Focused Care at Hogan Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, 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 7 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for residents rights The facility failed to ensure that staff were answering call lights in a prompt manner. This failure could place residents at risk of decreased feelings of self-worth. Findings include: Record review of Resident #1's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include iron deficiency anemia (is a common type of anemia. Anemia is a condition in which blood doesn't have enough healthy red blood cells to carry oxygen throughout the body), bipolar disorder (is a mental illness that causes unusual shifts in a person'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 manage the personal funds of the residents deposited with the facility for 6 of 6 confidential residents reviewed for personal funds. The facility failed to ensure Residents from a confidential group interview had ready access to their personal funds on the weekends. This failure could place residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. The findings included: During a confidential group interview on 12/07/2023 at 09:28 a.m., 6 confidential residents complained of only able to access funds on weekdays and not having access to funds on the weekends. During an interview on 12/07/2023 at 10:00 a.m., [NAME] stated residents asked for funds needed on the weekends on the Friday prior to her leaving for the day. [NAME] stated there was no way for residents to have access to funds on weekends. During an interview on 12/08/2023 at 11:32 a.m., ADMN stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #45, #263 and #24) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Residents #45, #263 and #24 were given a completed SNF ABN (a notice given to Medicare beneficiaries to transfer financial liability to the beneficiary before the SNF provides an item or service that would usually be paid for by Medicare, but Medicare was not likely to provide coverage because care was not medically reasonable and necessary, or was custodial in nature) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk for not being aware of changes 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 develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 3 of 5 (Resident # 2, Resident #21 and Resident #25) residents reviewed for care plan completion. The facility failed to ensure Resident #2, Resident #21, and Resident #25, comprehensive care plans had measurable objectives and time frames identified to meet residents needs. This failure could place residents at risk for not receiving appropriate supervision. Findings included: Resident #2 Record review of Resident #2's electronic face sheet dated 12/08/2023 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Paranoid Schizophrenia, Stroke , history of falls, anxiety, muscle weakness, psychotic disorder with delusions, hallucinations, and cognitive communication deficit. Review of Resident #2's Quarterly MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 5 of 7 (Residents #2, #20, #25, #45 and #262) residents reviewed for smoking safety. The facility failed to ensure Residents #21 assessed as supervised smokers were supervised when smoked. The facility failed to ensure Residents #2, #21, #25, #45, and #262 lighters and cigarettes were not stored on their person. These failures could affect residents who smoke at risk of serious bodily harm, physical impairment, or death. The findings included: Resident #1 Record review of Resident #2's electronic face sheet dated 12/08/2023 revealed resident was a [AGE] year-old male who was admitted on [DATE] with diagnoses that included: Paranoid Schizophrenia, Stroke, history of falls, anxiety, muscle weakness, psychotic disorder with delusions, hallucinations, and cognitive communication deficit. Review of Resident #2's Quarterly MDS dated [DATE] revealed: Section C- 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.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 4 and in 2 of 2 medication rooms , and 2 biohazard rooms reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended on 12/5/2023. The facility failed to ensure discontinued medication was locked in medication rooms. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 12/05/2023 at 1:30PM the medication cart was left unattended and unlocked by LVN E. The LVN E was observed looking at her phone sitting at the nurses station while the surveyors were at the unlocked medication cart opening the drawers. The LVN E stated it was her cart and she had left it unlocked. The LVN E proceeded to leave the nurses station and walked to…

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

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and placed them at risk for food born illnesses. Findings included: Record Review of the DM's employee file on 12/06/2023 revealed a hire date of 10/127/2023 as the DM. There was no documented evidence of a Dietary Manager Certificate found in the file. During an interview on 12/07/2023 at 2:00 PM the DM stated she had not started on her dietary manager certification. The DM stated she had been the DM over a month and had not been given a time frame to complete her DM certification. During an interview on 12/08/23 at 9:24 AM the ADMN stated her expectation would have been completed within 90 days, she stated she was not aware of what regulation or policy…

