River Bend Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform the resident's responsible party, consistent with his or her authority, when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 6 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party when Resident #1 had a medication error, change in condition, and was transferred to the hospital on [DATE]. This failure could place residents at risk of a decreased quality of life or hospitalization resulting in a decline in psychosocial or physical health.The findings included:Record review of an undated admission record revealed Resident #1 was an [AGE] year old female, admitted [DATE], with diagnoses that included Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors), fracture of the lower end of right femur (hip fracture), type 2 diabetes (a condition in which the body cannot use…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. 1. The facility failed to ensure 4 pitchers of beverages were covered and dated when prepared. 2. The facility failed to ensure box of powder sugar was dated with open date. 3. The facility failed to ensure opened bag of spaghetti was properly sealed with an opened date. 4. The facility failed to ensure opened bag of elbow noodles was dated with an opened date. 5. The facility failed to ensure food temperatures were taken in a sanitary fashion. 6. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 12/01/2024 at 9:24 a.m. during the initial tour of the kitchen revealed in the standing…

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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 11 residents (Resident #6, Resident #22 and Resident #62) reviewed for care plans. 1. The facility failed to ensure Resident #6's care plan reflected his receiving hospice services and did not have an active care plan. 2. The facility failed to ensure Resident #22's care plan reflected his pain management. 3. The facility filed to ensure Resident #62's care plan reflected his full code status, need for assistance with ADLs (activities of daily living), and only communicating in Spanish. These deficient practices place residents at risk for not receiving proper…

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 4 of 19 residents (Resident #4, Resident #25, Resident #30 and Resident #39) reviewed for care plan revisions. 1. The facility failed to ensure Resident #4's care plan was revised quarterly. 2. The facility failed to ensure Resident #25 care plan was revised after Significant Change in condition and when resident returned from the hospital. 3. The facility failed to ensure Resident #30's care plan was revised or reviewed after the quarterly MDS was completed on 09/25/2024. 4. The facility failed to ensure Resident #39's care plan was revised after revised after re-entry to facility and Significant Change in condition. These deficient practices could place residents at risk of not receiving appropriate interventions…

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, record review, and interviews, the facility failed to ensure resident received food prepared in a from designed to meet individual needs for 1 of 2 meals, reviewed for nutrition services. The facility failed to ensure the breakfast meal served on 12/03/2024 had the appropriate consistency for the meat serving for the puree textured diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss. The findings included: Observation on 12/03/2024 at 8:40 a.m. revealed [NAME] D preparing breakfast plates for puree residents with meat (sausage) that appeared grainy, closer to a fine ground meat consistency than a pudding consistency. [NAME] D put gravy over the meat as he served the plates. [NAME] D placed a scoop of the puree meat on a plate when asked about the texture of the meat. The DM then took a plastic spoon and mashed the puree meat. The DM after mashing the meat with a plastic spoon then removed from the serving line and pureed the meat. [NAME] D only had 2 tray…

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

Based on interview and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 19 staff (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for training, in that: The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory QAPI annual training. This failure could place residents at risk for care by staff who had been insufficiently trained while working in the facility. The findings included: Record review of the annual staff training information revealed the following staff had not completed their mandatory QAPI annual training requirement: *CNA-K (hired 11/02/2023), *CMA-L (hired 05/09/2023), *CMA-M (hired 11/14/2019), *CMA-N (hired 01/18/2021), *CNA-O (hired01/13/2021), *Hospitality-P (hired09/23/2023), *CNA-Q (hired08/07/2023), *Hospitality-R…

