Cherrydale Health & Rehabilitation Center

Based on observations, resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to provide beverages to include, but not limited to milk, in accordance with meal tickets to maintain resident hydration for multiple residents on two units out of four units (Unit 4 and Unit 5). The findings included: 1. The facility staff failed to serve milk according to the planned menu for Resident #102, Resident #128, Resident #129 and Resident #130. On 6/24/25 at 12:40 p.m., an observation was made of the lunch meal being served in the dining room on Unit 4. There were approximately 15 residents in the dining room for lunch. The residents were served their meals and four of the residents, Resident #102, Resident #128, Resident #129 and Resident #130 were not served their milk according to their menu. There was a gallon of 2% milk available to be served to the residents in the dining room. On 6/24/25 at 1:00 p.m., Resident #129 said, I like my milk. He asked a staff member for milk and was never served the milk during the lunch meal. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in a sanitary manner in accordance with food service safety standards in the main kitchen. The findings included: In the main kitchen the facility staff failed to label food and store in a way to prevent contamination and to protect the integrity of the food. On 6/24/25 at 11:25 a.m., a tour of the main kitchen was conducted with the dietary manager in attendance. In the walk-in cooler there was a bag of green peas that had been opened and was not labeled with the open date or use by date. There was also a full case of green peas that the bag was open to air. The dietary manager was asked about the storage of opened items and stated, I had cases for each meal, they put that little bit back, I will have to ask why, we don't use partial cases because we have 200 residents. I would expect the bags to be tied up and the box closed. When asked about the date of open items, 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 observations, staff interview, resident interview, clinical record review and facility document review the facility staff failed to ensure staff followed proper infection control practices to include hand hygiene and handling of table linens to prevent contamination during meal service on two of four units ( Unit 4 and Unit 5) and failed to wear the proper personal protective equipment (PPE) for enhanced barrier precautions for Resident #108. The findings included: 1. The facility staff failed to change gloves between tasks and placed clean table linens on the floor before use in the dining room on Unit 4. On 6/24/25 at 12 noon, observations were conducted of the lunch meal service in the fifth-floor dining room. Facility staff were observed wearing gloves to prepare the beverages for resident's trays and while handling and distributing meals to residents in the dining room. The surveyor observed the dietary manager go to the handwashing sink but then leave the dining room. Because the surveyor was going to be observing food temperatures, the plating of food and partaking…

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, resident interview, staff interview, and facility documentation review, the facility failed to maintain an effective pest control program affecting four of four resident units. The findings included: On 6/24/25 at 12:10 p.m., while touring the facility and making observations, the surveyor entered a dually occupied resident room on the fourth floor. In the bathroom observations were made of multiple cockroaches crawling around on the floor. On 6/24/25 at 12:15 p.m., an interview was conducted with the maintenance assistant (Other Employee #5-OE#5). OE#5 was asked about pests within the facility and reported it is a problem. He reported a pest control contractor comes and has bait stations in the ceiling that chemicals are put in. OE #5 accompanied the surveyor to the resident room and confirmed the cockroaches crawling around the floor in the bathroom and stated they were coming from the corner and kicked the wall. When he kicked the wall approximately twenty cockroaches emerged from the wall and began crawling around. OED#5 stated he would caulk the baseboard.…

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 staff interview, clinical record review, and facility documentation review, the facility failed to notify the resident and the resident's legal representative of a medication change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was out of the facility on an extended leave of absence and was not available for interview during the survey. R112's clinical record included a power of attorney, which appointed his wife as his legal representative. According to R112's admission record/face sheet, it noted that R112's wife was his A/R [accounts receivable] guarantor, responsible party, and POA [power of attorney]- financial. The wife alleged that the facility started the resident on a muscle relaxer that she was not aware of. On 6/24/25-6/25/25, during a clinical record review it was noted that on admission, R112 was ordered cyclobenzaprine, which was a muscle relaxer, to be administered every eight hours as needed for muscle spasms. Then on 3/8/25, the order was changed to only be 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.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a resident with written notice and reason for a room change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was on leave of absence and was not scheduled to return prior to completion of the survey, therefore he was not able to be interviewed. On 6/24/25-6/25/25, during a clinical record review, according to the census tab, R112 was admitted to a room on the fifth floor. On 3/6/25, R112's room was changed to a different room on the fifth floor. On 5/22/25 R112 was moved from the fifth floor to a room on the fourth floor. Then on 6/13/25, R112 was again moved to another room on the fourth floor. According to the nursing progress notes there were no entries dated 3/6/25, to document the room change. There was a progress note dated 3/8/25, that read in part, . notified of room change on 03/08/2025 12:00 AM. [R112's wife's name redacted] notified on 03/08/2025. Reason 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.

Based on observation, resident interview, staff interview, clinical record review and facility documentation the facility staff failed to ensure that one resident (Resident #102) out of a survey sample of 20 residents, was treated with respect and dignity by performing personal grooming without the resident's consent. The findings included: The facility staff shaved off Resident #102's full beard without first obtaining permission. On 6/24/25 at 11:30 a.m., during the initial tour of unit four of the facility an observation was made of Resident #102 standing at the nurse's station very upset about his beard being shaved off this morning. Resident #102 was observed with a redness and razor burn appearance to his face. Resident #102 had beard hair that was still on his neck area. He was very anxious and pacing on the unit. Resident #102 was saying that something needs to be done now for this hurting and burning on my face. On 6/24/25 at 11:35 a.m., an interview was conducted with Resident #102. Resident #102 said, I was anxious to be getting a shower and when in the shower room 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 resident interviews, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer medications to one of twenty residents (Resident #111- R111). The findings included: On 6/24/25 at 12:45 p.m., while in the dining room, R111 reported, I've never been in a facility that runs out of medications like this one, and runs out of pain medicine so often, why do they have such a problem getting meds to the patients? On 6/25/25, a clinical record review was conducted of R111's chart. According to the physician orders, R111 had orders that included, but were not limited to, Atorvastatin Calcium 40 mg tablet, that was to be given at bedtime daily and Apixaban 5 mg tablet that was to be administered every 12 hours. According to R111's medication administration record (MAR) on 6/19/25, the scheduled administration for 9 p.m., was blank with no indication that the medications were administered. R111's chart had no progress notes dated 6/19/25, that addressed why the medications were not administered. R111's chart contained no progress…

