Midtown Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for 1 out of 36 sampled residents, the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, a resident was admitted to the facility and his baseline care plan was not developed until 10 days after his admission. Resident identifier: 70. Findings included: Resident 70 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with psychotic disturbance, carrier or suspected carrier of methicillin resistant staphylococcus aureus, type 2 diabetes, Parkinsonism, Post Traumatic Stress Disorder, and pain. Resident 70's medical record was reviewed on 4/27/25 through 4/30/25. An admission screening dated 1/31/25, revealed resident 70 was oriented to person only upon admission, had normal gait, was confused, had a flat…

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, for 1 out of 36 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, a care plan was not developed for the treatment, monitoring, and assessment of a resident's arteriovenous fistula (AVF). Resident identifier: 32. Findings included: Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic kidney disease, hypertension, and AVF. Resident 32's medical record was reviewed. Resident 32's physician orders revealed the following: a. On 2/4/25, an order was initiated for check blood was flowing through the fistula properly (thrill) every day and night shift. b. On 2/4/25, an order was initiated for no lifting more than 5 pounds for 12 weeks. c. On 2/4/25, an order was initiated for Do not use Lt. [left] Arm for I.V. [intravenous]/I.M…

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, for 2 out of 36 sampled residents, the facility did not ensure that the services provided met professional standards of practice. Specifically, two residents did not have their tube feed formula bag labeled with the formula name, the administration route, rate, and duration, and the initials of who prepared, hung and checked the enteral formula against the order. Resident identifiers: 14 and 54. Findings included: 1. Resident 14 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which consisted of gastrostomy status, dysphagia, folate and iron deficiency anemia, severe protein-calorie malnutrition, stage 2 pressure ulcer, congestive heart failure, ischemic cardiomyopathy, and dementia. On 4/27/25 at 9:26 AM, an observation was made of resident 14's Tube Feed (TF) infusing. A bag of Isosource 1.5 calorie was infusing at a rate of 45 milliliter/hour (ml/hr) and the water flush was infusing at a rate of 50 ml/hr. The formula bag…

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, for 2 out of 36 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident sustained multiple falls without continued attempts at interventions to prevent additional falls and a cognitively impaired resident had access to cleaning chemicals. Resident identifiers: 37 and 76. Findings included: 1. Resident 37 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, obstructive sleep apnea, heart disease, and anxiety disorder. Resident 37's medical record was reviewed between 4/27/25 and 4/30/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident 37 had a Brief Interview for Mental Status (BIMS) score of 8 suggesting moderate cognitive impairment. It also revealed that resident 37 required supervision for most self care activities, was dependent for…

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, for 1 out of 36 sampled residents, the facility did not ensure that the resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. Specifically, a resident was observed lying flat during an enteral tube feed infusion. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of anoxic brain damage, gastrostomy status, Parkinsonism, aphasia, dysphagia, and severe protein-calorie malnutrition. On 4/28/25 at 7:40 AM, an observation was made of resident 54's tube feed (TF) infusing. Resident 54 was lying flat in bed on the left lateral side. The head of the bed was not elevated. A bag of Isosource 1.5 calorie was infusing at a rate of 72 milliliters per hour (ml/hr) with 200 milliliters (ml)…

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, for 2 out of 36 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, residents oxygen tubing was not properly labeled. Resident identifiers: 33 and 37. Findings included: 1. Resident 33 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, major depressive disorder, and sleep apnea. On 4/27/25 at 9:48 AM, an interview was conducted with resident 33. During the interview resident 33 was asked about his use of oxygen. Resident 33 stated he had just started using the oxygen the day before. An observation was made of the concentrator in resident 33's room. There was no labeling on the tubing or the concentrator. Resident 33's medical record was reviewed on 4/27/25 through 4/30/25. 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.

