Northeast Rehabilitation and Healthcare Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to date a bag of whipped cream in the fridge. 2. The facility failed to keep dry food delivery off the floor. 3. The facility failed to take and log temperatures for alternate items prior to meal service. 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 on 3/18/25 at 9:19 a.m. a bag of whipped nondairy cream was in the fridge. The bag had no date and was soft. The label read, best if used 1 year frozen (unopened) and 14 days refrigerated. During an interview on 3/18/25 at 9:19 a.m. the DS stated someone had just moved the whipped cream from the freezer box that day to use for meal service. The DS stated they should have dated it when they took it out of the box that had a date. 2. During an observation on 3/18/25 at 9:23 a.m. there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 of 3 residents (Residents #22, Resident #49, and Resident #147) reviewed for infection control. 1. The facility failed to ensure PTA O wore a gown while in providing care to resident #22 who was on EBP. 2. The facility failed to ensure CNA N performed hand hygiene and changed gloves during incontinent care on Resident #49. 3. The facility failed to ensure ADON B used appropriate infection control principles, including hand hygiene/glove changes during wound care. These failures could affect residents who required assistance with incontinent care and wound care treatments and could place residents at risk for cross contamination and infections. The finding included: 1. Record review of Resident #22's admission Record, dated 03/19/25, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 2 of 2 residents (Residents #46 and Resident #49) observed for physical restraints in that: 1. The facility failed to obtain a consent for Resident #46 to wear a wander guard. 2. The facility failed to obtain a consent for Resident #49 to wear a wander guard. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life. The findings included: 1. Record review of Resident #46's admission record, dated 3/20/25 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), 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, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 (Resident #22) of 8 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #22's OOH DNR was signed by 2 witnesses. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: Record review of Resident #22's admission Record, dated [DATE], revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of dementia without behavioral disturbance (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), dysphagia (difficulty swallowing), pneumonitis (when air sacs in the lungs become inflamed due to irritant substances and disturb the normal functioning of the lungs),…

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 assessment accurately reflected the resident's status for 1 of 19 residents (Resident #91) reviewed for assessments: Resident #91's admission assessment MDS dated [DATE] did not accurately reflect the resident could not be rated for incontinence since the resident required an indwelling urinary catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #91's face sheet dated 3/20/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included urinary tract infection, obstructive and reflux uropathy (condition in which the normal flow of urine is blocked leading to kidney damage; uropathy refers to kidney damage caused by backward flow of urine from the bladder into the ureters and kidney), and chronic kidney disease stage 3 (moderate decrease in kidney function). Record review of Resident #91'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 interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 2 of 2 residents (Resident #47 and Resident #90) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #47 and Resident #90 had the mental illness diagnosis of bipolar disorder which would qualify Resident #47 and Resident #90 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses. The findings included: 1. Record review of Resident #47's admission sheet, dated 8/25/23, noted the resident was admitted to the facility on [DATE] with a diagnosis of bipolar disorder on admission [DATE]). Record review of Resident #47's quarterly MDS assessment, dated 2/5/25, noted the resident's BIMS was 2, indicating severe cognitive impairment; mood indicators were…

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 was possible for 1 of 24 residents (Resident #89) reviewed for accidents and hazards: The facility failed to ensure Resident #89 did not have a pair of scissors, a large pair of nail clippers, and a disposable razor 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 #89's face sheet dated 3/19/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included gastro-esophageal reflux disease with esophagitis (a chronic condition where stomach acid frequently flows back into the esophagus causing inflammation and irritation), duodenitis without bleeding (inflammation of the first part of the small intestine without gastrointestinal bleeding), dysphagia, oropharyngeal phase (difficulty swallowing in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #49 and Resident #91) reviewed for incontinent care: 1. The facility failed to ensure CNA I and CNA N properly cleaned Resident #31's vaginal area, catheter tube, and buttock area during incontinent care. 2. The facility failed to ensure Resident #91's indwelling urinary catheter bag was not on the floor. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices. The findings included: 1. Record review of Resident #49's admission record, dated 3/20/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), hydronephrosis (when urine…

