Briarcliff Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for Advance Directives. The facility failed to ensure Resident #1's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #1's electronic face sheet dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia (a general, non-normal aging term for the progressive decline of cognitive functions - memory, language, problem-solving, and thinking - severe enough to disrupt daily life), Type 2 Diabetes Mellitus (a chronic condition where the body becomes resistant to insulin and/or fails to produce enough of it, causing sugar 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 ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 2 (Resident #2 and Resident #3) of 6 residents reviewed for unnecessary medications. 1.The facility failed to have an adequate indication for the use of the medication Lurasidone (an antipsychotic) for Resident #2 before administering the medication with a black box warning. 2.The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) and Seroquel (an antipsychotic) for Resident #3 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: Record review of Resident #2's admission record dated 03/03/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for five residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 10 residents reviewed for abuse. Resident #2 sustained facial injuries from an altercation with resident #4 on 05/27/25 7:59 PM as they passed each other in the 600 hall. Resident #3 sustained facial injuries from being hit in the face by Resident #2 on 05/19/25 @1:30 PM in Resident #3's room. \Resident #5 was slapped in the face by Resident #6 as she was trying to get by Resident #6. Resident #6 was scratched by resident #5 in retaliation for being slapped in the face by Resident #5 on 06/19/25 @4:39 PM. These failures have the potential to result in serious injury. Findings include: Resident#2 Record Review of Resident#2's face sheet dated 10/21/25 revealed a [AGE] year-old male initially admitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive disease that destroys memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 2 out of 10 residents (Resident #1 and Resident #2) reviewed for reporting of abuse/neglect. 1. The facility failed to report to the local law enforcement agency a resident-to-resident physical altercation involving Resident #2 and Resident #4 resulting in minor injuries that occurred on 05/27/25. 2. The facility failed to report an allegation of abuse of Resident #1 within 2 hours that occurred on 04/12/25 at around 1:00 PM. These failures could place residents at risk for potential abuse. The findings included:1. Record Review of Resident#2'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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan to include Resident #1's behaviors and interventions. This failure could place residents at risk of not receiving safe and appropriate care. The findings include: Record review of Resident #1's face sheet, dated 11/20/25, revealed an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce or block blood flow to the brain), moderate with mood disturbance, obstructive (blockage that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 6 (Resident #119, Resident #124, and Resident #205) and 1 shower bed (hall 300) out of 4 that were reviewed for safe environment. 1. The facility failed to ensure bathroom sinks' hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #119, Resident #124, and Resident #205. 2. The facility failed to ensure the shower bed in Hall 300 shower room was in good condition. These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. Findings Included: During an observation on 03/24/2025 at 04:14 p.m. with the Maintenance Director and using the maintenance director's digital thermometer, the bathroom sink hot water…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. 1.The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding. 2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings include: 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 the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #13) reviewed for accidents and hazards: The facility failed to ensure Resident #13 did not have disposable razors in his room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Record review of Resident #13's admission record, dated 03/24/25, reflected a [AGE] year-old male admitted to facility on 11/14/24. His relevant diagnoses included the need for assistance with personal care, epilepsy (disorder in which nerve cells activity in the brain is disturbed causing seizures), and intellectual disabilities (below average intelligence and set of life skills). Record review of Resident #13's quarterly MDS dated [DATE] reflected he had a BIMS score of 08, which indicated his cognition was moderately impaired. 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, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 18 (Resident #39) residents reviewed for respiratory care. The facility failed to ensure Resident #39 had an oxygen sign posted on their door to alert everyone that he was on oxygen. This deficient practice could place residents who receive respiratory care at risk for developing respiratory complications, make others unaware oxygen was in use, and of receiving inappropriate and inadequate care. The findings included: Record Review of Resident #39's face sheet, dated 03/24/2025, revealed an [AGE] year-old male admitted to the facility on [DATE] with pertinent diagnoses of Acute and Chronic Respiratory Failure with Hypoxia (low levels of oxygen in the body), Acute combined Systolic and Diastolic Congestive [NAME] Failure (occurs when the heart can't pump…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #66 and Resident #145) of 8 residents observed for infection control. 1. LVN F failed to sanitize hands before administering G-tube medications to Resident #66. 2. CNA O did not remove their contaminated gloves after catheter care prior to cleansing Resident #145 of bowel movement. CNA O proceeded to clean without performing hand hygiene and maintained usage of dirty gloves while cleaning posterior area and used the same gloves to apply a clean brief. These deficient practices could place residents at-risk for healthcare associated cross contamination and the spread of infection due to improper care practices. Findings included: 1. Record review of Resident #66's face sheet dated 03/26/2025 revealed the resident was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to prevent CNA A, from verbally abusing Resident #1 on 04/29/24 when she referred to her as ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you). This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Record review of Resident #1's admission record dated 01/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her relevant diagnoses included vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain), Parkinson's disease (A brain disorder that causes movement problems, including shaking, difficulty walking, and rigidity in muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a disorder that affects…