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 resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration to one of twenty residents (Resident #111- R111). The findings included: On 6/24/25 at 12:45 p.m., while in the dining room, R111 reported, I've never been in a facility that runs out of medications like this one, and runs out of pain medicine so often, why do they have such a problem getting meds to the patients? On 6/25/25, a clinical record review was conducted of R111's chart. According to the physician orders, R111 had orders that included, but were not limited to, Fluticasone Propionate Suspension to be administered with two sprays in each nostril in the morning. According to R111's medication administration record (MAR) on 6/21/25, the scheduled administration for 9 a.m., was noted with a 9, which according to the chart code legend indicated, Other/See progress notes. According to the progress note dated 6/21/25, it read, on order. On 6/25/25 at 2:15 p.m., an interview was conducted with 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 observation, interviews, and policy review, the facility failed to provide a qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional with appropriate competencies and skills ensures palatable, therapeutic meals are provided to meet the residents' needs and preferences and carries out the functions of the food and nutrition service for all residents at the facility. Findings include: 1. During observation of food preparation on 04/22/25 at 10:24AM, there was no qualified dietitian or other clinically qualified nutrition professional present. Interview with the Head [NAME] on 04/22/25 at 10:25AM, she stated that the qualified nutrition professional quit about three weeks ago. The Registered Dietitian (RD) from the sister facility has been helping a couple times a week. During the interview 04/22/2025 at 11:20AM, the RD from sister facility stated there was no clinically qualified nutrition professional at this facility. It's been…

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 facility policy review, the facility failed to date, label, and/or store food products safely to decrease the risk of food borne illness, potentially affecting 185 of 189 residents who consume food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Storage Areas dated 11/20/24 indicated, It is the intent of this center to store food in a manner that maintains quality and safety. First in first out should be followed with Refrigerator Food codes and internal tools may be used as a reference for proper dating. Observation on 04/21/25 from 02:30 PM to 03:15 PM, during the initial kitchen inspection with the Registered Dietitian (RD), from a sister facility, revealed dinner rolls and crescent rolls being stored in the main refrigerator. The kitchen's bread storage racks revealed dinner rolls in an open plastic bag inside a cardboard box, exposed to air, unlabeled, and undated. The crescent rolls were wrapped in plastic wrap but were undated and unlabeled. In the kitchen's dry goods storage room, it 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, interview, and policy review, the facility failed to ensure a resident's rights (R90) were honored during dining and that staff provided a homelike dining experience during meals affecting many residents on 1 of 4 units. Findings include: Observations on 04/22/25, at 12:45 PM, revealed 15 residents were seated in the dining room during lunch and on 04/21/25 at 5:43 PM there were 19 residents seated in the dining room for dinner. All residents were served on trays. Staff did not remove resident's plates, silverware or cups and place them on the dining table. Observation on 4/22/25 at 12:46 PM, R90 was seated at a dining room table. Certified Nurse Aide (CNA)7 placed the resident's tray down and while still standing next to the resident stated, She's a feeder. During an interview on 04/21/25 04:58 PM, CNA 4 said that they serve meals on the trays because it has always been done that way. She said they always leave the trays on the table with the resident's food on the tray because it was probably cleaner than the table. During an interview on 04/22/25 at 12:50…

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, staff interview and facility documentation review, the facility staff failed to prepare and serve meals in accordance with the menu, affecting residents on four of four units. The findings included: For the lunch meal on 6/24/25, it was observed that the facility staff failed to prepare the dessert as written on the menu. On 6/24/25 at 11:25 a.m., observations were conducted in the main kitchen. The facility dietary staff were observed preparing food to take to the steam table on each unit to distribute. On 6/24/25 at 12:31 p.m., the food arrived in the fifth-floor dining room accompanied by a dietary aide and the dietary manager. The entire meal service of residents on the fifth floor was observed and it was noted that each resident's meal ticket displayed that an apple crisp was the dessert being served. However, residents were served mixed fruit instead. The dietary manager was observed comparing each plate served in the dining room and permitted the plates to be served with no apple crisp served. On 6/24/25 at approximately 1 p.m., the dietary manager 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 and interview, the facility failed to ensure food was served at proper and appetizing temperatures for seven (Resident (R) 32, R35, R49, R66, R86, R89 and R154) out of 46 sampled residents, increasing the risk for altered nutritional status. Findings include: During the resident council meeting on 04/23/25 at 1:30PM, R32, R35, R49, R66, R86, R89 and R154 complained that the food they receive at their meals was served cold. On 04/21/25 at 3:35PM, a policy for food palatability was requested from the Registered Dietician (RD), who was from the sister facility. The RD stated that there was no policy regarding palatability. The RD explained that there were some issues from different residents about the food not being served hot. When questioned, the RD stated that she had not done a test tray at this facility to determine whether the food that was served to the residents was served hot. When questioned further, the RD stated that she had not implemented any interventions to address the complaints about the food being cold. On 04/23/25 from 12:30 PM to 12:35 PM, food…

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

Based on observations, interviews, and facility documentation, the facility failed to provide drinks at meals that were consistent with the residents' preferences and meal slips for 12 of 46 residents. Findings include: On 04/22/25 at 12:35PM, the lunch meal was observed in the main dining room on Unit 2. It was observed that twelve residents did not receive their milk with their lunch. Review of all 12 residents' meal slips showed that milk should have been included with their meals. A review of the lunch menu noted that milk was to be served for all diets. Upon interview on 04/22/25 at 12:40PM, Resident (R) 89, R66, and R86, all stated that milk had not been provided or offered to them. R89, R66 and R86 stated that meals had been served in the past that did not include milk. Review of the meal slips for R89, R66 and R86 showed that six ounces of milk should have been provided. During the lunch observation on Unit 2 on 04/23/25 about 12:30PM, it was again observed that there were 12 residents who were served their lunch meal without milk, which was confirmed by a corporate…

