Hilltop Village Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report all allegations of 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 to the administrator of the facility and to other officials in accordance with State law through established procedures for 1 (Resident #7) of 7 residents reviewed for reporting requirements. The DON failed to report to the Administrator and the state survey agency when Resident #7's family reported rough care and treatment. This failure could put the residents at risk of abuse and harm. The findings included: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. 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 interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 9 residents (Resident #7) reviewed for abuse. The facility failed to ensure an allegation of rough care and treatment was investigated and the DON's notes/documentation were retained regarding Resident #7 family complaints of rough care and treatment. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. The findings included: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. Record review of Resident #7's modification of 5-day admission MDS assessment dated [DATE] revealed a BIMs score of 15 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 resident (Resident # 7) reviewed for activities of daily living. The facility failed to ensure CNA B utilized a gait belt to transfer Resident #7 while toileting. This failure could place residents at risk for falls, injury and a diminished quality of life. The findings include: Record review of Resident #7's face sheet dated 5/29/2025 revealed a [AGE] year-old female, admitted on [DATE] and readmitted [DATE] with diagnoses which included: noninfective gastroenteritis and colitis (inflammation of the stomach and colon), generalized muscle weakness and urge incontinence. Record review of Resident #7's modification of 5-day admission MDS assessment dated [DATE] revealed a BIMs score of 15 which indicated the resident was cognitively intact. The assessment indicated Resident #7 required maximum assistance with transfers. 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 observations, interviews, and record reviews, the facility failed to ensure residents' right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 4 of 4 residents (Residents #2-5) reviewed for medication self-administration. 1. The facility failed to assess Residents #2-5 for medication self-administration and ensure the medications were being administered per the physician's order. 2. The facility failed to implement care planning for Residents #2-5 for medication self-administration. These failures put residents at risk for incorrect medication administration, which could lead to unintended medication side effects, ineffective therapeutic effects of medications, or illness. In an interview with the DON on 4/17/2025 at 09:13 AM, the DON reported that 4 total residents at the facility have physician orders to self-administer medications. The DON provided the names of the four residents (Residents #2-5). 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 observations, interviews, and record reviews, the facility failed to store all drugs in locked compartments for 4 of 4 residents (Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for self-administration of medications. The facility failed to ensure that residents (Residents #2-5) with physician orders to self-administer medications had methods of securing medications that prevented other residents from having access. This failure could lead to unintended access and ingestion of medication causing illness. Findings included: In an interview with the DON on 4/17/2025 at 09:13 AM, the DON reported that 4 total residents at the facility have physician orders to self-administer medications. The DON provided the names of the four residents (Residents #2-5). Record review of the residents' electronic medical records revealed the following: Resident #2's face sheet dated 4/15/2025 reflected an [AGE] year-old male with an initial admission date of 7/3/2024. Relevant diagnoses included occipital…

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 from abuse for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from abuse of unwanted sexual exposure from Resident #6 when he masturbated in front of her. This failure puts residents at risk for abuse and diminished quality of life. Findings included: Record review of Resident #1's facesheet reflected an [AGE] year-old female with admission date of 8/21/2024. Relevant diagnoses included anxiety disorder, depression, and aftercare following joint replacement surgery. Review of Resident #1's quarterly MDS submitted on 4/3/2025 noted that BIMS score was not assessed. The prior quarterly MDS, submitted on 11/21/2024, reflected a BIMS score of 15, indicating intact cognition. Record review of Resident #1's progress notes revealed an entry authored by LVN G on 2/2/2025 at 10:59 PM that stated: Res. Told CNA on Saturday 2-1-25 and Sunday 2-2-25…