Based on interview and record review, the facility did not ensure that the individual working in the facility as a nurse aide was not employed for more than 4 months unless that individual had completed a training and competency evaluation program approved by the State and had been deemed competent to provide nursing related services. Additionally, the facility may not use a temporary, per diem, or any other than a permanent employee who does not meet the competency evaluation program. Specifically, a staff member who did not complete the nurse aide competency evaluation program within 4 months continued to provide nursing related services to residents. Staff identifier: Nurse Assistant (NA) 1. Findings included: On 4/28/25, the facility provided a current employee contact list with job title and date of hire. The list did not contain information for NA 1. On 4/29/25 at approximately 3:45 PM, an interview was conducted with the Administrator (ADM). The ADM provided the telephone number for NA 1. The ADM stated that NA 1 worked as needed and had initially been hired as a dietary…

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 did not ensure that each residents drug regimen was free from unnecessary drugs. Specifically, for 2 out of 36 sampled residents, a resident taking an anticoagulant medication did not have adequate monitoring and a resident taking a vasodilator for high blood pressure did not have that medication held per the physician's ordered parameters. Resident identifiers: 7 and 41. Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diastolic congestive heart failure, chronic atrial fibrillation, essential hypertension, and venous insufficiency. Resident 41's medical record was reviewed on 4/28/25. A care plan Focus initiated on 4/2/24, documented that resident 41 was on anticoagulant therapy related to atrial fibrillation. The interventions initiated included, but were not limited to, a. Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness…

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, for 1 out of 36 sampled residents, the facility did not provide or obtain laboratory services only when ordered by a physician. Specifically, a lab was obtained for a Valproic acid level without a physician order. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, insomnia, dementia, post-traumatic stress disorder, major depressive disorder, and alcohol abuse. A physician order dated 2/20/25, documented, Valproic Acid Oral Solution 250 MG [milligram]/5ML [milliliter] (Valproate Sodium) Give 15 ml by mouth two times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE. On 12/18/24, resident 14 had a laboratory result obtained for a Valproic Acid level. No documentation could be found for a physician order for the lab. On 4/28/25 at 1:06 PM, an interview was conducted with the Charge Nurse (CN). 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, for 2 out of 36 sampled residents, the facility did not maintain medical records on residents that were complete, accurately documented, readily accessible, and systematically organized. Specifically, a resident had omissions on the Medication Administration Record (MAR) and a resident had medication documented as administered when it was not. Resident identifiers: 14 and 79. Findings included: 1. Resident 14 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, folate deficiency and iron deficiency anemia, benign prostatic hyperplasia, hypothyroidism, chronic pain, insomnia, dementia, post-traumatic stress disorder, major depressive disorder, and alcohol abuse. Resident 14's medical record was reviewed. Resident 14's physician orders revealed the following: a. Levothyroxine Sodium Oral Tablet 25 micrograms (mcg), give 25 mcg by mouth one time a day. The order was initiated on 2/21/25. b.…

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, for 1 out of 36 sampled residents, the facility did not ensure that residents were free from abuse. Specifically, a resident with a history of aggressive behavior,who required supervision, struck another resident. Resident identifiers: 18 and 33. Findings included: An entity 358 incident report was submitted to the State Survey Agency on 5/15/24. The report revealed that a smoking aid was taking resident 33 out to assist him to smoke. The smoking aid turned to open the door and resident 33 struck resident 18. The incident happened in the Foyer of the nursing home at approximately 5:35 PM. No serious bodily injury was reported. The report stated that resident 33 had a history of aggressive behaviors and required supervision. The report stated both residents were redirected, with resident 33 being redirected to his room. Resident 33's legal guardian was at the facility at the time of the incident and was informed. Law enforcement and Adult Protective Services were notified. It…