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 assessment accurately reflected the resident's status for 2 (Resident #4 and Resident #6) of 11 residents reviewed for accuracy of assessments. 1.The facility failed to ensure Resident #4 was coded in the MDS for a fall on 2/28/24. 2.The facility failed to accurately identify Resident #6's unstageable pressure ulcer on her Discharge Return Anticipated MDS Assessment on 01/30/24. This failure could place residents at risk of receiving inadequate care and services based on inaccurate assessments. The findings included: 1. Record review of Resident #4's admission record dated 1/29/2025 reflected Resident #4 was an [AGE] year-old male originally admitted on [DATE] with diagnoses of Intervertebral Disc Disorders (the breakdown and degeneration of the cushions between the vertebrae in the spine), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks),…

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 needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care. The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: Record review of Resident #2's face sheet dated 1/29/25 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). 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 review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 4 Residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure LVN A accurately documented that Resident #1 was currently on an anti-coagulant. 2. The facility failed to ensure LVN A accurately documented neurological check findings for Resident #1 post fall. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. Findings included: Record review of Resident #1's admission Record, dated 02/14/24, revealed an [AGE] year-old female with diagnoses of vascular dementia (a type of dementia that occurs when blood vessels in the brain are damaged, reducing blood flow and oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 10 residents (Resident #2, Resident #3, Resident #10) reviewed for care plans. The facility failed to ensure Resident #2, Resident #3, and Resident #10's care plans reflected the risk of elopement/wandering and their placement in the secure unit. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans. The findings included: 1. Record review of Resident #2's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 06/04/24. Her diagnosis included: unspecified dementia, type 2 diabetes, hypertension, mood disorder, delusional disorders, depression, insomnia, need for assistance with personal care, abnormalities of gait and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for pest control. The facility failed to ensure the current pest control program was effective to eradicate and contain common household pests including roaches in multiple areas including resident rooms, hallways, and dining room. This failure could place all residents at risk of insect borne illnesses, to live in an uncomfortable/non-homelike environment free of pests, and a decreased quality of life. The findings included: Interview with Resident #1 on 10/09/24 at 12:45 PM revealed Resident #1 said she had seen roaches. Resident #1 said the last time she saw a roach was about a month ago, in her room, on the wall, and it was alive. Resident #1 said she told the staff but did not know if the roach was found or killed. Resident #1 said she did not have any injuries related to roaches, bugs, or other pests. Interview 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 observations, interviews, and record review, the facility failed to provide foot care and treatmenet to maintain mobility and good foot health for 1 (Resident #2) of 1 residents reviewed for foot care services. The facility failed to ensure Resident #2 received podiatry services as Resident #2's toenails were long (about an inch overgrown), not trimmed, and Resident #2 was not treated by the in-house podiatrist during their last visits. This failure could place residents at risk of potential negative outcomes related to foot health including pain, discomfort, poor foot hygiene, or a decline in residents' physical condition. The findings included: Record review of Resident #2's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 06/04/24. Her diagnoses included: unspecified dementia, type 2 diabetes, hypertension, mood disorder, delusional disorders, depression, insomnia, need for assistance with personal care, abnormalities of gait and mobility, cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 1 of 4 residents (expired Resident #1) reviewed for oxygen in that: LVN A failed to document baseline pulse, respiratory rate, O2 saturation, and lung sounds before and after a nebulizer treatment for Resident #1. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. The findings included: Record review of Resident #1's face sheet dated [DATE] reflected he was initially admitted on [DATE]. Resident #1's relevant diagnoses were chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia (the absence of enough oxygen in the tissues to sustain bodily function), hypertension, and vascular dementia (brain damage caused by multiple strokes). Record review of Resident #1's MDS quarterly assessment dated [DATE] reflected he had a BIMS…