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 ensure that all alleged violations involving abuse are reported not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law established procedures for 1 (Resident #1) of 7 residents reviewed for abuse, neglect, and exploitation. The facility failed to report unwanted sexual exposure/sexual abuse to the Administrator and SSA from a resident to Resident #1. This failure puts residents at risk for abuse and diminished quality of life. Findings included: Record review of Resident #1's facesheet reflected an [AGE] year-old female with admission date of 8/21/2024. Relevant diagnoses included anxiety disorder, depression, and aftercare following joint replacement surgery. Review of Resident #1's quarterly MDS submitted on 4/3/2025 noted that BIMS score was not assessed. The prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility to provide supervision of Resident #2 while he was showering causing the resident to exit the bathroom independently. These failures could lead to injury or decreased quality of life. Findings included: 1. Record review of Resident #2's face sheet dated 4/15/2025 reflected an [AGE] year-old man with an initial admission date of 7/3/2024. Relevant diagnoses included other asthma (a respiratory disorder that can cause restriction of the lung tissue and difficulty breathing), chronic obstruction pulmonary disease (an ongoing respiratory disease that causes decreased oxygenation and difficulty breathing), other lack of coordination, muscle weakness (generalized), and unsteadiness on feet. Record review of Resident #2's quarterly MDS submitted on 4/1/2025 reflected a BIMS score of 13, indicating intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive care plan for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 had signed physician's orders and care planning for nightly use of continuous positive airway pressure (CPAP) therapy. This failure could place residents at risk for inadequate oxygenation and respiratory complications. Findings included: Record review of Resident #2's face sheet dated 4/15/2025 reflected an [AGE] year-old man with an initial admission date of 7/3/2024. Relevant diagnoses included other asthma (a respiratory disorder that can cause restriction of the lung tissue and difficulty breathing), chronic obstruction pulmonary disease (an ongoing respiratory disease that causes decreased oxygenation and difficulty breathing), and obstructive sleep apnea (a blockage of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 25 residents (Residents #94) reviewed for resident's rights, in that: On 07/09/24, Resident #94 was not served her lunch meal while other residents at her table had received their lunch meals and were eating. These deficient practices could affect residents' self-esteem and feelings of dignity. The findings were: Record review of Resident #94's admission Record, dated 07/12/24, reflected a female who was admitted to the facility on [DATE] with diagnoses to include cognitive communication deficit and need for assistance with personal care. Record review of Resident #94's quarterly MDS assessment, dated 04/27/24, reflected Resident #94 did not have a BIMS summary score coded [entries were - only]. It further reflected…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 5 of 32 residents (Residents #9, #36, #19, #13, and #44) whose records were reviewed for hygiene, in that. Nursing staff failed to ensure Residents #9, #36, #19, #13, and #44 received a shower on Monday 07/08/24. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for problems, and/or a diminished quality of life. The findings were: Record Review of Resident #9's admission record, dated 07/11/24, reflected an [AGE] year-old male with an admission date of 08/16/23 with diagnoses to include aphasia (comprehension and communication [reading, speaking, or writing] disorder), muscle weakness, retention of urine, and lack of coordination. Record Review of Resident #9's quarterly MDS assessment, dated 05/25/24, reflected Resident #9's BIMS score…

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 revealed the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 5 Residents (Resident #17) whose environment was observed for call light placement. Nursing staff failed to ensure Resident #17's call light was within reach for personal use during a lunch meal. This deficient practice could affect any resident and could result in residents' not getting their needs met. The findings were: Review of Resident #17's face sheet, dated 7/12/24, revealed she was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting right dominant side and Vascular Dementia. Review of Resident #17's annual MDS assessment, dated 4/5/24 revealed her BIMS was 12 of 15 reflecting moderate cognitive impairment and she required partial to moderate assistance with personal hygiene. Review of Resident #17's Care Plan, revised 3/19/24 revealed she had…

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 revealed the facility failed to provide a clean and homelike environment for 1 of 5 Residents (Resident #17) whose environment was observed for cleanliness. Staff failed to clean Resident #17's wall which was stained with food residue after eating her meals. 2. The facility failed to ensure a homelike environment on 1 hallway (D-wing Hallway) when a large industrial barrel was put into place, on an unknown date, to contain a ceiling water leak. This deficient practice could affect any resident and could result in residents' dissatisfaction. The findings were: Review of Resident #17's face sheet, dated 7/12/24, revealed she was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting right dominant side and Vascular Dementia. Review of Resident #17's annual MDS assessment, dated 4/5/24 revealed her BIMS was 12 of 15 reflecting moderate cognitive impairment and she required partial to moderate…