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 facility policy review, record review, and interviews, the facility failed to provide the required documentation and/or refusals related to administration of vaccinations for influenza, pneumococcal, and COVID-19 for four of five Residents (R)(13, 57, 56, 157) which increased the risk of acquiring, transmitting, and/or experiencing complications of respiratory infections. Findings include: Review of the facility's policy titled, COVID-19 Vaccinations dated 03/11/24 revealed .Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: Screen for eligibility (contradictions, precautions, previous doses, etc.) If contraindicated or refused, document in patient's medical record . Review of the facility's policy titled, Influenza Vaccination dated 05/01/23 revealed .Influenza vaccine should be offered annually. During flu season refer to the CDC influenza website for additional information. The optimal time to administer influenza vaccine is in late September or early…

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, resident interview, staff interview, and facility documentation review, the facility failed to maintain an effective pest control program affecting four of four resident units. The findings included: On 6/24/25 at 12:10 p.m., while touring the facility and making observations, the surveyor entered a dually occupied resident room on the fourth floor. In the bathroom observations were made of multiple cockroaches crawling around on the floor. On 6/24/25 at 12:15 p.m., an interview was conducted with the maintenance assistant (Other Employee #5-OE#5). OE#5 was asked about pests within the facility and reported it is a problem. He reported a pest control contractor comes and has bait stations in the ceiling that chemicals are put in. OE #5 accompanied the surveyor to the resident room and confirmed the cockroaches crawling around the floor in the bathroom and stated they were coming from the corner and kicked the wall. When he kicked the wall approximately twenty cockroaches emerged from the wall and began crawling around. OE#5 stated he would caulk the baseboard.…

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 record review and staff interview, the facility staff failed to ensure the resident was afforded the right to participate in the treatment plan for one of 46 residents. Resident #27 was not afforded the opportunity to participate in care planning and treatment. The findings include: Review of R27's clinical record did not evidence R27 had been given the opportunity to be involved in ongoing treatment/care planning. Diagnoses for R27 were documented to include: Dementia with behavioral disturbance, diabetes, depression, anxiety, and chronic kidney disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/23/2025, in which R27 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. On 4/23/25 at 9:00 a.m. the social worker (other staff, OS #2) was interviewed and asked to present evidence to show that R27 was invited to participate in care. OS #2 verbalized the information is usually kept in the clinical record and would review the record to find the information. On 4/23/25 at 11:27…

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 staff interview, clinical record review, and facility documentation review, the facility failed to notify the resident and the resident's legal representative of a medication change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was out of the facility on an extended leave of absence and was not available for interview during the survey. R112's clinical record included a power of attorney document, which appointed his wife as his legal representative. According to R112's admission record/face sheet, it noted that R112's wife was his A/R [accounts receivable] guarantor, responsible party, and POA [power of attorney]- financial. The wife alleged that the facility started the resident on a muscle relaxer that she was not aware of. On 6/24/25-6/25/25, during a clinical record review it was noted that on admission, R112 was ordered cyclobenzaprine, which was a muscle relaxer, to be administered every eight hours as needed for muscle spasms. Then on 3/8/25, the order was changed to only…

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 resident interview, staff interview, and clinical record review, the facility staff failed to honor a preference for twice weekly showers for one of thirty-nine residents in the survey sample (Resident #187). The findings include: According to the clinical record, Resident #187 (R187) was admitted to the facility with diagnoses that included femur fracture, osteoarthritis, chronic kidney disease, irritable bowel syndrome, gastroesophageal reflux disease, osteoporosis, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed R187 as cognitively intact. On 4/21/25 at 5:08 p.m., R187 was interviewed about quality of life/care in the facility. R187 stated most weeks, she was getting only one shower per week. R187 stated that she wanted showers twice a week and was aware there was a state requirement for residents to get at least two showers per week. R187's clinical record documented the resident was scheduled for weekly showers on Tuesday and Friday. R187's record documented a shower 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 staff interview, clinical record review and facility documentation review, the facility staff failed to provide a resident with written notice and reason for a room change for one of twenty residents (Resident #112- R112). The findings included: On 6/24/25, during a clinical record review, it was noted that R112 was on leave of absence and was not scheduled to return prior to completion of the survey, therefore he was not able to be interviewed. On 6/24/25-6/25/25, during a clinical record review, according to the census tab, R112 was admitted to a room on the fifth floor. On 3/6/25, R112's room was changed to a different room on the fifth floor. On 5/22/25 R112 was moved from the fifth floor to a room on the fourth floor. Then on 6/13/25, R112 was again moved to another room on the fourth floor. According to the nursing progress notes there were no entries dated 3/6/25, to document the room change. There was a progress note dated 3/8/25, that read in part, . notified of room change on 03/08/2025 12:00 AM. [R112's wife's name redacted] notified on 03/08/2025. Reason 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 facility policy review, record review, and interview, the facility failed to obtain food preferences upon admission for one of one residents (R175) in the sample of 46 residents, causing R175 not to have his preferences provided and honored. Failure to provide resident's food preference has the potential to result in weight loss. Findings include: Review of the facility's policy titled Dining and Food Preferences dated October 2019 revealed, .The Dining Service Director or designee will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, mealtimes, including times outside of the routine schedule, food, and beverage preferences . Review of the Face Sheet found in the electronic medical record (EMR) revealed R175 was admitted to the facility on [DATE] with a diagnosis of Guillian-Barre Syndrome. Review of the Physician Orders found under the order tab in the EMR 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.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to ensure reasonable care for the protection of personal property for one of forty-six residents, Resident #137 (R137). R137 did not have a personal property invoice completed upon admission. The Findings Include: Clinical record review revealed that diagnoses for R137 included acute respiratory failure, diabetes, urine retention, chronic pain, and obstructive uropathy. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/2/2025, which assessed R137 with a cognitive score of 12 out of 15, indicating cognitively intact. On 4/21/25 at 4:39 PM, an interview with R137 was conducted. R137 verbalized that he had been missing a pair of ear pods and felt that they had been taken by staff about 6 months prior. R137 explained that he did report the concern but could not remember who he reported it to. When asked if the facility staff had filled out an inventory list upon admission, R137 verbalized no one had ever…