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

Based on interview and record review, the facility failed to ensure compliance and ethics training was completed for 10 of 19 employees (CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director) reviewed for orientation training. The facility failed to ensure that CNA-K, CMA-L, CMA-M, CMA-N, CNA-O, Hospitality-P, CNA-Q, Hospitality-R, Dietary Manger, and Activity Director had completed their mandatory ethics training. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings included: Record review of the annual staff training information revealed the following staff had not completed their mandatory ethics annual training requirement t: *CNA-K (hired 11/02/2023), *CMA-L (hired 05/09/2023), *CMA-M (hired 11/14/2019), *CMA-N (hired 01/18/2021), *CNA-O (hired01/13/2021), *Hospitality-P (hired09/23/2023), *CNA-Q (hired08/07/2023), *Hospitality-R (hired11/22/2022), *Dietary Manger (02/26/2024), and *Activity Director (hired 11/12/2024). Interview on 12/04/2024 at…

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 reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 19 residents (Residents #34) reviewed for accommodation of needs. The facility failed to ensure Resident #34's call light was within reach while he was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: Record review of Resident #34's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admission date of 07/19/2019 and re-admission date of 11/29/2021 with diagnoses that included: Dementia (loss of cognitive function), hemiplegia and hemiparesis (weakness and loss of strength on one side of the body), muscle weakness, muscle wasting and atrophy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 19 residents (Residents #34) whose assessments were reviewed, in that: The facility failed to ensure Resident #34's quarterly MDS, dated [DATE], correctly assessed the resident's functional limitation in range of motion status as evidence by coding No impairment to upper extremity. However, Resident #34 had impairment regarding function limitation in range of motion to his left arm. These failures could place residents at-risk for inadequate care and services. The findings were: Record review of Resident #34's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admission date of 07/19/2019 and re-admission date of 11/29/2021 with diagnoses that included: Dementia (loss of cognitive function), hemiplegia and hemiparesis (weakness and loss of strength on one side of the body), muscle weakness, muscle wasting and atrophy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 3 (Resident #30) reviewed for respiratory care. Resident #30's physician order indicated the resident had oxygen via nasal cannular on 2 liter per minute, but the resident was observed on 12/01/2024 at 3:10 p.m. receiving oxygen 2.5 liter per minutes and on 12/03/2024 at 11:30 p.m. receiving 3.5 liter per minutes. This failure could affect residents with oxygen therapy and could lead to care as ordered by the physician. The findings included: Record review of Resident #30's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admission date of 11/13/2022 and re-admission date of 04/29/2024 with diagnosis of chronic obstructive pulmonary disease (restricted airflow and breathing problems). Record review of Resident…

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

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (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 2 medication room (Recovery Medication Room) and 1 of 4 medication carts (Recovery Nursing Cart) reviewed for pharmacy services. 1. There was one bottle of medication (Ocular Vitamins for eye) expired on 09/2024 found inside the Recovery medication room on 12/04/2024. 2. There was one gel of medication (antimicrobial skin and wound gel hospital and professional use only) expired on 08/01/2024 found inside the Recovery nursing cart on 12/04/2024. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Observation on 12/04/2024 at 10:14 a.m. revealed there was one bottle of medication (Ocular Vitamins for eye) expired on 09/2024 found inside the Recovery medication room. Interview on 12/04/2024 at 10:14 a.m. the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 1 of 5 (Resident #30) reviewed for unnecessary medications. The facility failed to discontinue Resident #30's Melatonin 5 mg for sleep after the resident's primary care physician agreed on 09/18/2024 to the pharmacist's recommendation on 08/21/2024, which was for Resident #30, melatonin 5 mg due for gradual dose reduction, consider as needed for 14 days, then discontinue. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health. Findings included: Record review of Resident #30's face sheet, dated 12/04/2024, revealed the resident was [AGE] years old male and an original admission date of 11/13/2022 and re-admission date of 04/29/2024 a diagnosis of insomnia (difficulty of sleeping). Record review of Resident #30's quarterly MDS,…