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 the assessment accurately reflected the resident's status for 2 of 21 residents (Residents #7 and #51) whose assessments were reviewed, in that: 1. Resident #7's quarterly MDS, dated [DATE], incorrectly documented the resident as receiving an anticoagulant medication. 2. Resident #51's quarterly MDS, dated [DATE],, reflected he did not have upper or lower range of motion limitations which was inaccurate related to the fact he had contractures on both upper and lower extremities. This failure could place residents at-risk for inadequate care and services due to an inaccurate assessments. The findings were: 1. Record review of Resident #7's face sheet, dated 07/10/2024, revealed an admission date of 04/01/2022 and, a readmission date of 07/13/2023 with diagnoses that included: Dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable 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 interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative and effort which includes referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status assessment for 2 of 5 residents (Resident #29 and #13) reviewed for PASRR. 1. The facility failed to ensure Resident #29 had an accurate PASRR Level 1 Screening which indicated a diagnosis of developmental disability related to Multiple sclerosis on 01/29/2022. 2. The facility failed to ensure Resident #13 had an accurate PASRR Level 1 Screening which indicated a diagnosis of developmental disability related to Multiple Sclerosis on 03/21/2024. This failure could place residents at risk of not receiving needed individualized care, and specialized services…

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 food prepared in a form designed to meet individual needs for 1 of 25 (#13) residents, in that: The facility failed to ensure Resident #13 was served a mechanical soft diet for 07/09/24 lunch, instead of a regular diet. The facility failed to ensure Resident #13 was not served gravy, as was voiced and preferred by resident. The date this was voiced was unknown. This could affect all residents with diet orders that were prescribed by a physician and could result in residents not served the correct diet texture, which could leave residents at risk for poor intake, weight loss and diminished quality of life. The Findings were: Record review of Resident #13's admission Record, dated 07/11/24, reflected Resident #13 was an [AGE] year-old female originally admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning that interferes with daily life and activities) and oropharyngeal phase dysphagia (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 observation, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 1 of 25 residents (Resident #13) reviewed for food and nutrition services, in that. The facility failed to ensure Resident #13 received her prescribed regular diet for 07/09/24 lunch. The resident was prescribed a regular diet and was provided a mechanical soft diet. This deficient practice could place residents who were provided a modified texture diet at risk for poor intake, weight loss, and diminished quality of life. The findings were: Record review of Resident #13's admission Record, dated 07/11/24, reflected Resident #13 was an [AGE] year-old female originally admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning that interferes with daily life and activities) and oropharyngeal phase dysphagia (swallowing difficulties that occur in the mouth and/or throat). Record review of MDS assessment, no type coded and dated 03/27/2024,…

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 revealed the facility did not provide special eating equipment and utensils for residents who need them for 2 of 7 Residents (Resident #21 and Resident #95) who were observed during meal service. Staff failed to ensure: 1. Resident #21 had a plate guard on her plate during a lunch meal to ensure she did not spill the food all over her clothes; 2. Resident #63 had a divided plate during a lunch meal so she could scoop up her food while eating the food on her plate. These deficient practices could affect residents who depended on assistive devices and infringe on the residents dignity and feeding independence. The findings were: 1. Review of Resident #21 face sheet, dated 7/12/24, revealed she was admitted to the facility on [DATE], with diagnoses to include Dysphagia (swallowing problem) and Other Abnormalities of Gait and Mobility. Review of Resident #21 annual MDS assessment, dated 4/26/24, revealed her BIMS was 0 out of 15 reflecting she was severely 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 observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 8 residents (Residents #18, #50 and, #80) reviewed for infection control, in that: 1. Medication Aide B did not sanitize the blood pressure cuff between Residents #50 and #80. 2. While providing incontinent care for Resident #18, CNA C did not change her gloves or wash her hands after touching the bed remote and between touching soiled and clean incontinent pads These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1. Record review of Resident #50's face sheet, dated 07/12/2024, revealed an admission date of 02/04/2019 and, a readmission date of 09/13/2021 with diagnoses which included: Parkinson's disease (progressive disorder that affects the nervous…