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, document review and review of facility policy, the facility failed to implement their abuse policy in notifying the Department of Health Professions (DHP) after receiving an allegation of sexual abuse against Registered Nurse (RN) 2, involving one resident (Resident (R)50) reviewed for abuse, out of a sample of 46 residents. Findings include: Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Crime dated 02/05/23 indicated, Procedure .b. Notify within 24 hours the DHP for incidences involving nurse aides, RNs, Licensed Practical Nurses (LPN's), Physicians, or other licensed or certified by DHP Review of the facility's event synopsis indicated, R50 reported that, on or about Saturday, 12/14/24, the wound nurse [RN2] came to her room to assess her wound on her peri-area and provide treatment. R50 states while he [RN2] was applying wound cream, he [RN2] began rubbing her vagina to a point where she stated it was excessive and told him [RN2] to stop several times prior to blocking him [RN2] with her hands and stopping him [RN2]. R50 denies…

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, interviews, and facility policy review, the facility failed to provide evidence that actual and potential allegations of abuse/neglect were thoroughly investigated for two residents (Resident 50, Resident 128), of 46 sampled residents. Findings include: 1. For Resident 50 (R50), facility failed to ensure an allegation of sexual abuse was thoroughly investigated. Review of facility's policy titled, Abuse/Neglect/Misappropriation/Crime dated 02/05/23 indicated, .The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations. Review of admission Record located under the Profile tab in the Electronic Medical Record (EMR) indicated R50 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the Resident Assessment Instrument (RAI), the facility failed to ensure that a comprehensive MDS assessment was completed accurately for one resident (R41) in the sample of 46 residents. Findings include: Review of R41's admission Record located in the Profile tab of the electronic medical record (EMR) revealed re-admission to the facility on [DATE]. Review of R41's admission Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 02/19/25, revealed the Brief Interview for Mental Status (BIMS) revealed a score of 14 out of 15, which indicated no cognitive impairment. Further review revealed that the nutrition section of this MDS did not indicate any weight loss. Review of R41's Progress Note, dated 01/09/25, written by the registered dietician (RD), revealed weight loss of -5.0% change over 30 days, -7.5% change over 90 days, and -10.0% change over 180 days, which constituted a significant weight loss. Review of R41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed after admission for one (Resident (R)40) out of 46 sampled residents. Findings include: Review of R40's admission Record located in the Resident Information tab of the electronic medical record (EMR), revealed R40 was re-admitted to the facility on [DATE] with diagnoses including bipolar and major depressive disorder. Review of R40's EMR and hard chart revealed no PASARR level I. During an interview on 04/23/25 at 12:47 PM the Director of Social Services (SSD) revealed she had not identified that R40 never had a PASARR Level 1 completed on admission but should have. During an interview on 04/23/25 at 1:05 PM the Administrator stated that R40 did not have a PASARR Level 1 completed at time of admission to the facility. During an interview on 04/24/25 at 8:20 AM the Director of Nursing (DON) stated when a resident was admitted he expected…

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, record review and interviews, the facility failed to develop and implement a care plan for two of two residents (Resident (R) 128 and R175), in the sample of 46 residents. Findings include: 1. For R175, the facility failed to develop and implement a person-centered comprehensive care plan that included his food preferences. Review of the Face Sheet found in the electronic medical record (EMR) revealed R175 was admitted to the facility on [DATE] with a diagnosis of Guillian-Barre Syndrome. Review of R175's Physician Orders found under the order tab in the EMR dated 02/12/25 revealed, .Regular diet, Regular texture, Thin Liquids consistency Large Portions . Review of R175's Care Plan found under the care plan tab dated 02/12/25 revealed, .the resident is at risk for weight loss or malnutrition and dehydration related to chronic disease, receiving therapeutic diet to promote wt. [weight] maintenance . The care plan did not address food preferences. Review of the quarterly Minimum Data Set…

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 facility policy review, record review, and interview, the facility failed to completely fill out a Durable Do Not Resuscitate form for one of one resident (R)185) in the sample of 46 residents which could cause the R185 to receive unnecessary treatment. Findings include: Review of the facility's policy titled, Do Not Resuscitate (DNR) dated [DATE] revealed .If the DNR is not intact or has been altered, or has not been filled out completely, it is not considered valid for withholding CPR [cardiopulmonary resuscitation] . Review of the Face Sheet found in the electronic medical record (EMR) under the Profile tab revealed R185 was admitted to the facility on [DATE] with a diagnosis of Spinal Stenosis. Review of the Durable Do Not Resuscitate Order found under the miscellaneous tab dated [DATE] revealed R185 signed the form, and the physician signed the form, but the form was not marked that the resident was capable of carrying out the decision. Review of the admission Minimum Data Set (MDS) with 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.

Based on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for one of thirty-nine residents in the survey sample (Resident #103). The findings include: A nurse administered a 50 mg (milligram) dose of the medication Lyrica to Resident #103 when the physician ordered a 25 mg dose. On 4/22/25 at 8:04 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #5), who was administering medications to Resident #103 (R103). Included in medications administered to R103 was one capsule of Lyrica 50 mg (milligrams). R103's clinical record documented a physician's order dated 4/18/25 for Lyrica 25 mg, with instructions to give one capsule per day for 30 days for treatment of myalgia. The clinical record included no current order for Lyrica 50 mg. On 4/22/25 at 9:01 a.m., LPN #5 was interviewed about the administered dose of Lyrica 50 mg, when the order required a 25 mg dose. LPN #5 reviewed the clinical record and stated that R103's Lyrica order was changed on 4/18/25 from a 50 mg per day to 25 mg per day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and facility documentation, the facility failed to ensure the environment was free of accident hazards, failed to implement fall intervention as care planned, and failed to conduct thorough investigation to identify post-fall causal factors for one resident (Resident 128 -R128) in the sample of 46 residents. Findings include: Review of R128's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included hemiplegia & hemiparalysis, muscle weakness, and cognitive communication deficit. Review of R128's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/25 and located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Further review revealed that his primary language was Spanish. Review of R128's Care…

