Southeast Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 02/09/2025 at 10:50 AM, the DM stated he was not a certified dietary manager or certified food service manager, he did not have an associate's or higher degree in food service management or in hospitality, and he had not been a dietary manager in a long-term care facility for over two years. This was his first…

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. 1. The facility failed to store plastic bowls to allow for air-drying in the dish room. 2. The facility failed to use the correct log to record the dish machine wash cycle temperatures and chlorine sanitizer concentrations, resulting in no record of chlorine sanitizer concentrations recorded. 3. The facility failed to properly store an opened package of cream cheese and pre-packaged hard-boiled eggs in the reach-in cooler. 4. The facility failed to discard hard-boiled eggs past their use-by date. 5. The facility failed to ensure the tabletop can opener blade and base were free of grime and debris. 6. The facility failed to ensure an opened bag of powdered sugar was properly sealed in the dry storage room. 7. The facility failed to remove a dented #10 can of beans from the rack of canned goods in the dry storage room. These failures could place residents at risk for food borne illness. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents had a right to a safe, clean, comfortable, and homelike environment for 2 of 24 residents (Residents #10 and #14 ) reviewed for a safe, clean, comfortable, and homelike environment, in that: 1. The bed-side dresser of Resident #10 was broken with drawers that would not stay closed. 2. Resident #14's bathroom did not have any toilet paper, and her waste basket was filled with used paper towels that she stated she had been using because she had no toilet paper. This failure could result in psychosocial harm due to diminished quality of life. The findings included: 1. Record review of Resident #10's face sheet, dated 2/12/25, revealed the [AGE] year female resident was originally admitted to the facility on [DATE] with diagnoses including: Parkinson's disease ( a disorder of the central nervous system that affects movements), type 2 diabetes mellitus ( a condition in which the body has trouble controlling blood sugar),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 6 resident hallways (Hallway A and Hallway F) reviewed for environmental concerns. 1. The facility failed to ensure resident rooms #104 and #107, located on hallway A, had back lids covers for the toilet bowl and room [ROOM NUMBER], also located on hallway A, did not have a 2 foot strip of floor baseboard molding attached to the wall. 2. The facility failed to ensure the bottom half of the bathroom door in room [ROOM NUMBER], on hallway F, was repaired and did not have numerous horizontal linear scrapes and a jagged opening near the door hinge where the outer cover of the door was partially missing, and failed to ensure the wall opposite the toilet inside the bathroom did not have numerous scrapes and small holes in the wall. These failures could place residents at risk of a diminished quality of life due to exposure to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 22 residents (Resident #175) reviewed for advanced directives, in that: The facility failed to ensure Resident #175's signature on his Out-of-Hospital Do Not Resuscitate (OOH DNR) was properly witnessed as Resident #175's signature was dated [DATE], and the two witness's signatures were dated [DATE]. This failure could place residents at risk of having their end of life wishes dishonored, and of having Cardiopulmonary resuscitation (CPR) performed against their wishes. The findings included: Record review of Resident #175's admission record, dated [DATE] revealed he was a [AGE] year-old man who had an initial admission dated of [DATE] with re-admission on [DATE], with diagnoses which included: Chronic Kidney Disease, Stage 5 (the most advanced stage of chronic kidney disease and indicates the kidneys are no longer able to perform their essential function), Hemiplegia and Hemiparesis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #42) of 8 residents reviewed for care plans. The facility failed to include oxygen treatment in Resident #42's comprehensive care plan initiated 02/10/2022. This deficient practice could affect residents who received oxygen and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. Findings Included: Record review of Resident #42's admission record dated 02/09/2025 revealed he was a [AGE] year-old man initially admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #42) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #42's oxygen tubing and nasal cannula were stored properly and that the humidifier bottle or tubing were dated on 02/09/2025 and 02/11/2025 This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and infection. Findings included: Record review of Resident #42's admission record dated 02/09/2025 revealed he was a [AGE] year-old man initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses which included: malignant neoplasm of colon (colon cancer); and dementia (a general term to describe loss of memory, thinking, language and ability to perform daily activities). Record review of Resident #42's Quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide pharmaceutical eservices (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication rooms reviewed for pharmacy services. Inspection on 02/11/2025 of the facility medication storage room revealed two expired vials Lorazepam 2mg/ml for Resident #50. This failure could place resident at risk of residents not receiving appropriate therapeutic effects from their medications. The findings include: Record review of Resident #50's admission record dated 01/12/2025 revealed he was a [AGE] year-old man initially admitted on [DATE] with re-admit on 09/12/2024 and with diagnoses which included: Dementia (a condition that causes memory loss and other cognitive decline); Epilepsy (seizure disorder); and Anxiety Disorder (mental health disorder characterized by feelings of worry anxiety, or fear strong enough to…