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 and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility did not date several items in the freezer and stored ground meat for greater than 7 days was located in the kitchen refrigerator. Findings Include: On 8/27/23 at 8:24 AM, an initial walk through of the kitchen was conducted. Inside the walk in fridge there was ground beef dated 8/19/23. Inside the freezer, there were several bags of frozen broccoli, hash brown cakes, and diced breakfast potatoes that had not been dated. A few of the diced breakfast potatoes bags had been opened and closed again and were not dated. On 8/28/23 at 12:09 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that food should not be in the fridge for more than 7 days. When asked why there were undated items in the freezer, the DM stated that the cardboard boxes that food items came in had the expiration date listed and that if kitchen staff opened a bag of frozen food, 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 it was determined that the facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented systematic analysis and action to ensure that improvements were effective and sustained to prevent adverse events. Specifically, the facility was found to be in non-compliance for some of the same deficiencies that were identified during last years recertification survey. Resident identifier 20 and 133. Findings included: 1. Based on observation, interview, and record review, it was determined for 2 of 32 sampled residents that the facility failed to ensure the resident's environment remained as free from accident hazards as much as possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident from obtaining a cigarette burn while smoking. This deficient practice was identified at a HARM level. Additionally, another resident left the locked facility without the consent 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, it was determined that for 3 of 32 sampled residents, that the facility did not ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. Specifically, the facility submitted three Minimum Data Set [MDS] assessments with incorrect resident medical documentation. Resident Identifiers: 16, 17, and 58. Findings included: 1. Resident 58 was originally admitted [DATE], readmitted [DATE], with diagnoses including: unspecified dementia unspecified severity with other behavioral disturbance, obstructive sleep apnea (adult) (pediatric), secondary polycythemia, morbid (severe) obesity due to excess calories, benign prostatic hyperplasia without lower urinary tract symptoms, other pulmonary embolism without acute cor pulmonale, tremor unspecified, chronic kidney disease stage 3 unspecified, secondary hyperparathyroidism of renal origin, proteinuria unspecified, obstructive and reflux uropathy 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 observation, interview and record review it was determined, for 1 out of 32 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident choice. Specifically, a resident requested to have an additional cigarette during the scheduled smoke time and the resident was ignored. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dislocation of the left hip, dementia, adult failure to thrive, presence of left artificial hip joint, hepatitis C, insomnia, palpitations, chronic pain, hypothyroidism, major depressive disorder, hypertension, gout, anemia, cardiac arrhythmia, and hyperlipidemia. On 8/27/23 at 10:56 AM, an interview was conducted with resident 18. Resident 18 stated that the facility had designated smoke break times. Resident 18 stated that the facility kept her lighter and cigarettes. Resident 18 stated that she does not go…

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, it was determined for 1 of 32 sampled residents that the facility failed to ensure that each resident received adequate supervision. Specifically, the facility did not provide adequate supervision to prevent a resident from eloping from the secured facility without the consent or knowledge of the facility. Resident identifiers: 133. Findings included: Resident 133 was admitted to the facility on [DATE] with diagnoses which included intracranial injury with loss of consciousness, neuralgia and neuritis, mild neurocognitive disorder, dysphagia, post traumatic seizures, aphasia, nontraumatic subarachnoid hemorrhage, hyperlipidemia, and constipation. Resident 133 was discharged from the facility on 3/18/23. On 3/13/23, resident 133's Hospital discharge paperwork documented that the resident was found down by his family member on 1/7/23. Upon admission to the hospital resident 133 was noted to have a post middle cerebral artery (MCA) stroke and a posterior cerebral artery (PCA)…

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 and interview it was determined that the facility did not store all drugs and biological's in locked compartments and permit only authorized personnel to have access. Specifically, observations were made of the medication cart left unlocked and unattended with medication on top during a medication administration observation. Resident identifier 6, 46, and 48. Finding included: On 8/29/23 at 7:58 AM, an observation was made of Registered Nurse (RN) 1 during the morning medication administration on the locked secure unit. RN 1 was observed to leave the medication cart unlocked and unattended in the hallway while he entered resident 46's room to administer medication. A bottle of lubricant tears eye drops were left on top of the medication cart. Resident 6 was standing next to the medication cart in the hallway and resident 48 was wandering up and down the hallway while RN 1 was away from the unlocked medication cart. An immediate interview was conducted with RN 1 upon exit of resident 46's room. RN 1 stated that he should lock the medication cart and make sure…

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 it was determined, for 1 of 32 sampled residents, that the facility did not ensure that each resident received the food and drink that accommodates the resident allergies, intolerance's, and preferences Specifically, a resident reported that he was lactose intolerant, had requested Lactaid milk, and was still receiving regular cows milk. Resident 29. Findings included: Resident 29 was admitted to the facility on [DATE] with diagnoses which included acquired absence of left leg below knee, dermatitis, osteomyelitis, non-pressure ulcer of right foot, benign prostatic hyperplasia, type II diabetes mellitus, restless leg syndrome, anemia, hypertension, and schizophrenia. On 8/27/23 at 10:18 AM, an interview was conducted with resident 29. Resident 29 stated that he was lactose intolerant. Resident 29 stated that he had requested Lactaid and had not been receiving it. Resident 29 stated that he was still getting regular milk. On 10/12/22, resident 29's physician ordered a reduced…