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

Based on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration to one of twenty residents (Resident #111- R111). The findings included: On 6/24/25 at 12:45 p.m., while in the dining room, R111 reported, I've never been in a facility that runs out of medications like this one, and runs out of pain medicine so often, why do they have such a problem getting meds to the patients? On 6/25/25, a clinical record review was conducted of R111's chart. According to the physician orders, R111 had orders that included, but were not limited to, Fluticasone Propionate Suspension to be administered with two sprays in each nostril in the morning. According to R111's medication administration record (MAR) on 6/21/25, the scheduled administration for 9 a.m., was noted with a 9, which according to the chart code legend indicated, Other/See progress notes. According to the progress note dated 6/21/25, it read, on order. On 6/25/25 at 2:15 p.m., an interview was conducted with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interview, the facility staff failed to maintain safe and functioning equipment. Resident #80's (R80) hand assist bar in the bathroom was not securely anchored to the wall. The findings include: Clinical record documented that diagnoses for R80 included difficulty walking, dialysis, diabetes, chronic kidney failure, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/29/2025, which assessed R80 with a cognitive score of 15 out of 15, indicating cognitively intact. During an interview conducted on 4/21/25 at 3:53 p.m., R80 verbalized concerns regarding the hand assist bar in the bathroom. R80 reported that it is not secured to the wall and is worried about it being pulled off the wall when trying to get off the toilet. R80 said the concern has been reported but no one has repaired it. At this time, the hand rail was observed loosely anchored to the wall and when pulled…

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 facility policy review, record review, and interview, the facility failed to obtain food preferences upon admission for one of one residents (R175) in the sample of 46 residents, increasing the risk for weight loss, malnutrition, and dehydration. Findings include: Review of the facility's policy titled Dining and Food Preferences dated October 2019 revealed, .The Dining Service Director or designee will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, mealtimes, including times outside of the routine schedule, food, and beverage preferences . Review of the Face Sheet found in the electronic medical record (EMR) revealed R175 was admitted to the facility on [DATE] with a diagnosis of Guillian-Barre Syndrome. Review of the Physician Orders found under the order tab in the EMR dated 02/12/25 revealed .Regular diet, Regular texture, Thin Liquids consistency Large…

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 staff interview, facility document review, and clinical record review, the facility staff failed to assess and implement interventions for care/treatment of pressure ulcers for two of six residents in the survey sample (Residents #1 and #5). The findings include: 1. Resident #5 (R5) had no comprehensive assessment or treatment orders implemented for a pressure ulcer until seven days after the ulcer was identified. According to the clinical record, Resident #5 was admitted to the facility with diagnoses that included diabetes, history of traumatic subdural hematoma, dysphagia, anxiety, dementia with behaviors, urinary tract infection, atrial fibrillation with pacemaker, hypertension, complete heart block and protein-calorie malnutrition. The minimum data set (MDS - assessment tool) dated 11/13/23 assessed R5 with severely impaired cognitive skills. R5's clinical record documented weekly skin audits, indicating the resident had no pressure ulcers prior to a hospitalization on 11/6/23. Following a 3-day…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a change in condition requiring treatment for one of six residents in the survey sample (Resident #5) The findings include: Facility staff failed to notify Resident #5's physician/provider of a pressure ulcer assessed on the resident's sacrum at the time of readmission to the facility, following a hospitalization. According to the clinical record, Resident #5 was admitted to the facility with diagnoses that included diabetes, history of traumatic subdural hematoma, dysphagia, anxiety, dementia with behaviors, urinary tract infection, atrial fibrillation with pacemaker, hypertension, complete heart block, and protein-calorie malnutrition. The minimum data set (MDS - assessment tool) dated 11/13/23 assessed R5 with severely impaired cognitive skills. R5's clinical record documented weekly skin audits, indicating the resident had no pressure ulcers prior to a hospitalization on…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of seven residents in the survey sample. The findings include: Resident #1 (R1), assessed as needing help with personal hygiene, was observed with long facial hair. R1 was admitted to the facility with diagnoses that included schizophrenia, anxiety, and right arm pain. The minimum data set (MDS - assessment tool) dated 11/8/23 assessed R1 as being cognitively intact and requiring help with self-care. On 2/26/24 at 3:00 PM, R1 was interviewed regarding personal hygiene. R1 verbalized being able to do most things independenly, then pointed to multiple facial hairs (approximately an inch in length), and said, I don't like this. I'm a woman. When asked if the staff had offered to remove the facial hair, R1 said, No. R1 verbalized not being able to cut it herself. On 2/27/24 at 9:40 AM, license practical nurse (LPN #2, assigned to R1) was asked to observe R1's facial hair. LPN #2 went to R1's room and conversed with R1…

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 staff interview and clinical record review, the facility staff failed to notify the physician of unavailable medications for one of thirty-seven residents in the survey sample. Resident #78's physician was not notified that the resident missed multiple doses of the medication epoetin alfa-epbx (Epogen) for treatment of anemia. After missing eight consecutive doses of the medication over a period of eight weeks, Resident #78 experienced critically low hemoglobin levels of 6.8 and 6.7 g/dL (grams per deciliter) requiring treatment with a blood transfusion. The findings include: Resident #78 was admitted to the facility with diagnoses that included anemia in chronic kidney disease, diabetes, osteomyelitis, multiple myeloma in remission, peripheral vascular disease, dysphagia, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, major depressive disorder, gout and urinary retention. The minimum data set (MDS) date 6/27/22 assessed Resident #78 as cognitively…