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

Based on observations, interviews, and record reviews, the facility failed to keep information that is resident-identifiable from the public for all of the residents of the facility, in accordance with professional standards and practices, in that: The facility failed to prevent having identifiable resident information on top of a counter in the dining room, unattended. These deficient practices could affect all residents whose records are maintained by the facility and could place them at risk for violation of privacy. The findings included: During an observation and interview on 12/17/23 at 10:25 AM, there was a binder laying out on the countertop inside of the dining room. This binder was accessible to anyone who would want to open the binder. The binder labeled Diet Listing, on the front, included 11 pages of the Order Listing Report printed 12/15/2023 for all of the residents at the facility. The DM revealed that LVN N updated the binder daily so that the nursing staff is aware of what diets that the residents had. During an observation and interview on 12/17/23 at 12:51 PM,…

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' right to formulate an advance directive for 4 of 32 residents (Residents #5, #15, #67, and #144) reviewed for advanced directives, in that: 1. Resident #5's OOH-DNR was missing the physician's license number. 2. Resident #15's OOH-DNR was missing the witness signatures. 3. Resident #67's OOH-DNR was missing the executor's signature. 4. Resident #144's OOH-DNR was witnessed two department heads, one of whom provided direct care. These failures could place residents at-risk for residents' rights not being honored and having CPR performed against the residents' will. The findings included: 1. Record review of Resident #5's face sheet, dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), Alzheimer's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences, for 1 of 2 residents (Resident #20) reviewed for respiratory care in that: The facility failed to monitor Resident #20's oxygen therapy by failing to monitor oxygen saturation levels to monitor the resident's respiratory condition and response to therapy provided. This failure could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition. The findings included: Record review of Resident #20's face sheet, dated 12/17/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure Residents are free of any significant medication errors, for 1 of 8 residents (Residents #87) reviewed for significant medication errors, in that: 1.Resident #87 was administered clonazepam 1mg without a physician's order by LVN G 77 times from 07/25/2023 to 12/19/2023. These failures placed residents at risk for receiving medications not prescribed by a physician. The findings included: Record review of Resident #87's face sheet, dated 12/18/23 revealed a male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), hemiplegia and hemiparesis (weakness or loss of strength on one side…

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

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. In the reach-in refrigerator, there was/were: a. A head of lettuce in a plastic bag, undated. b. A container wrapped in foil with P labeled on top instead of fortified pudding with no use-by date. c. Overcrowding of boxes on the top rack. These boxes were less than 6 inches away from the ceiling. d. Sandwiches wrapped in plastic that did not have a use-by date. e. A container of pickles with circles of black substances on top of the container f. A container that was labeled FP and not fortified pudding with no use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. During an observation and interview on 12/17/23 starting at 10:14 AM, a. In the walk-in refrigerator, there was a head of lettuce in a plastic bag, undated. The DM took the head of lettuce out 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 observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Bistro refrigerators reviewed for food safety, in that: The facility failed to ensure that the Bistro refrigerator had a temperature log attached to the refrigerator and the contents of refrigerator were labeled with date and name of the food product. This failure could place residents at risk for food borne illnesses and at risk for choking. Findings included: During an observation on 12/17/23 at 11:20 AM, the Bistro room, there was where families brought outside foods and ate with residents, a refrigerator that contained food in several Styrofoam to-go containers. There were no names and no dates written on these containers to identify the food products. There was not a temperature log for this refrigerator. This refrigerator had no locks on the refrigerator doors making it easily accessible to anyone in the facility. During an observation and interview on 12/17/23 at 11:25 AM, RN X confirmed that there was food in the Bistro…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #35, #42, #97 and #82) observed for infection control in that: 1. During the medication pass, LVN K did not sanitize the wrist blood pressure cuff used between Resident #35 and Resident #42. 2. During the medication pass, CMA L did not sanitize the wrist blood pressure cuff used between Resident #97 and Resident #82. These deficient practices could place residents at risk of infection. The findings included: 1. a. Record review of Resident #35's face sheet, dated 12/18/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (high…

