeled with an identifier and/or opened date. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings included: In an observation on 4/28/24 at 8:42 AM, during the initial tour of the facility kitchen revealed the following: Refrigerator: *Sweet N Sour sauce-No open date *1-gallon jar-unknown substance, no open date *1 clear plastic zipper sealed bag with 1 sliced lemon-No label with an identifier to indicate the food item, or when it was placed in the bag. *1 bottle of ketchup-No open date *1 large clear plastic zipper sealed…

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 a resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #16) reviewed for urinary catheters in that: The facility failed to ensure that Resident #16's urinary catheter type and size was documented in the Physician order. The facility failed to ensure Resident #16's urinary catheter was irrigated as ordered. The facility failed to ensure Resident #16's urinary catheter care, every shift as ordered was completed. The facility failed to ensure Resident #16's urinary catheter output every shift as ordered was completed. This deficient practice could affect residents who had urinary catheters and could result in trauma or urinary tract infections. Findings included: Record review of Resident #16's electronic Face Sheet dated 05/01/2024 revealed he was a [AGE] year-old male that was re-admitted to the facility on [DATE] with a diagnosis that included neuromuscular…

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 ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 2 of 3 months (October, November) reviewed for nursing services. The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on 2 days in October 10/1/2023, 10/15/2023, and 1 day in November 11/19/2023. This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's nursing schedule for RN coverage for October, November, and December 2023 revealed, the Director of Nurses worked Monday through Friday upon her start date of November 8, 2023. Review of RN coverage for October and Novemberand November 2023 revealed onrevealed on there was no coverage on the following dates: Sunday 10/1/2023, Sunday 10/15/2023, and Sunday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable well-balanced diet that meets daily nutritional and special dietary needs for 1 of 36 (Resident #6) resident reviewed for needs and preferences. The facility failed to ensure Resident #6 received a Carbohydrate controlled diet with added protein powder to his food three times a day as ordered. This failure placed residents at risk of not having their needs met resulting in delayed healing of pressure ulcer. Findings included: A record review of Resident #6's face sheet dated 4/30/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (body doesn't produce enough insulin causing high blood sugar level negatively effecting the kidneys), pressure ulcer to right ankle unstageable (wound to right ankle), essential hypertension (high blood pressure), and muscle weakness. A record review of Resident #6'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 observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 2 residents (Resident #16) whose care was reviewed in that: Resident #16's indwelling urinary catheter bag was not covered. These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs. The findings were: Record review of Resident #16's electronic face dated 05/01/2024 sheet revealed he was a [AGE] year-old male that was re-admitted to the facility on [DATE] with a diagnosis that included neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage) and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream and inability to urinate). Record review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure personal privacy by securing signed consents for the use of security cameras for 1 of 2 (Resident #28) residents reviewed for privacy. The facility had operational security cameras in a resident's room without obtaining consents from the resident who occupied the room. This failure could place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians. Findings included: Record review of Resident #28''s face sheet dated 05/01/2024, revealed that she was [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included the following: bipolar with psychotic features (episodes of mood swings ranging from depressive lows to manic highs with disconnection from reality), Depressive episodes (periods of feeling low), and venous insufficiency (improper functioning of the vein valves 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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 2 residents (#5 and #30) reviewed for respiratory care. A. The facility failed to ensure oxygen tubing for Residents #5 were changed weekly. B. The facility failed to ensure Resident #5's nebulizer mask was dated or kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Resident #5 Record review of Resident #5's Face Sheet, dated 04/30/2024, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis was chronic combined systolic and diastolic heart failure (heart not pumping blood efficiently). Record review of Resident #5's MDS Annual Assessment, dated 09/21/2023 revealed a BIMS score of 09…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors in accordance to accepted professional standards and principles for 1 of 6 residents (Resident #14) reviewed for medication administration accuracy. The facility failed to administer Resident #14's insulin as ordered by their physician. This failure could place residents receiving insulin at risk for adverse consequences by not receiving therapeutic dosages of their medications as ordered by the physician. Findings included: Record review of Resident #14's face sheet dated 05/01/2024 revealed the resident was a 76 -year-old female readmitted to the facility on [DATE] with a diagnosis which included Type 2 Diabetes with Diabetic Chronic Kidney Disease (uncontrolled blood sugar caused kidney damage), Diabetes Mellitus with underlying condition with polyneuropathy (uncontrolled blood sugar that causes nerve damage throughout the body). Record review of Resident #14's Physician orders,…