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, resident interview, staff interview, medical record review, and in the coarse of a complaint investigation the facility failed to develop a care plan for three of 37 resident's, and failed to meet with the resident and family regarding care plan goals for one of 37 resident's. A care plan was not developed for the care and monitoring of a Midline (A Intravenous line inserted into the upper arm, usually used for the treatment of antibiotics) for Resident #20. Resident #93 did not have a care plan for dialysis or shunt for dialysis. Resident #46 did not have a care plan for the care and monitoring of a forehead lesion/growth. Care plan goals were not discussed with Resident #166 or the family. This was a complaint deficiency. The Findings Include: 1. Diagnoses for Resident #20 included: Sepsis, stenosis of left carotid artery, depression, and urinary tract infection. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/30/22. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 3 of 37 residents in the survey sample, Resident #135, Resident #42, and Resident #95. Resident #135's CCP was not reviewed and revised for the discontinuation and care of a PICC/Midline and for the change in discharge plans. Resident #42's CCP was not reviewed and revised for the discontinuation of anti-coagulant medication. Resident #95's CCP was not reviewed and revised for the discontinuation of tube-feeding and care of a gastrostomy tube. The findings include: 1a. Resident #135 was admitted to the facility with diagnoses that included urinary tract infection, difficulty walking, hyperlipidemia, anemia, hypertension, bacteremia, and COVID-19. The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #135 as moderately impaired for daily decision making with a score of 08 out of 15. Resident #135's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, facility document review and staff interview, the facility staff failed to respond to call bells in a timely manner. Facility staff failed to answer call bells in a timely manner as evidenced by resident interviews and as documented in the resident council meeting minutes. The findings include: On 08/16/2022, Resident Council minute minutes were reviewed for the months of May 2020 through July 2022. Observed on the July 29, 2022 minutes was the following statement, .Residents are requesting that CNA's (certified nursing assistants) do better with answering the call lights On 08/17/2022 at 2:00 p.m., a group meeting was held with 17 residents. The group was asked about the call bell response time. Seven residents responded with the following statements regarding call bell response time. Resident #106 was admitted to the facility with diagnoses that included type 2 diabetes, long-term use of insulin, constipation, ileus, weakness, hyperlipidemia, obesity, depression, hypertension. 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 staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of thirty-seven residents in the survey sample. Resident #78 missed twelve doses of the medication epoetin alfa-epbx (Epogen) for treatment of anemia. Following the eight consecutive weeks of the unavailable medication, the resident experienced critically low hemoglobin levels that required treatment with a blood transfusion. The findings include: Resident #78 was admitted to the facility with diagnoses that included anemia in chronic kidney disease, diabetes, osteomyelitis, multiple myeloma in remission, peripheral vascular disease, dysphagia, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, major depressive disorder, gout and urinary retention. The minimum data set (MDS) date 6/27/22 assessed Resident #78 as cognitively intact. Resident #78's clinical record documented a physician's order dated 1/18/22 for epoetin…

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 staff interview and clinical record review, the facility staff failed to ensure one of 37 residents (Resident #316) was free of unnecessary medications. Resident #316 had a physician's order to stop Lovenox injections when the resident's INR (international normalization rate) (measures the time for the blood to clot) reached above 2.0, the medication was not stopped at that time. Findings include: Resident #316 diagnoses included, but were not limited to: high blood pressure, seizure disorder, history of DVT (deep vein thrombosis), brain tumor and Factor V Leiden (an inherited blood clotting disorder, which can be life threatening). Resident #316's most recent full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident was assessed as requiring extensive assistance of at least one staff person for all ADL's (activities of daily living). Section N0410.…

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 staff interview and clinical record review, the facility staff failed to implement a gradual dose reduction for one of thirty-seven residents in the survey sample. Resident #159 continued to receive a 75 mg (milligram) dose of the antipsychotic medication Seroquel for 15 weeks after the physician ordered for a dose reduction to 50 mg per day. The findings include: Resident #179 was admitted to the facility with diagnoses that included history of traumatic brain injury, transient ischemic attach, cerebral infarction, major depressive disorder, history of hip fracture, hypertension, psychosis, vascular dementia and acute respiratory failure. The minimum data set (MDS) dated [DATE] assessed Resident #179 as cognitively intact. Resident #179's clinical record documented a physician's order dated 8/24/22 for Seroquel 75 mg at bedtime each day for treatment of psychosis. The clinical record documented a consultant pharmacist recommendation dated 2/22/22 stating, This resident has been taking Quetiapine…

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, resident interview, group interview, staff interview and facility document review, the facility staff failed to ensure food was served at safe temperatures and meals were palatable and appetizing on one of four units. Fourth floor residents were served food items below safe holding temperatures from the steam table. Residents stated food was not hot or appetizing. Findings were: On 08/16/2022 at approximately 10:45 a.m., Residents # 103, 105, and 112, assessed as cognitively intact, asked to speak with the surveyor. All three residents voiced concerns regarding food at the facility. Complaints included the food was cold, served late, not what was on the scheduled menu, and did not taste good. On 8/16/22 at 11:18 a.m., Resident #40, assessed by the facility as cognitively intact, was interviewed about quality care/life in the facility. Resident #40 stated her main problem was with food service. Resident #40 stated before COVID food was good but a new company ran the kitchen and now the food was worse. Resident #40 stated they rarely got fresh fruits/salads and…

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

Based on observation, staff interview and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner. Dietary staff entered the kitchen without washing hands. Refrigerated foods were stored beyond use by dates and/or without labels indicating dates opened. Food temperatures were not checked on the steam tables prior to plating food. Hot foods were stored and served from the unit steam tables below the safe/recommended holding temperature of 135 degrees (F). The findings include: 1. On 8/16/22 at 8:38 a.m., a dietary employee (other staff #7) entered the kitchen. The dietary employee did not wash her hands upon entering the kitchen and proceeded to obtain a section of plastic wrap from a bulk dispenser and then left the kitchen area. On 8/16/22 at 8:40 a.m., the dietary manager entered the kitchen and failed to perform hand hygiene. On 8/16/22 at 8:44 a.m., accompanied by the dietary manager, food storage areas were inspected. Stored in the walk-in refrigerator was an unsealed plastic bag of ground sausage with no date opened or use by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure two of 37 residents were assessed for self administration of medications (Resident #99 and Resident #127). 1. Resident # 99 was not assessed to self administer eye drops. A bottle of eye drops were observed at the resident's bedside. 2. Resident #127 was not assessed to self administer eye drops (a bottle of betadine eye drops and a bottle of artificial tears were found at the resident's bedside). Findings include: 1. Resident #99's diagnoses included, but were not limited to: severe protein malnutrition, dysphagia following a stroke, high blood pressure, hemiplegia/hemiparesis, history of UTI (urinary tract infection), and atrial fibrillation. The resident's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 11, indicating the resident had moderate impairment of daily decision making skills. 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to allow two of 37 residents to have private time together. Resident #103 and Resident #105, both cognitively intact, and consenting, were not allowed by the facility staff to spend time together alone. Findings were: On 08/16/2022 at approximately 10:00 a.m., Resident #103 and Resident #105 were interviewed per their request. Both residents raised concern that they were not allowed to be in each others rooms. They were asked to explain. Resident #103 stated, We are friends. They won't let us spend time together, we can't have innocent coffee without them separating us they told us we can't be in each other's rooms .there is some rule about males and females being alone in a room .I got so upset the other day I thought I was going to have a stroke .they kept saying we had to stay away from each other .we want to be together and they won't let us. Resident #103 was asked who They were. He stated, The nurses, the aids, all of them. Resident #105 nodded her head…