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

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with correctly accepted professional principles reviewed for 1 of 4 medication carts (E-Hall Nurse's medication cart) reviewed for secure storage. The facility failed on 02/11/2025 to ensure LVN G secured Resident #'13's Fiasp Insulin (a synthetic form of rapid-acting insulin used to treat diabetes mellitus), when it was left unattended on top of the Nurse's medication cart when LVN G entered Resident #13's room and the medication cart remained outside the room out of line of sight from LVN G. This failure could place residents at risk for drug diversion or misuse of medications. Findings include: Observation on 02/11/2025 at 11:44 a.m. revealed LVN G removed from the medication cart all the supplies she would need to do an accu-check on Resident #13, and also removed Resident 13's Flex Touch pen of FIASP insulin, placing it on top of the medication cart. LVN G then gathered up the accu-check supplies, entered 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.

Based on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly. The facility failed to ensure the sliding doors on both sides of the dumpster were completely closed. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings were: Observation on 02/11/2025 at 12:13 PM revealed the sliding doors on both sides of the facility's dumpster were completely open, exposing bags of refuse reaching approximately halfway up the inside of the dumpster. During an interview on 02/11/2025 at 12:14 PM, the Regional DM stated the doors on the sides of Dumpster #1 were both open and should not have been. It was important for the doors to be completely shut to prevent pests from entering the dumpsters and potentially spreading foodborne illness. During an interview on 02/12/2025 at 9:30 AM, the Administrator and DON stated the facility had a resident with a behavior of frequently opening the dumpster doors when they were shut, as he believed this made the staff's job easier.…

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 prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #43) reviewed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN B provided Enteral feeding via a G-tube (a gastrostomy tube - a flexible tube inserted through abdominal wall and into stomach to provide a direct route for delivering food and medications) to Resident #43. This deficient practice could place residents at-risk for spread of infection. Findings include: Record review of Resident #43's admission record dated 02/10/2025 revealed a [AGE] year old man, with an initial admission date of 12/30/2022 and re-admit on 12/17/2024. Resdient #42 had diagnoses which included: Cerebral Palsy (a congenital disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for one (Resident #14) of 8 residents reviewed for resident call system. The facility failed to ensure Resident #14's call light system was working properly. This failure could place resident at risk for delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #14's face sheet dated 02/09/2025 revealed she was a [AGE] year old woman originally admitted to the facility on [DATE] with re-admit on 08/24/2020 and with diagnoses which included: Conversion Disorder with Seizures (a psychiatric condition where psychological stressors manifest as physical symptoms that can't be explained medically); Dementia (general term for impairment of brain function such as memory,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for 1 of 89 residents (Resident #38) reviewed for safe, clean, comfortable, and homelike environment, in that: In Resident #38's room, the cord for the window blinds was broken and cold air was entering the room via the window. This deficient practice could result in a loss of quality of life due to living in an uncomfortable home environment. The findings were: Record review of Resident #38's face sheet, dated 01/12/2024, revealed the resident was admitted on [DATE] with diagnoses which included: Major Depressive Disorder, Need for Assistance with Personal Care, and Unspecified Dementia. Record review of Resident #38's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated moderate cognitive impairment. Record review of Resident #38's care plan, revised 09/10/2020, revealed, Visual Function (Impaired): [Resident #38] has impaired vision…

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 the resident environment remains as free of accident hazards as was possible for 1 of 6 resident halls (F Hall) reviewed for accidents and hazards, in that: 1. The shower room on the F Hall was unlocked and accessible to residents and had insulation in the floor from a hole in the ceiling. 2. A pipe emanating from the wall to the right of the kitchen's back door was leaking and resulted in standing water outside the back door of the kitchen. These deficient practices could lead to accidents and/or injury. The findings were: 1. Observation on 01/09/2024 at 2:10 p.m. revealed the shower room on F Hall was unlocked and accessible to residents. Further observation revealed there was a hole in the ceiling and insulation in the floor. During an interview with CNA V on 01/09/2024 at 2:20 p.m., CNA V stated the shower room was not currently in use due to repair work in progress. CNA V confirmed the presence of insulation on the floor and confirmed the door was unlocked, leaving the material accessible to…