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, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #9) reviewed for oxygen therapy: Resident #9's oxygen concentrator filters were covered in a thick white/gray substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: Record review of Resident #9's face sheet dated 3/20/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure (a condition in which the respiratory system fails to provide adequate oxygen to the blood or remove carbon dioxide from the body), dementia (decline in cognitive function…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 3 residents (Resident #9) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #9. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #9's face sheet dated 3/20/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included end stage renal disease (condition in which the kidneys have lost nearly all their function and can no longer effectively filter waste, excess fluids, and toxins from the blood, resulting in dialysis or a kidney transplant), cognitive communication deficit (refers to difficulty with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 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 Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures for 1 of 6 residents (Resident#2) reviewed for abuse and neglect. 1. The facility failed to report to the state survey agency an allegation of abuse reported by a family member of Resident #2. 2. The facility failed to report to the state survey agency an allegation of abuse when Resident #3 allegedly hit Resident #2. This failure could place residents at risk 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 have evidence that all alleged violations were thoroughly investigated for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse involving Resident #2. This failure could place residents at risk of allegations of abuse causing mental, physical or emotional harm. The findings include: Record review of Resident #2's, undated, face sheet revealed Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Encephalopathy (a disease in which the function or structure of the brain is affected, typically caused by infection, tumor or stroke), Dementia (a general term for impaired ability to remember, think or make decisions), Legal Blindness and Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). Record review of Resident #2's MDS Assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 8 residents (Residents #1 and #2) reviewed for resident assessments, in that: 1. The facility failed to ensure Resident #1 was coded on his Quarterly MDS, dated [DATE], for a physical behavior that occurred on 06/12/2024. 2. Resident #2's Discharge MDS , dated 06/30/2024, was inaccurately coded as discharged to Home/Community instead of to Hospital. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #1's admission Record, dated 08/07/2024, reflected Resident #1 was initially admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old. Record review of Resident #1's Medical Diagnoses from the resident's electronic medical record, accessed 08/07/2024, reflected Resident #1 had diagnoses of chronic systolic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 4 of 24 residents (Residents #8, #32, and #33) reviewed for resident assessments, in that: 1. The facility failed to complete a BIMS for Resident #8 prior to the submission of the resident's quarterly MDS. 2. The facility failed to complete a BIMS for Resident #32 prior to the submission of the resident's quarterly MDS. 3. The facility failed to complete a BIMS for Resident #33 prior to the submission of the resident's quarterly MDS. These failures could result in inadequate care due to an incomplete assessment of the residents' mental status. The findings included: 1. Record review of Resident #8's face sheet dated 2/16/2024, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included: Dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), muscle wasting and atrophy (wasting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 3 of 3 residents (Resident #388, #9 and #65) reviewed for dialysis, in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Residents #388, #9 and #35. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: 1. Record review of Resident #388's face sheet, dated 2/14/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dependence on renal dialysis (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions naturally), type 2 diabetes (a chronic, long-lasting health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 60% based on 15 out of 25 opportunities, which involved 8 of 13 Residents (Residents #14, #24, #27, #36, #38, #56, #57, and #99) reviewed for medication administration, in that: 1. The facility failed to ensure LVN B administered 8 medications within acceptable parameters for safe medication administration for Residents #14, #24, #36 #38, #56 #99 and #57. 2. The facility failed to ensure LVN C administered Resident #27's medications via PEG tube according to physician orders. 3. The facilty failed to ensure LVN C administered the correct medication to Resident #27 when LVN C administered a capsule of amantadine with out physician orders. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was plastic storage container of food thickener in the dry storage room that was not properly sealed. 2. There was a clear plastic bag with pieces of raw bacon in the reach in cooler that was not sealed, labeled or dated. 3. There was a box containing individual portions of roll dough in the walk in freezer that was open and the bag inside the box was open. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 02/13/2024 at 10:14 AM in the dry storage room revealed a white 10-gallon food storage container on a rack. The lid on the storage container was labeled Thickener 1/19/24 and was not properly sealed onto the container, exposing the contents to the ambient air in the dry storage room and potential contamination by pathogens, bacteria and pests. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 5 staff (LVN B, LVN C, and CNA G) reviewed for infection control, in that: 1. The facility failed to ensure CNA G sanitized the blood pressure cuff between Resident #81, #83, #100, and #101. 2. The facility failed to ensure LVN B did not enter Resident #9's room without the proper PPE for droplet precautions. 3. The facility failed to ensure LVN C did not touch Resident #27's medication with his bare hands during administation. These deficient practices could place residents at-risk for infections. The findings included: 1. During an observation on 02/13/23 at 3:21 p.m. CNA G checked blood pressures using one wrist blood pressure cuff for residents on the C hallway. CNA G checked Residents #81, #83, #100, and #101 blood pressure and did not sanitize…