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 review of employee files, staff interview, and review of facility policy and procedure, the facility failed to fully implement their policy for the screening of new employees. The facility filed to conduct a Criminal Background check for one of 24 employee files reviewed, and failed to ensure the Sworn Statement form was completed for two of 24 employee files reviewed. The findings were: During the review of 24 employee files, the following was found: A CNA (Certified Nursing Assistant) hired on 5/16/2022, did not have a Criminal Background Check completed. A CNA hired on 10/4/2021, did not have the Sworn Statement form completed. The Sworn Statement form, dated 10/3/2021, bore the employee's electronic signature. None of the barrier crimes listed on the form were responded to with either a Yes or No. A CNA hired on 6/20/2022, did not have the Sworn Statement form completed. The Sworn Statement form, dated 6/20/2022, bore the employee's electronic signature. None of the barrier crimes listed on the form were responded to with either a Yes or No. At approximately 3:30 p.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 staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for two of 37 resident's in the survey sample. Resident #167's discharge MDS assessment was coded as being discharged to the hospital instead of home. Resident #136 was not properly coded for infection in the foot. The Findings Include: 1. Diagnoses for Resident #167 included: Right femur fracture, right hip replacement, and anxiety. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/25/22. Resident #167's cognitive score was a 15 indicating cognitively intact. During a closed record review, Resident #167 was added to the sample as a hospital discharge review. On 8/17/22 Resident #167's clinical record was reviewed. Section A2100 of Resident #167's discharge MDS (dated 6/9/22) documented Resident #167 had been discharged to Acute Hospital. Review of Resident #167's progress notes dated 6/9/22 read in part Pt [patient] 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 staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to develop and provide a summary of a baseline care plan to one of 37 residents, Resident #166. Findings were: Resident #166 was admitted to the facility with the following diagnoses, including but not limited to: hypothryoidism, pneumonia, acute kidney failure, hypertension, acute pulmonary edema, congestive heart failure. An admission MDS (minimum data set) with an ARD (assessment reference date) of 02/22/2022, assessed Resident #166 as cognitively intact with a summary score of 14. The clinical record was reviewed beginning on 08/17/2022 at approximately 3:15 p.m. Review of the clinical record did not reveal any documentation regarding a base line care plan meeting with Resident #166 or her family. The Regional Director of Clinical Services was interviewed on 08/18/2022 at 9:10 a.m. She was asked if baseline care plans were completed at the facility and were the residents/family members involved in the development of the care plan…

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 staff interview, facility document review and clinical record review, the facility staff failed recognize and report irregularities in the medication regimen review for one of thirty-seven residents in the survey sample. Two monthly pharmacist reviews failed to recognize and report that Resident #78 was not administered weekly injections of epoetin alfa-epbx (Epogen) as ordered by the physician for treatment of anemia. The findings include: Resident #78 was admitted to the facility with diagnoses that included anemia in chronic kidney disease, diabetes, osteomyelitis, multiple myeloma in remission, peripheral vascular disease, dysphagia, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), hypertension, hyperlipidemia, major depressive disorder, gout and urinary retention. The minimum data set (MDS) date 6/27/22 assessed Resident #78 as cognitively intact. Resident #78's clinical record documented a physician's order dated 1/18/22 for epoetin alfa-epbx 4000 units/milliliter with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medication pass and pour observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure a medication error rate less than 5 percent. There were two errors out of 27 opportunities resulting in a medication error rate of 7.41 percent. Resident #101's Olanzapine 10 milligrams (mg) ordered for Schizophrenia and Folic Acid 1 mg ordered for anemia was unavailable for administration. The Findings Include: On 09/27/22 at 9:00 am a medication pass and pour observation was conducted. Resident #101's Olanzapine 10 mg and Folic Acid 1 mg was ordered to be given at 9:00 AM. License practical nurse (LPN #1) could not find either of the medications in the medication cart. LPN #1 said he would check to see if the missing medications were in the Omni Cell (pharmaceutical distribution center located in the medication room) to see if the medications were at the facility. LPN #1 then went to the Omni Cell and discovered the medications were not there. LPN #1…

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 staff interview, the facility staff failed to ensure proper functioning of the dishwasher and a functioning paper towel dispenser in the kitchen. The dishwasher was operated with water leaking from under the center stainless steel panel into the floor. A paper towel dispenser at the handwashing sink near the kitchen entrance was not functional. The findings include: 1. On 8/16/22 at 8:37 a.m., an initial tour of the kitchen was conducted accompanied by the dietary manager (other staff #6). Upon washing hands at the sink near the kitchen/dishwasher room entrance, the motorized paper towel dispenser was observed not working. The surveyor was directed by kitchen staff to another sink near the food prep area to obtain a paper towel to dry hands. On 8/16/22 at 8:40 a.m., accompanied by the dietary manager, the towel dispenser was observed not working and a red light was illuminated on the front of the dispenser. The dietary manager was interviewed at this time about the dispenser. The dietary manager stated he did not know why the dispenser was not working. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, staff interview and clinical record review, the facility staff failed to ensure one of 36 residents, Resident #49, was free from unnecessary medications. Resident #49 was prescribed Depakote without adequate monitoring. The resident had not had a Depakote level drawn in over 14 months. Findings include: Resident #49 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: dementia, schizoaffective disorder, depression, psychotic disorder, major depression, and contracture of left ankle. The resident's most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment and severe impairment in daily decision making skills. The resident was assessed as requiring extensive to total assistance from at least one staff person for most all ADL's (activities of daily living). On 01/28/20 at 9:36 AM and again at 10:41 AM, Resident #49 was observed sitting at the nurses station…

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, staff interview and facility document review, the facility staff failed to ensure drugs and biologicals were labeled and stored in a safe manner. The facility failed to ensure narcotics were stored in a separately locked, permanently affixed compartment on 2 of 2 floors (3rd and 4th floors) and failed to ensure one of five medication carts had an insulin pen properly labeled (medication cart 'U' side on 4th floor). Findings include: On 01/28/20 at 9:48 AM, a medication room storage observation on Unit 3 was conducted with LPN (Licensed Practical Nurse) #2 along with LPN #1 (the unit manager). LPN #2 unlocked the main medication room door and then went to the refrigerator door and opened it and retrieved two medications. The refrigerator door was not locked. LPN #2 stated that these medications were ready for administration and then exited the room. The refrigerator door had a code key lock on the front of it. LPN #1 stated that key code was not used and stated that the refrigerator was supposed to have a lock on it and pointed to the side of the refrigerator…