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 residents had the right to be free from verbal abuse for 3 of 7 residents (Residents #1, #2, and #3) reviewed for abuse. 1. The facility failed to prevent RN A from verbally abusing Resident #1 and Resident #2 when RN A yelled at both residents. 2. The facility failed to protect Resident #3 when OT called resident a liar and yelled at her. These failures could place residents at risk of verbal abuse from facility staff. Findings include: 1. Record review of the Facility Incident Report, dated 3/22/2024, reflected RN A was witnessed telling Resident #1, I want to spray you with Ativan spray because you are getting on my nerves. Furthermore, it was also witnessed that RN A told Resident #2 that you can't get your ass clean or your shit because the girls are busing feeding. During an interview on 6/28/2024 at 10:18 am with CNA B, she stated that Resident #1 was just asking questions when she witnessed RN A became upset and yelled at Resident #1. CNA B also witnessed RN A tell Resident #2 that you can't get your ass…

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 each resident was free of any significant medication errors for 1 of 7 residents (Resident #4) reviewed for medications. -The facility failed to provide Resident #4 with Doxycycline (an anti-infective). This deficient practice could result in a risk to the residents' health and complications which can lead to infection. The findings included: Record review of the Facility Incident Report, dated 4/22/2023, reflected LVN C transcribed Resident #4's medication orders. The order for Doxycycline was 100 mg BID X 21 days for epididymitis (inflammation on a coiled tube behind the testes). When LVN C transcribed the order, she entered the order to read every 21 days instead of for 21 days. This resulted in Resident #3 missing 25 doses from 4/4/2023 to 4/16/2023. Record review of Resident #4's MAR showed no Doxycycline medication administration from 4/2/2023 to 4/26/2023. Record review of Resident #4's doctors Notes, dated 4/15/2024 showed Trial of doxycycline for possible epididymitis. I discussed with the patient that this…

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 for 1 of 1 kitchen for review: 1. DA L had facial hair and was not wearing a facial hair restraint while engaged in food preparation. 2. There were frozen omelets, pizza crusts, pie crusts and garlic bread that were improperly stored in the reach-in freezers. 3. There was an opened carton of thickened orange juice and an opened carton of thickened sweet tea without labels indicating the dates they were opened. 4. There was a case of frozen fish fillets and a case of frozen carrots that were improperly stored in the walk-in freezer. 5. CNA S touched Resident #36's sandwiches with her bare hands while cutting them on his plate. These failures could place residents who received meals and/or snacks from the kitchen and who were assisted with their meals at risk for the spread of diseases and food borne illness. The findings included: 1. Observation on 05/23/2023 at 11:05 a.m. revealed DA L had hair along…

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 had the right to be free of discrimination from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights for 1 of 7 residents (Resident #69) reviewed for resident rights, in that: Facility staff did not ensure Resident #69 had equal rights to smoking privileges as other residents. This failure could place residents at risk of feelings of poor self-esteem and loss of dignity. The findings were: Record review of Resident #69's face sheet, dated 05/27/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses that included: chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe), epilepsy (a neurological condition that causes unprovoked, recurrent seizures) and essential hypertension (high blood pressure). Record review of Resident #69's Quarterly MDS, dated [DATE], 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.