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

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 4 nursing carts (treatment cart) reviewed for storage, in that: The facility failed to ensure the Treatment Cart was locked when left unattended. This failure could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations. The findings were: During an observation on 12/02/2024 at 11:57 a.m. revealed the treatment cart was found unlocked and unattended on the 200 hall. This surveyor was able to open all drawers revealing multiple creams, scissors, and bottles of medications. Interview on 12/02/2024 at 11:58 p.m. with Wound care nurse RN-G stated the treatment cart was unlocked and unattended on the 200 hall. The wound care nurse RN-G stated he did not realize he left the treatment cart unlocked. The wound care nurse RN-G stated it was important the treatment cart was locked at all times due to resident, visitor, and staff safety. The wound care nurse RN-G stated by 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 that the hospice services met professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services for 1 of 3 residents (Resident #27) reviewed for administration: There were no hospice nursing notes, records of visits or care available for Resident #27 at the facility. This failure could place residents receiving hospice services at risk of not receiving their needed services and care, and a decreased continuity of care between facility staff and hospice staff. The findings were: Record review of Resident #27's face sheet dated 12/4/24 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #27's diagnoses included heart failure (the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen.), age related cognitive decline (refers to the concern of or difficulty with a person's thinking, 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 observations, interviews, and record reviews, 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 2 residents (Residents #48 and #59) of 19 residents reviewed for infection control. 1. The facility failed to Resident #48's suction tube Yankauer (oral suction tool used in medical procedure) to be covered in a plastic bag when it was not used on 12/01/2024. The Yankauer was connected to the suction machine and hanging without a plastic bag. 2. When CNA-H was providing incontinence care to Resident #59, the CNA-H had multiple pass with one wipe and touched new and clean brief with old and dirty gloves on 12/03/2024 at 2:07 PM. These deficient practices could place residents at risk for cross contamination and infections. The findings included: 1. Record review of Resident #48's face sheet, dated 12/04/2024, revealed the resident was [AGE]…

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 (the Medication Cart) for 1 medication cart out of 3 medication cart's reviewed for medication storage. The facility failed to ensure medications were secured on medication cart # 2 The non-compliance was identified as past non-compliance. The noncompliance began on 10/3/2024 and ended on 10/5/23. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings were: Record review of Resident # 1 face sheet dated 11/13/24 , revealed an [AGE] year old male admitted to the facility on [DATE] with diagnosis that included: Congestive heart failure,(is a long-term condition in which your heart can't pump blood well enough to meet your body's needs) , Osteoarthritis…

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's right to be free from misappropriation of resident property for 1 of 3 residents (Resident #1), reviewed for drug diversion. Resident #1's scheduled narcotic pain medication, 81 tablets (2 pharmacy cards) went missing from the medication cart and was never found. This failure could place residents at risk of misappropriation, and could result in increased pain, and poor quality of life. The findings were: Record review of Resident #1's face sheet dated 7/3/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. His diagnoses included alcohol dependence with alcohol induced persisting dementia (form of dementia caused by long-term, excessive consumption of alcohol, resulting in neurological damage and impaired cognitive function.), Type 2 diabetes with other circulatory problems (chronic condition that affects the way the body processes blood sugar and has…

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 pharmaceutical services (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 3 residents (Resident #1) reviewed for pharmacy services. Resident #1's narcotic pain medication was not counted as required, the keys to the medication cart left unsecured, and resulted in 81 tablets being drug diverted and the resident missed 4 doses of his scheduled pain medication . This failure could place residents at risk of misappropriation by drug diversion, and could result in increased pain, and poor quality of life. The Findings were: Record review of Resident #1's face sheet dated 7/3/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE]. His diagnoses included alcohol dependence with alcohol induced persisting dementia (form of dementia caused by long-term,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Residents #1, #2, and #3) out of 3 residents reviewed who required wheelchair leg rests and foot pedals for comprehensive resident centered care plans. 1. Resident #1's comprehensive care plan (undated) did not reflect she partially depended on staff to wheel her in a wheelchair for locomotion and she needed the leg rests and foot pedals for support. 2. Resident #2's comprehensive care plan inaccurately reflected she was ambulatory and mobilized in her wheelchair. It did not address she was in a tall wheelchair dependent on staff to be mobile and needed leg rests with foot pedals for support. 3. Resident #3's comprehensive care plan did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #1) of 3 resident reviewed who required having their wheelchairs for transport for freedom from abuse, neglect, and exploitation. The facility failed to ensure the Maintenance Director, who drove Resident #1 to an appointment, reported that Resident #1 had an incident with her right foot and leg dropping down under the moving wheelchair and getting caught as she was assisted out of the van, until the next morning. This deficient practice affects residents in wheelchairs who require leg rests and foot pedals and affects residents transported to appointments and placed residents at risk of pain…