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 properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure storage of ice scoop with handle was outside of ice cooler. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: Observation on 12/05/2023 between 8:50 AM and 9:30 AM revealed: Refrigerator #1 1. An open container of Sour Cream with a use by date of 10/11/2023 2. Two bags of shredded carrots with a use by date of 11/19/2023 3. A plastic bag with a zipper that was not sealed with no description or an open date. Freezer #1 1. 14 packages of hot dog buns with use by date of 9/07/2023 2. 1 package of hamburger buns with a preparation date of 10/13/2023 3. 1 package of hamburger buns with a preparation date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #21, Resident #25 and Resident #262) of 5 residents reviewed for resident records. The facility failed to ensure smoking assessments were completed for Resident #262. The facility failed to ensure smoking assessments were accurate for Resident #21 and Resident #25. This failure could place residents at risk of having errors in care and treatment. Findings included: Resident #21 Record review of Resident #21's electronic face sheet dated 12/06/2023 revealed resident was a [AGE] year-old male who was admitted on [DATE] and an original admission date of 09/27/2018 with diagnoses that included: Nicotine Dependence, muscle weakness, Quadriplegia, lack of coordination and cognitive communication deficit. Review of Resident #21's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (CNA B and CNA C) of 4 staff reviewed for infection control practices. The facility failed to ensure CNA B and CNA C performed hand hygiene when changing gloves at the appropriate times while providing incontinence care for Resident #9. The facility failed to ensure CNA C performed hand hygiene in between filling ice into resident's pitchers on A hall for multiple residents. These failures could affect the residents by placing them at risk for the spread of infection. Finding included: 1.Review of Resident #9's electronic face sheet dated 12/07/2023 revealed he was a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that include: hemiplegia and hemiparesis following cerebral…

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.

During an interview on 12/08/2023 at 10:46 AM, the RCN stated the facility staff had done trainings at townhall meetings. That at this time would be when they would catch up on all of the annual trainings for staff. The RCN stated the ADON told the DON she could not find the binder and had no documentation of trainings. She stated the upper management have trained the staff, and also had a clinical educator with corporate that sent all of the trainings to the ADON then follow up with staff. She stated the ADON resigned the previous day or 12/07/2023 thus unable to find the paperwork needed. The RCN stated with staff not having trainings could lead to residents getting sick from illnesses as well as Abuse and/or treating residents with good care. She stated the ADON and IP monitor the trainings for staff. She stated the failure occurred in not being able to obtain and monitor since the prior survey, as well as not verifying the ADON had the trainings completed. The RCN stated her expectations were for new hires have a checkoff lists and have orientation. During an interview on…

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

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 7 of 18 employees (SW, DM, MS, LVN-H, CNA-J, CNA-K, and HS) reviewed for training. The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to SW, DM, MS, LVN-H, CNA-J, CNA-K, and HS. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings included: Record review of the personnel file for SW revealed a hire date of 04/14/2014 and no evidence of new hire training on resident rights and facility responsibilities. Record review of the personnel file for DM revealed a hire date of 07/15/2019 and no evidence of new hire training on resident rights and facility responsibilities. Record review of the personnel file for MS revealed a hire date of 09/12/2019 and no evidence of new hire training on resident rights and facility…

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

Based on interviews and record reviews, the facility failed to implement and maintain an effective Infection Control training program for all new and existing staff for 11 of 18 (DON, SW, DM, MS, RN-F, RN-G, LVN-H, CNA-I, CNA-J, CNA-K, HS) personnel files reviewed for training. The facility failed to train for Infection Control for DON, SW, DM, MS, RN-F, RN-G, LVN-H, CNA-I, CNA-J, CNA-K, and HS. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: DON-Hire date of 02/24/2015 - Had no Infection Control training. SW-Hire date of 04/14/2014 - Had no Infection Control training. DM- Hire date of 07/15/2019- Had no Infection Control training. MS- Hire date of 09/12/2019 - Had no Infection Control training. RN-F - Hire date of 9/23/2015 - Had no Infection Control training. RN-G - Hire date of 04/25/2023 - Had no Infection Control training. LVN-H - Hire date of 09/28/2018 Had no Infection Control training. CNA-I-Hire date of 01/25/2013- Had no Infection Control training. CNA-J-Hire date of 11/06/2018- -…

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

Based on interviews and record reviews, the facility failed to implement and maintain an effective Compliance and Ethics training program for all new and existing staff for 16 of 18 (ADMN, DON, SW, DM, MS, RN-F, RN-G, LVN-D, LVN-H, CNA-I, CNA-J, CNA-K, HS, CNA-L, CNA-M, and CNA-N) personnel files reviewed for training. The facility failed to train for Compliance and Ethics for ADMN, DON, SW, DM, MS, RN-F, RN-G, LVN-D, LVN-H, CNA-I, CNA-J, CNA-K, HS, CNA-L, CNA-M, and CNA-N These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: ADMN-Hire date of 11/29/2022- had no Compliance & Ethics training. DON-Hire date of 02/24/2015 - had no Compliance & Ethics training. SW-Hire date of 04/14/2014 - had no Compliance & Ethics training. DM- Hire date of 07/15/2019- had no Compliance & Ethics training. RN-F - Hire date of 9/23/2015 - had no Compliance & Ethics training. RN-G - Hire date of 04/25/2023 - had no Compliance & Ethics training. LVN-H - Hire date of 09/28/2018 had no Compliance & Ethics training.…