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 a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 4 shower rooms (Shower room [ROOM NUMBER]), in that: Observation on 12/17/2023 at 10:42 a.m. in Shower room [ROOM NUMBER], next to resident room [ROOM NUMBER], revealed approximately six razors were found on top of a storage bin and within reach of residents. Additionally, the toilet located inside the shower room was loosely affixed to the wall and the toilet room had a foul odor resembling sewer gas. During an interview with Social Worker AA on 12/17/2023 at 10:45 a.m., Social Worker AA confirmed approximately six razors were found on top of a storage bin and within reach of residents, the toilet located inside the shower room was loosely affixed to the wall, and the toilet room had a foul odor resembling sewer gas. Social Worker AA stated she would inform the Maintenance Director of the needed repair [electronic notification…

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

Based on observations, interviews, and record reviews the facility failed to support resident rights to voice grievances to the facility or other agency or entity that hears grievances for 1 of 29 residents (Resident #80) and the months reviewed (October, November, and December 2023) reviewed for grievances, in that; LVN P did not initiate a grievance report on behalf of Resident #80 when Resident #80 reported mistreatment by CNA D. This failure placed residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and unresolved issues. The findings included: A record review of Resident #80's admission record dated 12/21/2023 revealed an admission date of 03/24/2023 with diagnoses which included congested heart failure [AKA Heart Failure - a long-term condition in which your heart can't pump blood well enough to meet your body's needs.] and acute pain due to trauma. A record review of Resident #80's quarterly MDS assessment, dated 12/13/2023, revealed Resident #80 was assessed with a BIMS score of 9 out of a possible 15,…

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 develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 32 residents (Resident #87) reviewed for care plans in that: The facility failed to implement Resident #87's comprehensive person-centered care plan to address dehydration and ADL self-care performance deficit related to eating. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: 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 licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 1 of 7 residents (Resident #35) reviewed for nursing competencies, in that: LVN K failed to administer Resident #35's blood pressure medication within the acceptable parameters for safe medication administration and did not obtain/document Resident #20's oxygen saturation readings prior to administering oxygen per the physician's orders. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: Record review of Resident #35's face sheet, dated 12/18/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities),…

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 all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 7 Medication Carts (600 Hall Medication Cart) reviewed for storage of drugs, in that: The 600 Hall Medication Cart was left unlocked and unattended with the cart keys attached to the lock. This failure could place residents at risk of medication misuse and diversion. The findings included: Observation on 12/18/23 at 4:08 p.m., revealed LVN M opened the 600 Hall Medication Cart to obtain the glucometer with glucometer strip and a lancet, entered a resident's room, closed the door behind her and left the keys on the lock of the 600 Hall Medication Cart with the drawer pulled slightly open. The 600 Hall Medication Cart was facing into the hallway next to a resident's room in the memory unit. During an interview on 12/18/23 at 4:14 p.m., LVN M revealed she became distracted when asked by a resident where 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 develop a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 of 8 residents reviewed for care plans. (Resident #1) The facility did not develop and implement a comprehensive care plan when Resident #1 was discovered with a fracture to the base of the left 5th proximal phalanx. July 26,2023 and was not addressed until September 19,2023. This deficient practice could affect residents with a status change at risk for not receiving the necessary care in a timely manner. The findings were: Record review of Resident #1's electronic face sheet dated 12/01/23 reflected he was admitted to the facility on [DATE]. His diagnoses included Myopathy(disease that affects the muscles that control voluntary movement in the body), Type 2 Diabetes without complications, Chronic Kidney Disease, Stage 3, Hypertension (high blood pressure), Atherosclerotic Heart Disease (thickening or hardening of the arteries), Vascular…

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 is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure staff verified equipment was secure before initiating a transfer. CNA E and G did not verify Resident #1 bed wheels were locked before initiating a transfer leading to Resident #1 losing balance and falling back into bed. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's face sheet, dated 11/10/23, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: unspecified disorder of synovium (connective tissue that lines joints) and tendon (fibers that connect muscle to bone) multiple sites, type 2…

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.