Based on observation, interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 1 of 1 resident council group whose minutes were reviewed. The facility failed to address the groups grievances presented since February 2023. This deficient practice could affect residents in attendance and result in feelings of worthlessness. The findings were: Review of the Resident council minutes from February 2023 to May 2023 revealed the following concerns: February 2023 Dietary Concerns: Menus were not being presented to residents prior to the scheduled meal. Residents did not know their meal choices for the day and or the kitchen did not always serve food items according to the menu. Condiments were not provided for all meals and some food were served repetitively. Housekeeping Concerns: The floors on the E wing were not getting cleaned especially in the resident bathrooms. March 2023: Dietary Concerns: Daily menus were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the right to refuse and/or discontinue treatment and to formulate an advance directive for 4 of 24 Residents (Resident #28, #53, #69 and #324) whose records were reviewed for DNR status. 1. The facility failed to ensure Resident #28's DNR include his date of birth making it an invalid document. 2. The facility failed to ensure Resident #53's DNR contained two witness signatures twice on the document. 3. The facility failed to ensure Resident #69's OOH-DNR was valid. 4. The facility failed to ensure Resident #324's DNR had a licensed physician signature. The DNR was signed by a nurse practitioner. These failures could place residents at-risk for having their end of life wishes dishonored. The findings were: 1. Review of Resident #28's admission sheet, dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses to include unspecified Dementia mild, with anxiety, unspecified Atrial Fibriliation and Heart Failure. Further review…

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 complete an accurate assessment of each resident's functional capacity for 4 of 16 residents (Residents #1, #18 and #116) whose assessments were reviewed. 1. The facility failed to accurately assess Resident #1's diagnosis of UTI after returning from the hospital. 2. The facility failed to accurately assess Resident 18's fall history on her quarterly assessment. 3. The facility failed to accurately assess Resident #116's cognition status on his admission assessment. These failures could lead to the residents' not receiving the care and services they needed based on their assessment. The findings were: 1. Review of Resident #1's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Neuromuscular dysfunction of bladder (disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and unspecified Dementia (general name for a decline in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 1 facility and that each resident received adequate supervision to prevent accidents for 2 of 24 residents (Residents #41 and #103) reviewed for accidents/supervision, in that: 1. Resident #41 had a lighter and package of cigarettes on her bed. 2. Resident #103 was smoking unsupervised prior to assigned smoking times. 3. The metal receptacle in the smoking area for ashes, marked no trash, contained a can and cigarette package. These failures could place residents at risk for smoking-related injuries. The findings were: 1. Record review of Resident #41's face sheet, dated 05/27/2023, revealed the resident was admitted to the facility on [DATE], with diagnoses that included: dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), metabolic encephalopathy (a medical term…

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 who needed respiratory care were provided such care, consistent with professional standards of practice, for 4 of 16 residents (Residents #24, #37, #55 and #274) reviewed for respiratory care, in that: 1. Resident #24's nebulizer mask was unbagged and resting on top of the resident's bedside table. 2. The water reservoir attached to Resident #37's oxygen concentrator was empty and was not replaced in accordance with the facility's changing schedule. 3. Resident #55's nebulizer mask was unbagged and resting on top of the cabinet behind the resident's bed. 4. Resident #274's CPAP mask was unbagged and resting on top of the cabinet behind the resident's bed. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. The findings were: 1. Record review of Resident #24's face sheet, dated 05/23/2023, revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents. The facility failed to ensure its own its own laboratory services met the applicable requirements for laboratories in that: The facility did not have a current CLIA certificate of waiver. This deficient practice placed residents' laboratory tests at risk of not meeting certain quality standards due to lack of oversight from CMS. The finding was: Record review of the binder provided by the facility that contained its contracts revealed there was no CLIA certificate waiver present. Interview on [DATE] at 7:30 p.m. with the Administrator revealed that she had taken over the position of Administrator in [DATE] and discovered that the facility's CLIA waiver had expired [DATE] while reviewing documents left by the previous administrator. The administrator acknowledged that this waiver must be renewed and maintained in the facility to ensure the laboratory testing performed 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.