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

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen reviewed, in that: 1. The ice machine cover was loose and was soiled on the outside. 2. The air fryer was soiled with crumbs inside the machine and contained oil which was dark in color and soiled with crumbs. 3. A staff member's personal jacket was hanging on the corner of a food storage rack in the pantry. 4. The freezer to the right of the door inside the pantry held two cases of frozen hamburger patties which were open, leaving the patties exposed to contaminants and frost. 5. The freezer to the left of the door inside the pantry help a case of frozen cookies and a case of missed vegetables which were open, leaving the patties exposed to contaminants and frost. 6. The drink machine had a sticky residue on the outside. The front sections and handles of each door of both freezers inside the pantry and the large refrigerator inside the kitchen were soiled with sticky residue. 7.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control in that: Staff of multiple disciplines were not utilizing appropriate PPE over multiple days and various shifts while the facility was experiencing a COVID outbreak. These failures placed all residents at risk for the spread of infection through cross-contamination of pathogens and illness which could result in a decline in health and well-being or even death. Findings included: Record review of COVID Positive Residents, dated 1/09/2024 provided by the DON, revealed 17 residents and 8 staff as COVID positive. In an observation on 1/09/2024 between 12:12 PM and 12:23 PM, CNA VV exited COVID positive room [ROOM NUMBER]. CNA VV did not change PPE gown, gloves or N95 mask and CNA VV…

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 reasonable accommodation of resident needs for 2 of 15 residents reviewed for call light (Residents #13 and #19) reviewed for reasonable accommodations, in that: 1. Resident #13's call light was on the floor of the resident's room and not within the resident's reach on 01/10/2024. 2. Resident #19's call light was on the floor on the resident's room and not within the resident's reach on 01/10/2024. This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: 1. Record review of Resident #13's face sheet, dated 01/10/2023, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: [Peripheral Vascular Disease] a disorder of narrowed peripheral blood vessels resulting from a buildup of plaque, [Muscle atrophy] is the wasting or thinning of muscle mass, and [Muscle weakness] occurs when total effort…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #40) reviewed for advanced directives, in that: Resident #40's Out-of-Hospital Do Not Resuscitate (OOHDNR) was not dated by the resident and the physician at the time it was signed, and did not have the resident's name printed, rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings include: Record review of Resident #40's face sheet, dated [DATE], revealed an initial admission date of [DATE] with a recent admission of [DATE] and diagnoses which included: atherosclerotic heart disease (narrowing or hardening of coronary arteries), tachycardia (heart rate that exceeds the normal resting rate), dysphasia with oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat) and peripheral vascular disease (PVD, systemic…

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 Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #93) reviewed for PASRR screening, in that: Resident #93's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Record review of Resident #93's Face Sheet dated 1/10/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included: [bipolar disorder] disorder associated with episodes of mood swings ranging from depressive lows to manic highs,[Post-traumatic stress disorder] mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety and [Periodontal disease] condition that's the result…

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 1 of 24 residents (Resident #66) reviewed for comprehensive care plans, in that: Resident #66's care plan did not address the resident's psychological care and wound care being provided by the facility with goals or interventions. This deficient practice could result in a loss of quality of life due to residents receiving improper care. The findings were: Record review of Resident #66's face sheet, dated 01/12/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Senile Degeneration of Brain, Dementia, and Cognitive Communication Deficit. Record review of Resident #66's Quarterly MDS, dated [DATE], revealed a BIMS score of 06, which indicated the resident was severely cognitively impaired. Record review of Resident #66's care plan, revised 10/24/2023, revealed a problem, Resident has a behavior problem as evidenced by self-inflicted wounds 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Resident #8) for care plan revisions, in that: Resident #8's care plan was not revised to reflect the resident's change to DNR status after [DATE]; the resident's care plan still indicated the resident was Full Code. This failure could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: Record review of Resident #8's face sheet, dated [DATE], revealed an initial admission date of [DATE] with a recent admission of [DATE] and diagnoses which included: Alzheimer's disease, schizophrenia, type 2 diabetes mellitus with hyperglycemia (high blood sugar). Further review of Resident #8's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR: Do Not Resuscitate Order in Place. Record review of Resident #8'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 residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 8 residents (Resident #37) reviewed for ADLs, in that: The facility failed to ensure Resident #37 received or documented baths or showers between 12/21/2023 and 1/12/2024. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a diminished quality of life. Findings included: Record review of the admission Record revealed Resident #37 was a [AGE] year-old man admitted on [DATE]. Record review of Resident #37's quarterly MDS assessment, dated 10/09/2023, revealed primary medical condition category for admission was coded as medically complex conditions related to diabetes mellitus [a metabolic disorder in which the body has high sugar levels for prolonged periods of time]. Further review revealed the resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 2 of 12 residents (Residents #28 and #57) reviewed for indwelling catheters and perineal/incontinent care, in that: 1. The facility failed to ensure Resident #28 indwelling catheter was attached to prevent pulling or tugging to the urethra. 2. The facility failed to ensure Resident #57 foreskin was pulled back during perineal care. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections due to improper care. The findings were: 1. Record review of Resident # 28's face sheet, dated 01/11/24, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: [Hypospadias] birth defect in boys in which the opening of the urethra…