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 assure that residents received a therapeutic diet as prescribed by the physician for 1 of 5 residents (Resident #4) reviewed in that: Resident #4 was on a regular diet with no fried or high fat foods and was given fried okra during meal service which did not meet his dietary needs. This failure could affect residents who are prescribed a no fried or high fat foods diet and could result in heart disease or stroke. The findings include: Record review of Resident #4's face sheet dated 2/15/2024 revealed Resident #4 was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included colostomy status (an opening into the colon from the outside of the body, providing a new path for waste material to leave the body after bowel surgery or injury), vascular dementia (a form of dementia caused by an impaired supply of blood to the brain), bipolar disorder with psychotic features (a mental disorder that causes unusual shifts…

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 special eating equipment for 1 of 5 residents (Resident #1) reviewed for assistive devices in that: Resident #1 was not provided with a plate guard (helps prevent food from accidently being pushed off the plate while eating) during meal service to minimize food spillage and help the resident remain as independent as possible. This deficient practice could affect residents who required assistive devices for meals and could result in poor nutritional intake. The findings were: Record review of Resident #1's face sheet, dated 2/15/2024 revealed she was a [AGE] year old female admitted on to the facility on 8/29/2023 and had diagnoses that included hemiplegia and hemiparesis (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis) following cerebral infarction (occurs due to disrupted blood flow to the brain…

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 of residents' rooms revealed the facility failed to equip for adequate nursing care, comfort, and privacy of residents, 8 out of 8 Rooms (110, 212, 210, 209, 208, 408, 514, and 512) reviewed for equipped for adequate nursing care, in that: rooms [ROOM NUMBERS], were used as storage rooms. Rooms 210, 209, 208, 408, and 514, AC blower was not working. room [ROOM NUMBER], the AC unit was not working. These failures could result in rooms not being available for an influx of new residents in the event of a local or national emergency. The findings were: Observation on 01/04/24 at 4:12 PM of room [ROOM NUMBER] (Hall 100) revealed: the room was used for storage of PPE boxes, about 50 ; 3 briefs boxes; 2 gauze bags; and 13 hand sanitizers. Observation on 01/04/24 at 4:15 PM revealed: room [ROOM NUMBER] was used for storage; no resident was present. Room temperature taken by Maintenance Director's laser reader revealed: average of 67 F and hot water in the sink was 98 F.…

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 top of the dish machine was soiled with a sand-like substance. 2. The door of the freezer near the dish room was soiled. 3. Three containers of ground meat wrapped in plastic were thawing on a countertop. 4. Powdered milk container in the pantry was labeled milk and also labeled rice. 5. The containers of loose sugar and flour had lids that were not secure. 6. The large walk-in refrigerator had debris in the floor and contained: -two thermometers with different temperature readings -a container of heads of lettuce with multiple brown spots. -a container of breadsticks labeled keep frozen -a container of heavy whipping cream with a best by date of 09/27/2023 -a container of individual servings of sour cream with a best by date of 09/18/2023 -a container of scrambled egg blend labeled keep frozen -an open container of teriyaki sauce with no date -a container…

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 and protect and promoted the rights of the resident for 2 of 15 residents (Resident #7 and #64) reviewed for dignity, in that: Residents #7, and #64 urinary drainage bags were not covered or in a dignity bag for privacy. This deficient practice could place residents at risk of embarrassment, lack of privacy, and loss of dignity. The findings were: Record review of resident #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased 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.