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

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 2 (Medication Cart A) medication carts and 1 of 1 medication rooms reviewed for pharmacy services. The facility did not ensure medications carts and mediation storage room were secured and locked. This failure could place the residents at risk of a drug diversion. Findings included: During an observation and interview on 04/29/2024 at 3:24 PM, LVN A left the Medication Cart A she was assigned to unlocked inside the unlocked medication room with the door propped open. She revealed that she left the medication cart unlocked accidentally and that the medication room door was closed when she left her cart. She revealed that this failure could cause a resident to gain access to her meds in the unlocked cart or the unlocked opened medication room. During an observation and interview on 05/01/2024 11:15 AM, LVN A left the Medication Cart A she was assigned to unlocked inside the unlocked medication room with the door open. She revealed that she left the medication cart unlocked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 12 (Resident #16) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes related to catheter care for Resident #16. The facility did not maintain accurate and current medication records for Resident #16. This failure could place residents at risk for improper documentation. The findings were: Record review of Resident #16's electronic face sheet dated 05/01/2024 revealed he was a [AGE] year old male that was re-admitted to the facility on [DATE] with a diagnosis that included congestive heart failure (heart does not pump blood adequately), neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage), hypertension (high blood pressure) and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream 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 record reviews and interviews, the facility failed to maintain a general training program to ensure staff were trained for 4 of 10 (RN B, LVN C, CNA D, CNA E) reviewed for general training. The facility failed to ensure all staff were trained for communication. The facility failed to ensure all staff were trained for QAPI. The facility failed to ensure all staff were trained for Behavioral Health. The facility failed to ensure all staff were trained for HIV. The facility failed to ensure all staff were trained for Restraint Reduction. The facility failed to ensure all staff were trained for Falls. These failures could place residents at risk of at receiving care from incompetent/untrained staff. Findings included: Record Review of Personnel Files revealed the following staff did not receive the following training: *RN B hired 08/22/2022- Communication QAPI Behavioral Health HIV Restraint Reduction Falls *LVN C hired on 06/11/2022- HIV. *CNA D hired 03/15/2024 QAPI Behavioral Health Restraint Reduction *CNA E rehired on 12/15/2023 Communication Behavioral Health Restraint…

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 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, for 1 of 1 resident (Resident #1) was immediately reported to the State Survey Agency. 1. Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, on [DATE] at approximately 10:20 AM. 2. Resident #1 became unresponsive on [DATE] at 11:15 AM and was transported by ambulance to the local hospital emergency room. 3. The facility notified the resident's physician and responsible family member but did not report the incident to the State Survey Agency. This failure placed the resident at risk for potential future harm and decline in health…

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 care plans for necessary treatments and conditions for one of four residents (Resident #1) reviewed for Comprehensive Care Plans. The facility failed to address Resident #1's preference for privacy and to not have staff with him while he was using the bathroom. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings included: Record review of Resident #1's Face Sheet, dated 02/09/24, revealed a [AGE] year-old-male, admitted to the facility on [DATE], with admitting diagnoses of dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), spondylolysis lumbar region (a small crack between two vertebrae - the bones in your spine), fracture of first cervical vertebra (commonly called a broken neck, is a fracture of any 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 observations, interviews, and record reviews , the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Residents #1) whose records were reviewed for assessments. The facility failed to recognize and re-assess Resident #1 after a significant weight loss and a decline in ADL function. This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments. The findings included: Record review of Resident #1's Face Sheet, dated 09/06/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis (weakness or inability to move on one side of the body, making it hard to perform everyday activities), Cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), and vascular dementia (brain damage due to multiple…

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 accurately assess each resident's status for 1 of 3 (Resident #1) reviewed for assessment accuracy in that: Resident #1's MDS assessment records, after admission, was not coded yes for weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Finding included: Record review of Resident #1's Face Sheet, dated 09/06/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis (weakness or inability to move on one side of the body, making it hard to perform everyday activities), Cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), and vascular dementia (brain damage due to multiple strokes). Record review of a Quarterly 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 interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 9 (Resident #1, #2, #5, #6, #9, #11 , #18 #22, and #23) of 11 residents who were reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #5, #9, #18 and #23. 2. The interdisciplinary team failed to review and revise the plan of care for Residents #1 #2, #5, #6, #9, #11, #18, #22, and #23. These failures could affect residents by placing them at risk for not having their individual needs met. Findings include: Resident #1 Record review of Resident #1's Face Sheet, dated 03/14/2023, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis included hypertension…

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 a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (#1, #5 and #11) reviewed for respiratory care. A. The facility failed to ensure oxygen tubing for Residents #1, #5, and #11 were changed weekly. B. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 03/14/2023, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included hypertension (high blood pressure), hypoxemia low blood oxygen level, pneumonia unspecified organism moderate protein calorie malnutrition (a deficient nutritional state caused due 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.

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 one of one kitchen reviewed in that, raw hamburger was stored in the freezer above other foods. This failure by the facility could place residents in the facility at risk of acquiring food borne illnesses and a decline in health status. Findings include: On 03/12/2023 at 09:50 AM, during the Kitchen Initial Tour, an observation was made of raw hamburger and raw hamburger patties stored above bread dough and a box labeled Tony's Deep Dish Pizza, both hamburger products were in the left side of the freezer on the second-to-the bottom wire shelf. On 03/13/2023 at 04:10 PM, during the comprehensive kitchen inspection, the same boxes of raw hamburger and hamburger patties were observed in the same location within the freezer, above bread dough and frozen pizzas. On 03/13/2023 at 04:20 PM, in an interview with the Dietary Manager, the Dietary Manager said raw hamburger should not be stored above bread and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 1 resident (Resident #9) reviewed for pressure ulcers. The facility failed to provide wound care services for Resident #9 on the date of 03/13/2023 as ordered by the resident's physician. This failure could lead to an increased and unnecessary risk of complications including worsening of existing wounds, development of new wounds, and infection. Findings Included: Record review of Resident #9's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue injury, cerebral infarction (death of brain tissue due to disrupted blood flow), pressure ulcer (injury to skin and underlying tissue) and repeated falls. 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 residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Residents #6) reviewed for unnecessary medications. Resident #6 had an order and administered Seroquel (an antipsychotic medication) for a diagnosis of behaviors, which was not an appropriate indication for use. This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status. Findings include: Record review of Resident #6's Face Sheet, dated 03/14/2023, revealed an [AGE] year-old female last admitted to the facility on [DATE]. Diagnoses included: vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), unspecified psychosis (a collection of symptoms,…

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.