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 7 of 18 (CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and CNA-N) employees whose in-service records were reviewed had received the required minimum 12 hours annual in-service, and received training that addressed the care of the cognitively impaired for nurse aides providing services to individuals with cognitive impairment. The facility failed to provide the required annual performance care training to CNA-I, CNA-J, CNA-K, CNA-L, CNA-M, and CNA-N. These failures placed residents at risk for unmet needs due to untrained staff. Findings included: Record review of Personnel Files revealed: CNA-I-Hire date of 01/25/2013- did not receive cognitive impairment training. CNA-J-Hire date of 11/06/2018- did not receive cognitive impairment training. CNA-K-Hire date of 10/11/2022- did not receive cognitive impairment training. CNA-L-Hire date of 06/19/2018 - did not receive cognitive impairment training. CNA-M-Hire date of 05/31/2021- did not receive cognitive impairment training. CNA-N-Hire date of 11/15/2022- did not receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 1 (Resident #10) reviewed for respiratory care. The facility failed to ensure that Resident #10's oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen at risk of respiratory complications and/or possible respiratory infections. Findings included: Record review of Resident #10's Facesheet dated 12/06/2023 revealed: A [AGE] year-old female, last admitted to the facility on [DATE] and an original admit date of 4/17/2017. A DX list included: Shortness of breath, Dependence on Supplemental Oxygen, weakness, generalized weakness and COPD. Record review of Resident #10's annual MDS dated [DATE] revealed: Section C; BIMS of 09 meaning moderate cognitive impairment. Section…

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 that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, on 3/9/22. The facility failed to ensure the recipe was followed when prepared pureed Oven Fried Chicken. This deficient practice could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings included: During an observation and interview on 12/05/2023 at 12:40 PM the DM took the temperature of the food on the test tray. The temperature of the chicken was 112.4 degrees Fahrenheit. The DM stated the chicken should have been warmer. The DM tasted the chicken, broccoli and stated that the chicken was not flavorful. Observation on 12/05/23 at 11:35 AM [NAME] A added cold milk to fried chicken and steamed broccoli while he prepared the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #1) of four residents reviewed, in that: 1. Resident #1's bedroom vertical venetian blinds were missing several slats, and had several slats cut unevenly allowing exposure into resident's bedroom. 2. Resident #1's bedroom inner sliding closet door was off the track. 3. Resident #1's bedroom wall adjacent to the restroom entrance had a 3 ½ by 2-inch hole approximately 12 inches from the floor. These failures could place residents at risk of injury due to closet door potentially falling on resident, risk for pests entering the room through exposed holes in the walls, and lack of dignity of residents' privacy. Findings included: Review of Resident #1's face sheet dated 09/27/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident 1's diagnosis included anxiety disorder (mental disorder characterized by feelings of worry, anxiety,…

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 allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 (Resident #15, #16, and #17) out of 8 resident rooms reviewed for environment. -The facility failed to have a working call light that would light up when the residents pushed the call bell for residents' room [ROOM NUMBER] and #44. This failure could place residents at risk of not being able to notify staff when care is needed. The findings included: Resident #15 Review of Resident #15's face sheet, dated 09/28/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included traumatic brain injury (brain dysfunction caused by an outside force, gastrostomy status (an opening into the stomach from the abdominal wall made surgically for introduction of food), and tracheostomy status (a procedure to help air and oxygen reach the lungs by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for three (halls A, B, and D) of four halls reviewed for environment, in that: -Three of four hallways show signs of needing repairs or maintenance with holes in the walls and missing covers. -Several resident bedrooms with holes in the ceiling, walls, and missing covers. These failures could place residents and staff at risk of living in an unsafe, unsanitary, and uncomfortable environment Findings included: Observation on 9/26/2023 at 10:53 a.m., the D-hall thermostat had no cover on the housing to the thermostat. The baseboard near room [ROOM NUMBER] was pulling inwards from the corner and the wall cracked just above the baseboard. room [ROOM NUMBER] had an unused electric outlet without a cover, a 2-inch hole in ceiling tile, and 4 inches by 2 inches hole in another ceiling tile. Observation on 9/26/2023 at 10:55 a.m., the A-hall room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an effective ongoing pest control program for 1 of 1 facility reviewed for pests. The facility failed to have pest control treat the building for rodents and insects. The noncompliance began on 03/03/2023 and ended on 09/19/2023. The facility had corrected the noncompliance before the survey began. These deficient practices could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: Review of Resident #1's face sheet dated 09/27/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident 1's diagnosis included anxiety disorder (mental disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking resulting from…