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, staff interview, and facility document review, the facility failed to ensure proper holding temperatures on the steam table for one of 4 floors. The 4th floor steam table had foods at holding temperatures below 135 degrees. The findings Include: On 01/28/20 at 12:20 PM, the food serving line was observed on 4th floor. Dietary aide (other staff, OS #5) was serving from the steam table and was asked to obtain food temperatures from the steam table. The following temperatures were observed: eggplant parmesan 120 degrees, chicken cordon bleu 118 degrees, and broccoli 120 degrees. When asked what food holding temperatures should be, OS #5 stated 135, 145, 150 degrees. On 01/29/20 at 5:19 PM, the above information was presented to the director of nursing and administrator during a staff meeting. A policy concerning holding food temperatures was requested. On 01/30/20 at 9:30 AM, a policy was presented tiled Safe Food Temperatures and read in part: :[ .] When holding hot foods for service, these will be held above 135 degrees [ .] No other information was presented…

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 observation, staff interview and clinical record review, the facility staff failed to ensure prevlon boots were maintained in sanitary condition and in good repair for one of 36 residents, Resident #42. Findings include: Resident #42 was admitted to the facility on [DATE], with the most current readmission on [DATE]. Diagnoses for this resident included, but were not limited to: anemia, high blood pressure, severe peripheral vascular disease, neurogenic bladder, history of a stroke with lower extremity paralysis, history of seizure disorder, depression and dysphagia. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. The resident was assessed as requiring extensive assistance to total assistance from staff for all ADL's (activities of daily living), from two staff members for dressing, toileting, hygiene and bathing. On 01/28/20 at 11:50 AM,…

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, clinical record review and staff interview the facility staff failed to review and revise comprehensive care plans for two of 26 residents. Resident #118's care plan was not revised to include hospice services, and Resident #49's care plan was not revised to include wheelchair positioning. Findings were: 1. Resident #118 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia, malignant neoplasm of pharynx, tracheostomy, malignant neoplasm of the colon with colostomy, pressure ulcer, and dysphagia. The most recent MDS (minimum data set) was a significant change with an ARD (assessment reference date) of 01/02/2020. She was assessed as moderately impaired in her cognitive status with a summary score of 09. The clinical record was reviewed on 01/29/2019 beginning at approximately 9:00 a.m. Observed in the clinical record was a form completed by a local Hospice facility. Resident #118 was admitted to their…

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 medication pass and pour observation, staff interview, facility document review, and clinical record review, facility staff failed to administer Janumet (a diabetic medication) within the specified timeframe for one of 36 residents in the survey sample, Resident #117. Findings included: Resident #117 was admitted to the facility on [DATE] with diagnoses including, but not limited to: fractured left ankle following ORIF (open reduction internal fixation), bilateral quadricep tendon tears with repair in both knees, and diabetes. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 01/01/2020. Resident #117 was assessed as cognitively intact with a total cognitive score of 15 out of 15. During the medication pass and pour observation conducted 01/28/2020 at 10:02 a.m., RN#2 (registered nurse) administered Resident #117's morning medications at 10:02 a.m. RN#2 was interviewed regarding pink and yellow boxes observed on the resident medication…

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 resident interview, staff interview, and clinical record review, the facility failed to provide glasses for one of 36 Residents, Resident #122. The findings Include: Resident #122 was admitted to the facility on [DATE]. Diagnoses for Resident #122 included; Osteoarthritis, bipolar disorder, chronic respiratory failure, and joint pain. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/7/20. Resident #122 was assessed with a cognitive score of 15 indicating cognitively intact. On 01/28/20 at 10:29 AM, an interview was conducted with Resident #122. During the interview Resident #122 stated that that it was hard to see to read and that an optometrist had came to the facility and did an examination and prescribed glasses but had never received the glasses. On 1/29/20 Resident #122's clinical record was reviewed and revealed an optometry consult dated 9/4/19 that indicated that Resident #122 was prescribed glasses as needed (reading glasses). On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide proper care and treatment for pressure ulcers for two of 36 in the survey sample, Resident #80 and Resident #355. Staff failed perform hand hygiene after glove changes during a pressure ulcer dressing change for Resident #80, and failed to follow physician orders for a dressing change for Resident #335. The findings include: Resident #80 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease - stage 3, dementia without behavioral disturbances, seizures, dysphasia, muscle weakness, hyperlipidemia, pressure ulcer - stage 4, anxiety disorder and pulmonary embolism. The minimum data set (MDS) dated [DATE] which was a quarterly assessment, assessed Resident #80 as severely impaired for daily decision making with a score of 0 out of 15. On 01/28/2020, Resident #80's clinical record was reviewed. Observed on 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, staff interview and clinical record review, the facility staff failed to ensure appropriate services, equipment, and assistance to maintain or improve mobility and positioning for one of 36 residents in the survey sample, Resident #49. Resident #49's wheelchair was not equipped with bilateral leg rests, and the resident's legs did not touch the floor, and were hanging approximately one foot off the ground. Findings include: Resident #49 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: dementia, schizoaffective disorder, depression, psychotic disorder, major depression, and contracture of left ankle. The resident's most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment and severe impairment in daily decision making skills. The resident was assessed as requiring extensive to total assistance from at least one staff person for most all ADL's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to attempt alternatives, identify risks/benefits and obtain informed consent prior to the use of bed rails for one of 36 residents in the survey sample (Resident #90). The findings include: Resident #90 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #90 included diabetes, high blood pressure, right hand contracture, history of bilateral knee replacements, chronic total knee dislocation, dysphagia, Alzheimer's, chronic pain, neuropathy, depression, atrial fibrillation and fractured left femur. The minimum data set (MDS) dated [DATE] assessed Resident #90 with severely impaired cognitive skills and as totally dependent upon two people for bed mobility. On 1/28/20 at 11:20 a.m., Resident #90 was observed in bed with short length bed rails in the raised position on both sides of the bed, near the head. Resident #90 was observed in bed again on 1/29/20 at 7:55 a.m. with the bed…

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.