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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to eliminate the risk of physical contaminates during food preparation. Findings include: On 10/27/2021 at 1:04 PM, an observation was made in the kitchen. It was observed that a shelf directly above the main food preparation table had what appeared to be white paint that was chipped and peeling. On 11/1/2021 at 8:34 AM, an interview was conducted with the dietary manager (DM). The DM stated that she was aware of the shelf that has paint chipping off of it above the food preparation table. The DM stated that she knew that the shelf needed to be fixed to eliminate the risk of paint chips falling on the food. A review of the Maintenance Log revealed that the kitchen shelf above the food preparation table was not scheduled to be fixed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 3 of 38 sample residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff were standing over a resident to feed him, and two residents who were seated together were provided meals at different times. Resident identifiers: 33, 60, and 66. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with diagnoses that included frontotemporal dementia with behavioral disturbance, insomnia, mood disorder, obesity, and B12 deficiency anemia. On 10/25/21 at 12:28 PM, resident 33 was observed to be sitting on a chair in an assisted dining room. Resident 33 was not seated at the table where the other residents were seated. A certified nursing assistant (CNA) 2 was observed feeding resident 33 while standing next to him.…

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 and interview, it was determined that the facility did not create a clean, safe and homelike environment. Specifically, the facility had holes in the ceilings, damaged walls and damaged or destroyed mini blinds in multiple resident rooms. Findings include: On 10/25/21 at 10:48 AM, it was observed that there were holes in the walls of the following areas: a. Large hole in the ceiling of Director of Nursing Office b. Several small holes in residents room particularly in the New Directions areas On 10/25/21 at 10:48 AM, it was observed that mini blinds in many of the rooms were damaged and inoperable. Observations made on 10/25/21 and 10/28/21, revealed that room [ROOM NUMBER] had wires that were torn out of the cable cover against the south wall that were spooled on the floor next to the mattress. On 10/26/21 at 12:35 PM, an interview with the Maintenance Director (MD) was conducted. MD stated that he was working on painting and repairing walls. On 10/27/21 at 9:50 AM, an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 60 was initially admitted to the facility of 12/27/13 and readmitted on [DATE] with diagnoses that included schizoaffective disorder, malignant neoplasm of esophagus, unspecified dementia, and epilepsy. Resident 60's electronic medical record review was completed on 11/1/21. A quarterly minimum data set (MDS) assessment was completed with an assessment reference date (ARD) of 10/23/21. The quarterly MDS assessment was signed by the Director of Nursing on 10/26/21. The quarterly MDS assessment was submitted on 10/26/21 which was 3 days past the ARD date. On 10/27/21 at 8:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was in charge of updating the MDS for resident 60. The ADON stated that she knew resident 60's MDS was not up to date. Based on Interview and record review the facility did not assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.…

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, for 2 of 38 sample residents, it was determined that the facility did not keep, maintain and follow residents care plans. Specifically, the facility did not update and/or follow residents care plans for safety issues. Resident identifiers: 63 and 71. Findings include: 1. Resident 63 was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), mood disorder, hyperlipidemia, osteoarthritis, anemia, cataract, prostatic hyperplasia, constipation, dementia, hepatitis C, traumatic subdural hemorrhage and alcohol dependence. On 10/25/21 at 9:18 AM, an interview was attempted with Resident 63. Resident was confused and only oriented to self. Resident 63 was mostly non-verbal. Resident 63 was observed with bruising under his left eye. No safety measures were observed in resident 63's area. On 10/26/21 at 8:56 AM, a review of the provided matrix indicated that resident has fallen within the past 90 days. Nurses notes which were 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 develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 38 residents. Resident identifier: 278. Findings include: Resident 278 was admitted to the facility on [DATE] with diagnoses that included dementia, insomnia, muscle weakness, bipolar disorder, and cognitive communication deficit. Resident 278's medical record was reviewed on 10/28/21. Resident 278's assessment reference date (ARD) for the comprehensive care plan was 10/19/2021. It was revealed that the comprehensive care plan was completed on 10/26/21, which was 7 days past the ARD date. On 10/27/21 at 8:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was in charge of updating the MDS (Minimum Data Set) for resident 278. The ADON stated that she knew the MDS's were not up to date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined the facility did not ensure that each resident received adequate supervision and services to prevent accidents for 1 of 38 sample residents. Specifically, a resident was not provided adequate supervision to prevent elopement from the facility. Resident identifier: 59. Findings include: Resident 59 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, anxiety disorder, metabolic syndrome, and unspecified symptoms and signs involving cognitive functions and awareness. On 10/25/21 at 2:20 PM, resident 59 stated that he spent a year trying to get discharged from the facility. Resident 59 stated that he has family in Idaho, and he really wanted to leave the facility. Resident 59 stated that he had difficulty using the phone. Resident 59 stated that he felt like a prisoner of war, and was yelled at for walking around a lot. On 11/1/21, a record review was completed for resident 59. On 8/4/21 at 8:00 PM, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined for 1 of 38 sample residents that the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of the enteral feeding. Specifically, a staff member did not check gastric residual volume and did not check the placement of the feeding tube prior to initiating a tube feed. Resident Identifier: 71 Findings include: Resident 71 was admitted to the facility on [DATE] with diagnoses that included unspecified convulsions, diaphragmatic hernia, gastro-esophageal reflux disease, and mood disorder. On 10/27/21 at 2:00 PM, an observation of resident 71's tube feed initiation was conducted. The Licensed Practical Nurse (LPN) 1 was observed initiating resident 71's tube feed without checking the feeding tube placement and without checking for gastric residual content. On 10/27/21 at 2:15 PM, an interview with LPN 1 was conducted. LPN 1 stated we usually check for placement…