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 routine and emergency drugs and biologicals to its residents for 1 of 8 residents (Resident #85) reviewed for medication administration, in that: The facility failed to ensure Resident #85 was administered Cinacalcet [used to treat increased amounts of a certain hormone in people with long-term kidney disease who are on dialysis] as ordered 14 times between 08/21/2023 and 09/06/2023. This deficient practice could place all residents at risk for not receiving the intended therapeutic effect of medications as their ordered by their physician resulting in diminished health and well-being. The findings were: Record review of Resident #85's admission record, dated 01/12/2024, revealed the resident was a [AGE] year-old man admitted on [DATE]. Record review of Resident #85's quarterly MDS assessment, dated 11/27/2023, revealed the resident was admitted for medically complex conditions with other active diagnoses that included: renal insufficiency,…

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 medication error rate was not 5% or greater. The facility had a medication error rate of 28%, based on 7 errors out of 25 opportunities, which involved (Resident #37) and 1 of 2 staff (LVN C ) reviewed for medication administration, in that: LVN C failed administered medications to Resident #37 on 01/18/24 according to the physician's orders and per professional standards, which resulted in a 28% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions. The findings are: Record Review of Resident #37's face sheet, dated 01/11/24, revealed a [AGE] year-old male with an admission date of 09/21/23 with a diagnosis that included: [Hypertension] when the pressure in your blood vessels is too high, [Dysphagia] is a medical term for difficulty swallowing, and [Atrial fibrillation] is an irregular and often very…

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 locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart for Halls B & E) reviewed for medication storage, in that; The Medication Cart for Halls B & E Cart was not locked when it was left unattended in the common area of the 100 hallway. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: Observation on 01/10/2024 at 6:31 AM, LVN I was preparing insulin administration and LVN I parked the Medication B & E Cart in the hallway outside of room [ROOM NUMBER]. Further observation revealed LVN I left the Medication B & E Cart unlocked and unattended in the hallway outside of room [ROOM NUMBER] to obtain a blood glucose reading from a resident in room [ROOM NUMBER]. LVN I returned to the cart, documented the reading, reviewed the…

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

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 1 facility reviewed, in that: There were a number of varied pieces of furniture and large durable medical equipment were haphazardly stacked near the portable storage units in the facility's back parking lot. This failure could lead to loss of quality of life due to and environment fostering the presence of insects and/or rodents. The findings were: Observation on 01/12/2024 at 11:00 a.m. revealed there were four wheelchairs, one bedframe, three overbed tables, one dresser, all in various states of disrepair, and assorted other refuse stacked near the portable storage units in the facility's back parking lot. During an interview with the Dietary Manager and Floor Technician W on 01/12/2024 at 11:04 a.m., the Dietary Manafer and Floor Technician W stated the assorted broken items had been in the back parking lot for, about a week. Record review of the facility's policy titled, Resident Rights, dated 2/20/2021, revealed, 8. Safe Environment. The resident has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were accurately documented for 1 of 8 residents (Resident #78) reviewed for accurate medical records, in that: 1. Resident #78's allergies were documented incorrectly to include acetaminophen [an over-the-counter medication to alleviate pain or fever]. 2. Resident #78's bathing assistance was listed as extensive assistance when he was independent or set up assistance. These deficient practices could affect place residents at risk of not receiving appropriate care through inaccurate documentation possibly resulting in deterioration in condition, exacerbation of disease process, undermedication, or a delay in assessments and treatment. The findings included: Record review of Resident #78's admission Record revealed the resident was a [AGE] year-old man admitted on [DATE], and under the heading, Other Information, the resident's allergies were listed as acetaminophen, and propoxyphene [one of the active…