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 when transferring or discharging a resident, documentation was present in the resident's medical record by the resident's physician for 1 (Resident #11) of 3 residents reviewed for discharge requirement. There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility. This deficient practice could place residents at risk of discharged from the facility without reason. Findings Include: Review of Resident #11's face sheet dated 09/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11's diagnosis included systemic lupus erythematosus (an inflammatory diseases caused when the immune system attacks its own tissues), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking resulting from organic disease of the brain), anxiety disorder (mental…

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 before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 (Resident #11) of 3 residents reviewed for discharge requirement. There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility. This deficient practice could place residents at risk of discharged from the facility without reason. Findings Included: Review of Resident #11's face sheet dated 09/26/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #11's diagnosis included systemic lupus erythematosus (an inflammatory diseases caused when the immune system attacks its own tissues), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking resulting from organic…

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

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation, in that: 1 Food was moldy. 2. The dishwasher did not get up to a sanitizing temperature 3. The facility was not clean, there were rodent droppings along the walls and under the storage shelves. 4. [NAME] C did not take food temperatures before meal service. 4. Leftovers were not labeled and stored in a manner that prevented contamination. 5. The milk refrigerator was not defrosted and had a build-up of ice on it. This deficient practice could place residents who receive meals prepared from the kitchen and served by facility staff at risk for food borne illness and cross contamination. The findings included: Observation and interviews on 10/18/22 between 8:27 a.m. and 9:20 a.m. revealed: Water was pooled in front of the three-compartment sink. The drain did not have a cover;, the cover was pushed through into the drainpipe. The sanitizer…

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 provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 3 meals (lunch meal observed) for resident rights. Residents sitting at the same table were not served at the same time. This failure could place residents at risk of not being treated in a dignified, respectable manner. CNA B Failed to acknowledge Resident #33 when he asked for his food tray. Findings include: Observation on 10/18/22 between 11:45 AM and 12:45 p.m. revealed: 11:45 am There were 7 residents in the Dining Room. 11:45am Drink carts were rolled out. 11:58 am The first cart of trays were rolled out of the kitchen, only 4 residents were served their trays, and the remaining trays were rolled out to the halls. Resident #50 asked for his tray by waving his arms, but CNA B told him that his tray was not on the cart. 12:06 pm The second cart of trays were rolled 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to respect the resident's right to personal privacy during care, for 2 of 3 residents (Residents #26) reviewed for privacy, in that: CNA's A and B failed to provide privacy when providing incontinent care to Resident #26 due to no privacy curtain available. During the care Resident #6 was able to observe Resident #26 being changed due to no privacy provided. This failure could place incontinent residents at risk for embarrassment, poor self-esteem, and unmet needs. The findings were: Record review of Resident #6's admission record dated 10/19/22 indicated she was admitted to the facility on [DATE] with diagnoses which included lack of coordination and muscle weakness. She was [AGE] years of age. Record review of Resident #6's MDS dated [DATE] indicated in part: Brief Interview for Mental Status = 15 indicating the resident was cognitively intact. Record review of Resident #26's admission record dated 10/18/22 indicated she was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 1 lunch meals reviewed for menus and nutritional adequacy on 10/20/2022 in that: The facility failed to follow the menu and/or recipe for the noon meal on 10/20/22. The facility failed to follow the recommended serving sizes for the noon meal on 10/20/22. These failures could place residents who eat regular foods and residents who eat pureed foods at risk of not having their nutritional needs met. Findings included: Interview on 10/19/22 at 1:33 p.m., 5 alert lucid residents with the Resident Council meeting stated sometimes the food tasted horrible and the kitchen did not respect resident's dietary needs. The Resident Council said if one thing could be fixed, they unanimously stated the food. Observation and interview on 10/20/22 at 11:28 a.m. the DM was making the desert of pudding. She stated she was using a ¼ cup for the desert. Observation on 10/20/22 at 11:50 a.m. [NAME] C got a new thermometer…

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 menus were followed, and the meals served met the nutritional needs of residents, as evidenced by: Cook C failed to follow the recipe for the noon meal for all residents receiving oral food by not serving pinto beans and ham. Cook C used milk to thin the puree ham. Cook C failed to make puree cornbread for residents. These failures placed residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake. Findings include: Observation of a meal ticket dated 10/20/22 at 10:32 AM showed the lunch was supposed to be pinto beans and ham, fried okra, corn bread, and a sugar cookie. Observation and interview on 10/20/22 at 11:32 a.m. revealed [NAME] C making the puree ham. She used milk to thin down the ham. She showed surveyor the texture which looked like mechanical soft ham with milk poured on top. Surveyor noted the meat had not incorporated well. [NAME] C stated, it never does and began to run…