Based on record review and interview the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that: The facility, licensed for 150 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met. The findings were: Record review of Facility Summary Report, undated, revealed the facility had a total licensed capacity for 150 beds. Record review of the staff roster, provided by the facility, undated, revealed SW M's position was listed as Qualified Social Worker and SW N's position was listed as Social Services. In an interview with the Administrator on 05/26/2023 at 9:48 a.m., the Administrator revealed the facility does not have a full-time SW. The Administrator confirmed she was aware of the need for a full-time SW and stated she had been trying to hire one for several months, by placing ads and contacting universities to approach new graduates but still had no applications. The Administrator added that the VA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 5 staff (LVN O and CAN P) reviewed for infection control, in that: 1. LVN O did not sanitize her hands prior to setting up wound care supplies for Resident #43. LVN O did not sanitizer the scissors prior to cutting gauze while setting up wound care supplies for Resident #43. 2. CNA P did not sanitize her hands in between glove changes while providing catheter care for Resident #1. These deficient practices could place residents who receive wound care or catheter care at-risk for infections. The findings included: During an observation on 05/24/23 at 10:28 a.m. LVN O prepared wound care supplies for Resident #43's pressure ulcers. LVN O washed her hands in the resident's bathroom. LVN O touched the resident's door upon returning to her nurse cart 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 interview and record review the facility failed to provide notice to residents of the change as soon as was reasonably possible. where changes in coverage were made to items and services covered by Medicare for 2 of 3 Residents (Resident #87 and Resident #277) whose records were reviewed for Medicare eligibility. 1. The facility failed to provide Resident #87 with a beneficiary protection notification before skilled services were terminated. 2. The facility failed to provide Resident # 277 with a beneficiary protection notification before skilled services were terminated. These deficient practices could affect residents whose covered status changed and could result in residents not having sufficient time to consider their options. The findings were: 1. Review of Resident #87's admission record, dated 5/27/23, revealed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (causes the brain to shrink and brain cells to eventually die, CVA (ischemic stroke occurs when 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 have physician orders for the resident's immediate care at the time the resident was admitted for 1 of 8 (Resident #274) residents whose records was reviewed for physician orders in that; The facility failed to obtain a physician order for Resident #274's CPAP machine. This failure could place residents at-risk of inadequate monitoring of medical conditions and not receiving the correct amount of oxygen while sleeping. The findings were: Record review of Resident #274s face sheet, dated 05/27/2023, revealed an admission date of 05/12/2023 with diagnoses that included: rheumatoid arthritis (a chronic inflammatory disease that affects the joints), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. Record review of Resident #274's admission MDS, dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 8 residents (Resident #274) reviewed for baseline care plan, in that: The facility failed to ensure Resident #274's baseline care plan included information related to resident's use of a CPAP. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings were: Record review of Resident #274s face sheet, dated 05/27/2023, revealed an admission date of 05/12/2023 with diagnoses that included: rheumatoid arthritis (a chronic inflammatory disease that affects the joints), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and chronic…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 8 Residents (Resident #116) reviewed for care plans.: The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #116 to address the resident's communication problem. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings were: Review of Resident #116's face sheet dated 05/23/2023 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included emphysema (a lung condition that causes shortness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #1 & #24) for care plan revisions, in that: 1. The facility failed to ensure Resident #1's Care Plan was revised to include his most recent hospitalization, diagnoses while in the hospital and referral for skilled services. 2. The facility failed to ensure Resident #24's care plan was revised to include oxygen therapy and nebulizer treatments. These failures could place residents at risk for not receiving care according to their needs. The findings included: 1. Review of Resident #1's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Neuromuscular dysfunction of bladder (disease or injury of the central nervous system or peripheral nerves involved in the control of urination) and unspecified Dementia (general name for a 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 observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 1 of 6 Residents (Resident #77) whose records were reviewed for food preferences. Facility staff failed to ensure Resident #77 received substitutes for foods he did not like. This deficient practice could result in residents not being satisfied with meal service when served foods they disliked. The findings were: Review of Resident #77's admission record, dated 5/27/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Cerebral Palsy and Cognitive Communication Deficit. Review of Resident #77's quarterly MDS assessment, dated 4/19/23,, revealed his BIMS was 15 of 15 reflective he was cognitively intact, he required supervision by 2 staff for eating and he was on a therapeutic meal plan. Review of Resident #77's Care Plan, revised on 3/8/23 revealed he preferred to eat in his room and preferred staff set up his…

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.