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 utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 5 days out of 30 (11/5/23, 11/12/23, 11/23/23, 11/25/23, and 11/26/23) reviewed for nursing services, in that: The facility did not utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week on 11/5/23, 11/12/23, 11/23/23, 11/25/23, and 11/26/23. This deficient practice could place all residents at risk of not receiving adequate care. The findings included: Record review of the facility's Daily Staffing Posting revealed the following: 11/05/23 - 1 RN Manager for the 6 am - 6 pm shift and 0 RNs for the 6 am - 6 pm shift 11/12/23 - 0 RN Managers for the day and 0 RNs for the day 11/23/23 - 2 RN Managers for the day and 0 RNs for the day 11/25/23 - 0 RN Managers for the day and 0 RNs for the day 11/26/23 - 0 RN Managers for the day and 0 RNs for the day Record review of the facility's Daily Punches revealed the following: 11/05/23 - No RN punches for the day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 4 Residents (Residents #5, #3, #4, and #6) reviewed for residents rights, in that: 1. Resident #5 was not served his lunch meal while other residents including his table mate ate and finished his meal. 2. Residents #3 and #4 received their trays after most of the tables in the dining room had received their trays and were already eating for a few minutes. 3. Resident #6 was not provided with a sack lunch before leaving the facility for a dialysis appointment. These deficient practices could affect residents self-esteem and feelings of dignity. The findings were: 1. Record review of Resident #5's face sheet, 10/13/23, revealed he was admitted to the facility on [DATE] with diagnoses to include Dementia in Other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 5 residents (Resident #1), reviewed for comprehensive care plans in that: Resident #1's care plan failed to address that the resident was exit seeking and a wander risk. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care. The findings included: Record review of Resident #1's face sheet dated 10/12/2023 revealed Resident #1 had an initial admission on [DATE] with diagnoses that included major depressive order, cognitive communication deficit, disruptive mood dysregulation disorder (recurrent irritable or angry mood and severe temper outbursts that interfere with their ability to function at home, in school, or with their friends), vascular dementia with behavioral disturbance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of medical records in that: LVN A and LVN B did not document the administration of Invega Sustenna to Resident #1 for April, May, and June 2023. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated 12/15/17, revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia [loss of cognitive functioning], other schizophrenia [disorder affecting the ability to think, feel and behave clearly], major depressive disorder (severe, with psychotic symptoms) [disorder that causes persistent depressed mood], anxiety disorder [disorder that causes feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 residents (Residents #5 and #6) reviewed for privacy, in that: The facility failed to ensure Resident #5 and Resident #6 had a privacy curtain between the two beds in a shared bedroom. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident 5's face sheet dated 8/03/2023 revealed an admission date of 4/18/2023 with diagnoses which included: chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder recurrent, mild. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMs of 13 which indicated the resident was cognitively intact. Record review of Resident #6's face sheet dated 8/03/2023 revealed an admission date of 6/11/2021 with a readmission date of 6/18/2021 with diagnoses which included: unspecified…

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 implement written policies that prevent abuse for 5 of 12 Residents (residents #7, #8, #9, #10, #12) reviewed for abuse, in that: The facility administration failed to immediately remove staff who were accused of by residents of verbal abuse, from working in the facility with residents. These failures could place residents at risk by leaving suspected abusers in contact with facility residents. The findings included: Record review of facility's policy titled Abuse, Neglect and Exploitation, dated 10/24/2022 revealed: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definition of verbal abuse, means that use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported not later than 2 hours if the events that cause the allegation involve abuse or neglect with serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1) of 8 residents reviewed for abuse. The facility failed to report to the State Survey Agency immediately or no later than 2 hours after staff discovered Resident #1's left foot great toe bandage had not been changed and wound care orders were not implemented and resulted in Resident #1 requiring hospitalization and treatment for sepsis and amputation. This failure could place the residents at risk of abuse and neglect allegations being uninvestigated. The findings included: Record review of TULIP revealed the facility self-reported an allegation of neglect to Resident #1 on [DATE] at 4:51 p.m. Record review of Resident #1 face…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Residents #1) for care plan revisions, in that: The facility failed to ensure Resident #1's Care Plan was revised to include wounds and wound care to his left foot great toe. These failures could place residents at risk for not receiving care according to their needs. The findings included: Record review of Resident #1 face sheet dated 7/25/23 revealed an admission date of 3/21/2022 with readmission date of 9/18/2022 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's annual MDS assessment dated [DATE] revealed a BIM's score of 8 which indicated a moderate cognitive impairment. The assessment was coded for no ulcers, wounds, or skin problems. Record review of a Doctor'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 reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 4 residents (Resident #1) reviewed for complete and accurate medical records, in that: The facility failed to ensure weekly skin assessments, wound assessments, physician orders were entered into Resident #1's permanent medical record. The findings included: Record review of Resident #1 face sheet dated [DATE] revealed an admission date of [DATE] with readmission date of [DATE] with diagnoses which included: type 2 diabetes mellitus with hyperglycemia, protein-calorie malnutrition (undernutrition), and hypertension (high blood pressure). Record review of Resident #1's Care Plan dated [DATE] revealed the resident had a diagnosis of diabetes with interventions to include: inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema and redness and report to the nurse. Record…

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.