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 it was determined for 1 of 38 sample residents that the facility did not prepare food in a form designed to meet individual needs. Specifically, a resident with physician orders for thickened liquids was provided thin liquids. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, traumatic brain injury, PTSD, depression, and dysphagia. On 10/27/21 at 7:25 AM, resident 18's breakfast was brought to resident 18 by a certified nursing assistant (CNA) 1. Breakfast was observed to include pureed entres and thin drinks. At 7:30 AM, CNA 1 was observed feeding resident 18 breakfast. Resident 18 was not observed attempting to assist with eating, but did eat breakfast when CNA 1 fed him. CNA 1 was observed providing resident 18 with drinks through a stray, including orange juice, water, and chocolate milk. CNA 1 stated that resident 18 was provided thin liquids, but if he coughed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined for 1 of 38 sample residents that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, speech therapy assessments and documentation regarding a resident's difficulty swallowing were not included in the resident's medical record. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, traumatic brain injury, PTSD, depression, and dysphagia. On 10/27/21 at 7:25 AM, resident 18's breakfast was brought to resident 18 by a certified nursing assistant (CNA) 1. Breakfast was observed to include pureed entrees and thin drinks. At 7:30 AM, CNA 1 was observed feeding resident 18 breakfast. Resident 18 was not observed attempting to assist with eating, but did eat breakfast when CNA 1 fed him. CNA 1 was observed providing resident 18 with drinks through a stray, including orange juice, water, and chocolate milk.…

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 and interview, the facility did not 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. Specifically, facility staff were not wearing personal protective equipment appropriately, staff were not washing their hands between residents when providing care, and uncovered food was transported to resident rooms. Findings include: 1. On 10/25/21 between 12:02 PM and 12:11 PM, a food cart was observed parked in the middle of the hall and CNAs were transporting lunch food trays to multiple resident rooms. The dish with the main course and beverages on the trays were observed covered. However, small blueberry pies were observed uncovered during transport to resident rooms that included room [ROOM NUMBER], 104, 108 and 115. 2. On 10/25/21 through 11/1/21 it was observed multiple times that some staff members were not wearing appropraite Personal…

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 and interview, it was determined that the facility did not maintain handrails in hallways to ensure that handrails were secure. Specifically, the facility had loose handrails in the facility that were not secure to prevent a fall if utilized. Findings include: On 10/27/21 at 9:23 AM, it was observed that there were loose hand rails in the hallways in the following locations: a. Across the hall from the Director of Nursing's office. b. Across the hall from the Day Room. c. Next to the nurse's station. The Maintenance Log was reviewed and revealed that handrails were not on the list of items to be fixed in the facility. On 10/26/21 at 9:50 an interview with the Maintenance Director (MD). The MD stated that he was unaware of loose handrails. He stated that the plan was to replace the handrails when he replaced the floors and painted the walls in the coming months.