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 (Hall 400) 8 halls reviewed for accident hazards, in that: A container of liquid disinfectant was stored in an unlocked room in Hall 400. This deficient practice could place residents at risk of harm by coming into contact with hazardous materials. The findings were: Observation on 10/24/2023 at 12:30 p.m. revealed a container of liquid disinfectant mixture in an unlocked room in Hall 400. During an interview with the Maintenance Director on 10/27/2023 at 4:20 p.m., the Maintenance Director stated the disinfectant was made up of peroxide disinfectant or bleach disinfectant, of which both containers were labeled, Danger and Keep Out of Reach of Children. The Maintenance Director confirmed the disinfectant mixture had been stored in an unlocked room on Hall 400 following its use during an outbreak of Covid-19. The Maintenance Director confirmed a resident could be harmed if he or she came into contact with 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 each resident was provided necessary respiratory care consistent with professional standards of practice for 3 of 6 residents (Residents #34, and #11, and #30) reviewed for respiratory care in that: 1. Resident #34's nebulizer tubing was outdated, and on the floor. The resident's nebulizer mask was disconnected from the tubing and on the floor on 4 of 4 days (10/24/23, 10/25/23, 10/26/23. and 10/27/23) of observations. 2. Resident #11's humidification water bottle was not connected. 3. Resident # 30 did not have physician orders for oxygen and oxygen was in use. This failure could place residents at risk of delays in receiving necessary respiratory care, and illness. The findings included: 1. Record review of Resident #34's profile dated 10/26/23 revealed the resident was a [AGE] year-old male admitted on [DATE] with readmission on [DATE] with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease - lung disease…

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 promote and facilitate the residents right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care for 1 of 4 residents (Resident #6) reviewed for self-determination in that: Resident #6 was taken to his room during a behavior and put in bed despite the resident protesting by yelling and hitting staff during transfer. This failure could place residents at risk of feeling like they have no rights, no choice, and no control, and could result in increased aggression, anger, and a decreased quality of life. The findings included: Record review of Resident #6's profile dated 10/27/23 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Cerebral infarction (stroke), profound intellectual disabilities (profound limitations in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #16) of 18 residents reviewed for advance directives, in that: Resident #16 was able to make her wishes known and her OOH-DNR was executed by her daughter. This deficient practice put residents at risk of not having their rights honored and of receiving CPR against their will. The findings were: Record review of Resident #16's face sheet, dated [DATE], revealed an admission date of [DATE] with diagnoses including: Type 2 Diabetes Mellitus with Hyperglycemia, Hypertensive Heart Disease with Heart Failure, and Bilateral Primary Osteoporosis of Knee. Record review of Resident #16's comprehensive MDS, dated [DATE], revealed a BIMS of 12 which indicated moderately impaired cognition. Record review of Resident #16's quarterly MDS, dated [DATE], revealed a BIMS of 11 which indicated moderately impaired cognition. Record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete an assessment within 14 days after the resident experienced a significant change in status for 1 (Resident #53) of 18 residents reviewed for resident assessment, in that: A feeding tube was placed for Resident #53 and the facility failed to re-assess the resident. This deficient practice could lead to improper care and diminished quality of life for residents whose needs are not fully assessed. The findings were: Record review of Resident #53's face sheet, dated 10/27/2023, revealed an admission date of 07/12/2023 with diagnoses including: Critical Illness Myopathy, Unspecified Severe Protein Calorie Malnutrition, and Adult Failure to Thrive. Record review of Resident #53's comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #53's care plan, as of 10/27/2023, revealed [Resident #53] require tube feeding [related to] weight loss. Record review of Resident #53's clinical 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.