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 respect the residents' right to confidentiality in his or her personal and medical records for 1 of 1 residents (Resident #80) reviewed for residents' rights, in that: The facility failed to ensure LVN C locked Medication Cart Hall D/E Computer and left Resident #80's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons. Findings included: Record review of Resident #80's face sheet, dated 02/16/2024, revealed the resident was admitted to the facilty on 01/16/2024 with diagnoses that included: Spina Bifida Unspecified, Paraplegia Unspecified, Sepsis Unspecified Organism, Tinea Pedis, and Anemia Unspecified. Observation on 02/15/2024 at 3:15 p.m. revealed a computer on LVN C's medication cart (Medication Cart Hall D/E Computer) in front the medication storage room and nurses' station was left unlocked and unattended with Resident #80's health information exposed for approximately one minute while LVN C went to open his office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #1) reviewed for indwelling urinary catheter care, in that: Resident #1's indwelling urinary catheter drainage bag was on the floor. This failure could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: Record review of Resident #1's face sheet, dated 2/14/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (damage to the brain due to lack of oxygen supply), dementia (a group of symptoms affecting memory, thinking and social abilities) with behavioral disturbance and agitation, and need for assistance with personal care. Record review of Resident #1's most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional standard for 2 of 13 residents (Resident #24 and Resident #81) reviewed for storage of drugs. 1. The facility failed to prevent an unlabeled IV bag of normal saline hanging on an IV pole in Resident #81's room. 2. The facility failed to ensure LVN B administered an insulin that had been open 41 days prior, 13 days past the expiration date, to Resident #24. 3. The facility failed to ensure LVN C did not leave a medicine cup containing 2 tablets of acetaminophen unsecured and unattended on top of the nurse medication cart. These deficient practices could place residents at risk of medication not meeting therapeutic levels, misuse and diversion. The findings were: 1. Record review of Resident #81's face sheet, dated 02/16/24, revealed Resident #81 was admitted to the facility on [DATE] with diagnoses of nondisplaced fracture of greater trochanter…

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 establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 1 non-designated smoking areas, in that: The facility failed to ensure there was a self-closing ash tray, fire blanket, or sign designating an area a smoking area. This deficient practice could result in harm to residents and staff due to improperly discarded and used cigarette butts if policies were not followed. The findings were: Observation on 02/14/2024 at 2:20 PM revealed Dietary Aide D sitting on top of a red metal trash can adjacent to the left wall of the facility. Further observation revealed there was no self-closing ash tray, fire blanket, or sign designating the area a smoking area. During an interview with Dietary Aide D on 02/14/2023 at 2:21 PM, Dietary Aide D revealed he was told by the Maintenance Supervisor that was the staff designated smoking area. Dietary Aide D acknowledged there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for one resident (Resident #1) of three residents reviewed for discharge. The facility failed to assure all the resident's medications were reviewed and provided when Resident #1 discharged home. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for anxiety or depression. Findings included: Review of Resident #1's Face Sheet, dated 01/24/2024, revealed a [AGE] year-old female originally admitted on [DATE], re-admitted on [DATE], and discharged on 01/10/2024 with diagnosis that included: cerebral palsy (a disorder that affects a person's ability to move and maintain balance and posture), diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), and atherosclerotic heart disease (a buildup of fats in the arterial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to ensure that residents had the right to be free from abuse for 1 of 5 (Resident #6) residents reviewed for abuse, in that: Resident #6 was involved in an altercation on 02/20/2023 in which CNA F verbally abused, shouted in a threatening manner, and spoke offensive language to Resident #6. The non-compliance was identified as past non-compliance. The non-compliance began on 02/20/2023 and ended on 02/22/2023. The facility had corrected the non-compliance before the investigation began. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm. The findings included: Record review of Resident #6's face sheet dated 12/05/2023 revealed an admission date of 12/17/2021 and a discharge date of 03/07/2023 and diagnoses which included: acute chronic systolic (congestive) heart failure, other recurrent depressive disorders, and cognitive communication deficit. Record review of Resident #6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 of 1 resident (Resident #7) reviewed for PASRR services, in that: The facility failed to submit a NFSS authorization request for PASRR specialized services (therapies and assessments OT and PT) through the TMHP Long Term Care (LTC) Portal for Resident #7 in the required timeframe. This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, and psychosocial well-being. The findings included: Record review of Resident #7's face sheet dated 12/06/2023 indicated Resident #7 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease with dyskinesia (a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems with involuntary, erratic,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 5 licensed staff (LVN A) reviewed for nursing competencies. The facility failed to ensure LVN A followed the physician's orders to test (Resident # 3) for COVID-19[Corona Virus Disease] not (resident # 2 ). This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide care that was safe and capable of minimizing accidents from procedural errors and errors in medication administration. Findings included: 1. Record Review of Resident's # 2 face sheet dated 12/06/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: [ Cerebral palsy]: is a group of disorders that affect a person's ability to move and maintain balance and posture. [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.