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 that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 5 of 5 resident in the Resident Council Meeting for 1 of 1 Lunch meals tested for nutritive value, flavor, and appearance: The lunch test tray received on 10/20/22 was lukewarm. The puree protein (ham) was made with milk and was unattractive. This deficient practice could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served. The findings were: Interview on 10/18/22 at 9:17 a.m. the DM stated she had worked at the facility for approximately 3 weeks During the confidential Resident Council Meeting on 10/19/22 at 1:33 p.m., 5 of 5 residents said the food was horrible and cold. The residents shared the meat was too hard to chew, and the toast was frequently burnt. The residents stated the toaster had broken . One resident said he was excited because he got pepper on his tray the other day, and he did 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.

Based on observation, interview, and record review, the facility failed to ensure residents received food that accommodate the preferences for five of five confidential resident group members for accommodation of residents' preferences. - Five confidential group members were not offered a meal substitution of equal nutritional value when they did not like what was being served. -The facility failed to have a meal substitution of equal nutritional value available or listed on the menu for residents. These failures place all residents who consumed food from the facility's kitchen at risk for dissatisfaction, poor intake, weight loss, and declined in health. Findings included: During the confidential Resident Council Meeting on 10/19/22 beginning at 1:33 PM, 5 alert residents said meal substitutes were not offered. Interview on 10/20/22 at 10:00 AM the DM stated the facility did not offer substitutes. She added we've barely started following the calendar (menu). Interview on 10/20/22 at 10:32 AM, [NAME] C said she kept asking the facility for more food, but they kept saying budget and…

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

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of kitchen reviewed for essential equipment. The facility did not maintain the dishwasher at a working temperature. The facility did not ensure the gas oven was in working order. The knob's paint had worn off so staff could not ensure proper temperature was set. The facility did not have a working toaster. This failure could place residents at risk of being exposed to equipment that does not function properly. Findings Include: Observations and interview of the facility's only kitchen on 10/18/22 between 8:27 a.m. and 9:20 a.m. revealed: There was water pooled in front of the facility's three-compartment sink. The dairy refrigerator had a large buildup of ice on the top of it . The dishwasher reached 100 degrees F. The DM was present and said that the previous facility she worked at the dish machine had to be at 120 F. She did not know why this facility would be different. She stated it meant the dishes 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 observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment in resident rooms and hallways throughout the facility. Resident rooms and other areas accessible to the residents had drywall damage, missing floor tile, missing receptacle covers, missing window blind slats and broken mini blinds. The drain in front of the three-compartment sink did not have a cover on it leaving it completely open. These failures affected the residents and placed them at risk of living in an unsafe and uncomfortable environment. Findings included: During an operation on 10/18/22 at 8:27 a.m. of the facility's only kitchen showed the drain in front of the three compartment sink open to the piping underneath. During an interview on 10/20/22 at 10:25 a.m. [NAME] C stated she had tripped in the open drain while doing food preparation. During an observation on 10/20/22 at 02:12 p.m. of resident room [ROOM NUMBER], there were broken ceiling tiles. During an…

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

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 adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accident hazards/supervision (Resident #42). The facility failed to ensure CNA D demonstrated appropriate transfer techniques for Resident #5. These failures could place residents at risk for injuries from inappropriate transfers. Findings included: Review of Resident #47's admission Record dated 10/18/22 revealed she was a ninety-seven-year-old female admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet, abnormalities of gait and mobility, age related debility, lack of coordination, muscle weakness, and difficulty walking. Review of Resident #47's Quarterly MDS Assessment revealed: she needed extensive assistance of two staff for transfers and she generally used a wheelchair. Review of Resident #47's Care Plan, revised on 3/17/21 revealed: Focus: Resident #47 had an ADL self-care…

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 communicable diseases and infections for 1 (Resident #26) of 2 residents reviewed for infection control incontinent care. The facility failed to ensure CNA A changed her gloves after they became contaminated during incontinent care while assisting Resident #26. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #26's admission record dated 10/18/22 indicated she was admitted to the facility on [DATE] with diagnoses which included age related cognitive decline and muscle weakness. She was [AGE] years of age. Record review of Resident #26's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =. 3. Always incontinent (no episodes of continent voiding). Bowel…

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.