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 for 1 (Resident #68) of 18 residents reviewed for comprehensive care plans, in that: Resident # 68's therapeutic diet was not listed on his care plan. This deficient practice could result in resident's receiving improper care and improper diets due to a lack of communication. The findings were: Record review of Resident #68's face sheet, dated 10/27/2023, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Metabolic Encephalopathy, Muscle Wasting and Atrophy, and Chronic Obstructive Pulmonary Disease. Record review of Resident #68's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #68's care plan, as of 10/27/2023, revealed it did not include the resident's therapeutic diet order. Record review of Resident #68's clinical record revealed a physician order 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 interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for 1 (Resident #53) of 4 residents with pressure ulcers reviewed, in that: Resident #53 did not receive treatment for her pressure ulcer for 10 days and the pressure ulcer worsened. This deficient practice could place residents with pressure ulcers at risk of pain and diminished quality of life due to wounds. The findings were: Record review of Resident #53's face sheet, dated 10/27/2023, revealed an admission date of 07/12/2023 with diagnoses including: Critical Illness Myopathy, Unspecified Severe Protein Calorie Malnutrition, and Adult Failure to Thrive. Record review of Resident #53's comprehensive MDS dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #53's care plan, as of 10/27/2023,…

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 received appropriate treatment and services to prevent urinary tract infections for 1 of 15 residents (Resident #7) who were reviewed for indwelling urinary catheter care, in that; a. Residents # 7's Condom catheter was not removed on 10/25/23 and 10/26/23 as per physician orders These deficient practices could affect residents with indwelling urinary catheters and place them at risk of urinary tract infections. The findings included: Record review of resident #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased urine flow, and [Depression] is a mood disorder that causes a persistent feeling of sadness and loss of interest…

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 32%, based on 7 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #40, Resident # 13) and 1 of 4 staff (CMA D) reviewed for medication administration. The facility failed to ensure CMA D administered medications according to the physician's orders and per professional standards which resulted in a 32% 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: 1. Record Review of Resident # 40's face sheet dated 10/25/23 revealed an [AGE] year-old female with an admission date of 02/27/2023 with a diagnosis that included: [Dementia] loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. [Anxiety] 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 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 # 7) reviewed for accuracy of medical records in that: Resident # 7's order to remove condom cathater in the [NAME] was not done and treatment record signed . 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 #7's face sheet undated revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnosis that included [Parkinson's disease], a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement. [Benign prostatic hyperplasia] causes your prostate to increase in size, leading to decreased urine flow, and [Depression] is a mood disorder that causes a persistent feeling 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.

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. DA A had facial hair and did not wear a facial hair restraint in the kitchen while portioning food for the lunch meal. 2. DA B did not change gloves or wash her hands after touching a cellular phone while preparing food in the kitchen. 3. DA B wore jewelry on her arm while engaged in food preparation in the kitchen. 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 10/05/2023 at 11:27 a.m. in the kitchen revealed DA A was standing in front of the steam table. DA A was portioning food from the steam table onto plates for the lunch meal. DA A had facial hair on his upper lip ¼ long and hair on his chin approximately ½ long. DA A did not wear a facial hair restraint. Interview on 10/05/2023 at 11:28 a.m. with DA A revealed he acknowledged he had facial hair and 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.

Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for 4 of five residents (Residents #1, #2, #3 and #4) reviewed for food meeting residents' needs, in that: Cook E did not puree ground beef to a pudding or mashed potato consistency as required for food served to residents who received a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of menu for 10/05/2023 revealed the menu for the pureed meal for residents included pureed soft beef tacos, pureed refried beans, pureed Spanish rice, pureed melon cup and a beverage. Record review of the electronic health records revealed for Residents #1, #2, #3, and #4 revealed all the residents had the following diet order: Regular diet, Pureed texture, Thin/Regular consistency. The dates of the order for the residents are as follows: Resident #1: 06/14/2022; Resident #2: 09/21/2023;…

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.