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 residents of 5 residents (Residents #2 and #3) observed for infection control, in that: LVN A failed to identify resident # 2 prior to conducting COVID-19 test [Corona Virus Disease] , leading to incorrect results reported and delay in treatment for Resident # 3 . This deficient practice could potentially affect Residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to pathogens that could lead to the spread of communicable diseases. The findings included: 1 Record Review of Resident's # 2 face sheet dated 12/06/23 revealed a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: [ Cerebral palsy]: a group of disorders that affect a person's ability…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (R#1), reviewed for care plan development. R#1 had a seizure on 07/12/23 requiring a hospitalization for three days and the care plan was not revised to reflect a goal and interventions for seizures. This deficient practice could place residents at risk for lack of coordination of services and continuity of care. The findings were: Record review of R#1's face sheet, dated 11/08/23 and EMR reflected, the resident was admitted on [DATE] and discharged to hospital on [DATE]; and re-admitted [DATE] and discharged [DATE] with diagnoses which included: seizures, [NAME] disease (overproduction of hormones) and lupus (inflammatory disease) . Resident was a female; age [AGE]. RP was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 24 residents (Resident #137) reviewed for advance directives, in that: Resident #137's OOH-DNR form was incorrectly executed and was therefore invalid. This deficient practice could place residents at risk of having their wishes regarding advance directives unknown or not honored. The findings were: Record review of Resident #137's face sheet, dated 12/09/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Vascular Dementia, Cerebrovascular Disease, and Aphasia Following Unspecified Cerebrovascular Disease. Further review of Resident #137's facesheet revealed the names and contact information for two of the resident's family members. Record review of Resident #137's facility clinical record revealed an MDS assessment had not yet been completed for the resident due to his recent admission. Record review of Resident #137's BIMS assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #23) reviewed for incontinent care, in that: While providing incontinent care for Resident #23, CNA B used a back to front motion to clean Resident #23's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #23's face sheet, dated 12/08/2022, revealed an admission date of 03/03/2022 and, a readmission date of 09/28/2022, with diagnoses which included: Urinary tract infection (09/28/2022), Diabetes mellitus (persistently high levels of sugar (glucose) in the blood), Hydronephrosis (urine collects in the kidneys because it is unable to flow to the bladder), Hypertension (High blood pressure), Irritable bowel syndrome…

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 ensure a medication error rate below 5% for 1 of 5 residents (Resident #8) and 1 of 1 staff LVN C reviewed for medication administration errors, in that LVN C administered late medications to Resident #8 resulting in an 8% medication administration error rate. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #8's face sheet, dated 12/08/2022, revealed an admission date of 07/02/2022, with diagnoses which included: Dysphagia (difficulty in swallowing), Hypothyroidism (Decrease production of thyroid hormone), Hyperlipidemia (Elevated level of lipids (fat)), Depression (Mental state of low mood or aversion to activity), Hypertension(High blood pressure), chronic kidney disease(Gradual loss of kidney function) A record review of Resident #8's Medication administration schedule/MAR, for December 2022, revealed, Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain medical records that were medical records for each resident that were complete and accurately documented for 1 of 24 residents (Resident #75) reviewed for medical records, in that: Resident #75's face sheet indicated DNR or do not resuscitate, and the resident's care plan indicated full code or do resuscitate. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #75's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease, Type 2 Diabetes Mellitus with Unspecified Complications, and Anemia in Chronic Kidney Disease. Further review of Resident #75's face sheet revealed Advance Directive: Status: DNR - Do Not Resuscitate. Record review of Resident #75's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #23) reviewed for infection control, in that: While providing incontinent care for Resident #8 CNA B did not wash or sanitize her hands between change of gloves, before touching the resident's briefs and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #23's face sheet, dated 12/08/2022, revealed an admission date of 03/03/2022 and, a readmission date of 09/28/2022, with diagnoses which included: Urinary tract infection (09/28/2022), Diabetes mellitus (persistently high levels of sugar (glucose) in the blood), Hydronephrosis (urine collects in the kidneys…

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.